Independent Prescribing | Supplementary Prescribing

Independent Prescribing | Supplementary Prescribing Introduction This portfolio has been compiled in order to complete the non-medical prescribing qualification through the University of Central Lancashire. Throughout the portfolio, the author has analysed situations encountered whilst working along a designated medical practitioner (DMP). The author is a mental health nurse and is employed in a community mental health team, offering support to individuals who suffer with severe and enduring mental health problems. In the practice area, new ways of working (Department of Health (DH), 2007) is beginning to take effect which has enabled expansion of current roles, including non medical prescribing. The portfolio is organised into sections, with an index page for navigation. Two consultations are presented; the first involving an individual with a neurotic illness, where independent prescribing was deemed appropriate in the absence of co-morbid illness or significant risk. The second consultation pertains to an individual with severe and enduring mental health problems who has suffered adverse reactions to medication previously and for whom supplementary prescribing appeared to be the safest prescribing option. The consultations are followed by an evidence section and appendices. Completion of the portfolio has facilitated extensive development of knowledge in terms of pharmacology, including physiological variance (evidence 15). Knowledge of psychotropic medicines has also greatly improved and the importance of physical health monitoring for service users has since become a priority. The author believes that becoming a non-medical prescriber will provide an ideal opportunity to have a direct effect on public health targets such as reducing avoidable death from suicide and offering quicker, more appropriate treatment options to people with mental illness. The author also feels confident that non-medical prescribing in mental health will lead to increased concordance and better service user satisfaction. The required practice hours of the course have been achieved (evidence 1) through working with members of the prescribing team (evidence 2a, 2b, 2c, 2d, 2e). Throughout the portfolio, the author has ensured protection of confidential information, as directed by the Nursing and Midwifery Council (NMC) (2008) by referring to the service users by pseudonyms i.e. Alexander and by anonymising information related to the Trust for which the author works. Furthermore, consent forms have been obtained for named professionals and user perspectives Independent Prescribing Independent prescribing is defined as prescribing by a practitioner (e.g. doctor, dentist, nurse, pharmacist) responsible and accountable for the assessment of patients with undiagnosed and diagnosed conditions and for decisions about the clinical management required, including prescribing (DH, 2006 p2). The author will critically analyse an independent prescribing situation, addressing learning outcomes 1,2,3,4 and 5 in doing so. Reference to the stages of the prescribing pyramid will be made as this is a useful model to ensure appropriate prescribing (National Prescribing Centre (NPC), 1999). The patient will be referred to as Anne Knowles. Anne was a 28-year-old woman with a history of depression, referred by her General Practitioner who suspected a relapse. In order to confirm this, a full assessment was undertaken. Fortunately in mental health, adequate time is allocated for practitioners to gather information. Prescribers are encouraged to approach consultations in a structured way (NPC, 2003) therefore the Calgary-Cambridge model (Silverman, Kurtz and Draper 1998) was used alongside a structured tool in support of this approach. Health authorities have formulated unique Care Programme Approach (CPA) assessment tools based on the original guidance in Caring for People (DH, 1990) to accomplish a holistic assessment and this is what is advocated by the NPC (1999), as the first element of good prescribing practice. The author used the tool designed by the local health authority in the assessment of Anne (evidence 3). While the CPA assessment is comprehensive, the author elected to enhance it with additional tools to better inform prescribing practice. Incorporating Mortons (1992) symptom analysis tool a thorough assessment of Annes presenting symptom was facilitated. Furthermore, an individualised report obtained using a solution-focused approach (de Shazer, 1988), gave the author an appreciation of what was currently happening and how improvement would be detected (evidence 3, page 13). The author also utilised Becks Depression Inventory-II (BDI-II) (Beck, Steer and Brown, 1996) (evidence 4). Although routinely used in the practice environment due to its ease and speed of completion, it has been criticised due to the gender and cultural bias (female, Caucasian), which it represents (Hagen, 2007). This is something with which the author would agree and plans to use the Montgomery-Asberg Depression rating scale (Montgomery and Asperg, 1979) in the future as this has a broader reflection than the BDI-II. The remainder of the assessment, including a full medical, social and medication history, allergy status and exploration of Annes beliefs about her illness and future treatment were also included in the assessment. It is commonplace in clinical practice for staff to present assessments to the medical team where discussion of differential diagnosis occurs. Such discussion facilitates accurate diagnosis and debate of treatment options; however it is reliant on a precise initial assessment and effective presentation of the case. Following this a diagnosis of moderate depression was agreed under section F32.1 of the International Classification of Disease (World Health Organization (WHO), 1992). Considering the prescribing pyramid, the second step requires deliberation of the appropriate strategy to use. As the diagnosis of moderate depression was established, the author knew that a prescription was needed. Guidance from the National Institute of Clinical Excellence (NICE) (2004) suggests that individuals diagnosed with moderate to severe depression should routinely be offered a pharmacological intervention before psychological interventions. When considering choice of products, the third step of the prescribing pyramid, prescribers have available various antidepressants from diverse groups, namely Monoamine-oxidase Inhibitors (MAOIs), Tricyclic Antidepressants (TCAs), and Selective Serotonin Reuptake Inhibitors (SSRIs). There are also listings in the British National Formulary (Royal Pharmaceutical Society (RPS) British Medical Association (BMA), 2007) for other antidepressant drugs that cannot be classified into specific groups due to their unique pharmacology i.e. Mirtazapine and Reboxetine. In choosing between the agents, the author consulted national guidelines (NICE, 2004) which examine the effectiveness, appropriateness, safety and cost-effectiveness of drugs. NICE (2004) favours use of SSRIs to other antidepressant groups. This is because they are as effective as TCAs but concordance is higher because of the better side effect profile (NICE, 2004). Barbui and Hotopf (2001) reported that Amitriptyline, a TCA was more effective than SSRIs however conceded that use of SSRIs was higher because of their enhanced tolerability. SSRIs are less likely to cause sedation and cause much fewer anti-muscarinic effects than TCAs (RPS BMA, 2007). The other major distinction is that should they be used in overdose, SSRIs are considered less toxic than TCAs. Use of an MAOI was not considered as first-line treatment for Anne. Although once viewed as less effective than other antidepressants, when used in adequate doses, MAOIs are as efficacious (Riederer, Lachenmayer and Laux, 2004). However MAOIs are generally better in treating atypical depression (Riederer et al, 2004) and are associated with dangerous dietary and drug interactions (Nash and Nutt, 2007). SSRIs are the agents of choice in the practice area (evidence 5), in line with national guidelines. The common pharmacology of SSRIs is the prevention of reuptake of the neurotransmitter serotonin into the pre-synaptic cell, leaving increased amounts of serotonin available to bind to post-synaptic receptors (Carrasco and Sandner, 2005). Although the central nervous system is the desired site of action, SSRIs also exert their effect throughout the body, which explains their side effects. Aside from the primary pharmacology of the SSRIs, each has diverse properties, knowledge of which assists prescribers to choose the most appropriate agent. NICE (2004) directs prescribers to opt for Fluoxetine or Citalopram due to their ease of discontinuation as with other SSRIs, users have reported distressing discontinuation symptoms. A review by Haddad (2001) found as many as fifty different discontinuation symptoms, ranging in severity from mild to severely disabling. These included dizziness, nausea, lethargy, headache, electric shock like sensations, insomnia and nightmares. An understanding of the physiological mechanisms underlying the syndrome has yet to be realised. Theorists such as Tamam and Ozpoyraz (2003) and Blier and Tremblay (2006) speculate that the readaptation of the neurotransmitter systems, which rapidly increase reuptake of serotonin and subsequently decrease the amount of serotonin able to bind to post-synaptic receptors, are the likely triggers. Drugs with shorter half lives i.e. Paroxetine are the most problematic and those with longer half-lives and active metabolites i.e. Citalopram and Fluoxetine appear to fair better (Taylor, Paton and Kerwin, 2007). In terms of appropriateness, all SSRIs share identical cautions and contraindications and research has shown that Citalopram is just as effective as Fluoxetine in treating depressive symptoms (Patris, Bouchard, Bougerol, Charbonnier, Chevalier, Clerc, Cyran, Van Amerongen, Lemming and Hopfner Petersen, 1996). Consideration of patient-specific factors during the history taking identified that Anne found previous success with Citalopram. The medical history had not highlighted any conditions where cautions apply such as epilepsy, cardiac disease, diabetes mellitus, allergies etc and the author was aware that use of all antidepressants was contra-indicated in mania (RPS BMA, 2007). The choice of product was made in discussion with Anne. She had a preference for Citalopram and after reviewing the available evidence, the author concurred with this choice and prescribed Citalopram (evidence 6). See evidence 7 for a profile of Citalopram. Next, it was necessary to negotiate a contract with Anne, stage four of the prescribing pyramid. Anne understood Citalopram from previous use, however education regarding what the prescription was for and how long it would take to work (evidence 7) was given. Anne did not have a preference in terms of formulation and therefore tablets were prescribed, as this was the cheapest option. The side effects and red flag concerns of the medication were then identified to Anne (evidence 1, section 6). All antidepressants have been linked with a possible increased risk of suicidality. Research into SSRIs and suicidality demonstrates conflicting findings in that Healey (2003) found increased risk in early treatment and Isacsson, Holmgren and Ahlner (2005) reported a reduction. The Medicines and Healthcare products Regulatory Agency maintain that prescribers of SSRIs should monitor and assess for this regularly. Due to the possibility of suicidality occurring as a red flag, a prescription for treatment to last seven days was given and the rationale explained to Anne and her partner. In the practice area, service users are given information from the United Kingdom Psychiatric Pharmacy Group (UKPPG), available via the Trust intranet; the data regarding Citalopram was given to Anne (Appendix 1). Furthermore, Anne was encouraged to refer to the patient information leaflet, dispensed with the product from the chemist. Annes partner expressed concerns about media reports questioning the efficacy of antidepressant medication; this was addressed by giving him a copy of the Trusts response to the information (Appendix 2). This information was successful in reassuring him (evidence 8), along with the arrangements for reviewing Anne on a regular basis. In terms of reviewing Anne, stage five of the prescribing pyramid, a further appointment was made for seven days, in line with NICE (2004) guidance due to her higher background risk of suicide as an individual under the age of thirty years. Based on the evidence that SSRIs can increase risk of suicide, planning to see any patient commenced on antidepressants within a week would better ensure safety and professional accountability, in addition to addressing the public health target to reducing suicide. Although increased energy and motivation is apparent a week into treatment, the antidepressant effect is not, therefore the individual may continue to experience depressive symptoms and have the impetus to act on suicidal thoughts (NICE, 2004). Frequent monitoring thereafter is recommended by NICE (2004) who suggest professionals look for signs of akathisia, suicidal ideas and increased anxiety and agitation, which can occur with all antidepressants, including Citalopram. The author elected to give Anne and her partner the contact details for the Crisis Team in the local area, should support be needed out of working hours, explaining that they could be contacted if her mental health further deteriorated or she began to suffer with suicidal thoughts. It was indicated to Anne that she would be unlikely to feel the full benefit from the treatment for approximately two weeks due to the pharmacology of the drug (evidence 7) and that once the depression had lifted; guidelines suggest treatment should continue for at least six months after this marker. Geddes, Carney, Davies, Furukawa, Kupfer, Frank and Goodwin (2003) found that treatment continued for this time frame reduces the risk of relapse. In terms of keeping records, stage six of the prescribing pyramid, Annes progress was recorded using the electronic Care Programme Approach (eCPA) system. Use of eCPA in the practice area is a new development, intended to replace the paper-record system, allowing immediate access to relevant mental health staff. It is currently inaccessible to other health professionals; therefore duplication of work is necessary in order to ensure effective communication. Currently, professionals involved in the care of an individual seen by psychiatric services are identified as part of the initial assessment (evidence 1, section 19) and are advised of their treatment plan and progress via separate letters (Appendix 3). Working in this manner ensures safe, ethical practice by good communication with members of the multi-disciplinary team (NMC, 2008). In line with the NMC standards for recordkeeping (NMC, 2005) the author recorded and disseminated the information in a timely manner, using the same format as her DMP. In the future, the author plans to work with the non-medical prescribing lead to develop an appropriate format for her practice, which should enhance professional accountability. The seventh and final principle of the prescribing pyramid encourages reflection on prescribing practice. The author was confident that a prescription was necessary and therefore did not feel pressured by the patient to issue treatment against better judgement as can be the case (Britten, Ukoumunne and Boulton, 2002). Neither did the advertising activities of the relevant drug company influence the choice of product. Reliance on independent research was used to inform prescribing practice. Supplementary Prescribing Supplementary prescribing is described as a voluntary partnership between an independent prescriber (a doctor or a dentist) and a supplementary prescriber to implement an agreed patient-specific Clinical Management Plan with the patients agreement (DH, 2005a paragraph 8). A critical analysis of a supplementary prescribing scenario will follow, addressing learning outcomes 1, 2, 3, 4 and 5. As in the IP scenario, reference will be made to the prescribing pyramid (NPC, 1999). The patient will be referred to as Alexander Stewart. Alexanders General Practitioner (GP) had been managing his care; however he had been referred to the service following discontinuation of antipsychotic medication Risperidone, due to sexual dysfunction. Alexander was under the care of a consultant psychiatrist who had diagnosed Schizophrenia of the paranoid type, under Section F20.0 of the International Classification of Disease 10 (WHO, 1992). At the time of meeting Alexander, early warning signs of relapse were evident in that he believed others were against him and were sending messages via media sources. Alexander had sufficient insight to be able to recognise that his mental health was declining and had attended the appointment in the hope that an alternative treatment could be prescribed. The independent prescriber (IP), Dr Gater, felt that Alexander was a suitable candidate for a supplementary prescribing arrangement as there were no issues of substance misuse, no co-morbid illnesses and he had a good history of engagement. It is recommended that these factors be considered before contemplating supplementary prescribing in mental health care (DH, 2005b). New Ways of Working in Mental Health (DH, 2005c) dictate that individuals with highly complex needs, including those with dual diagnosis, history of poor engagement, co-morbid physical illness and assessed high risk of harm to self or others are seen by more advanced, highly trained professionals such as consultants. Dr Gater discussed with Alexander the possibility of supplementary prescribing and he agreed to work in this way, with the author as the supplementary prescriber (SP), who also took on the role of care co-ordinator. The IP set the parameters of the Clinical Management Plan (CMP) and this was then drawn up and signed, (evidence 9) indicating agreement by the IP, SP and Alexander as is mandatory for supplementary prescribing situations (DH, 2005a). The IP and SP had shared access to the patient record. The CMP in this instance was broad and permitted prescription of antipsychotic medication from a wide choice of agents, however CMPs can be specific, for example, only allowing the SP to make dose or frequency of dose changes to an identified medicine (DH 2005b). In such cases, if a patient were to develop adverse side-effects from the medicine, a new CMP would have to be developed, leading to increased workload and time delays for treatment. In this instance, because of the knowledge and experience of the SP, the close working relationship of the IP and SP and the accessibility of comprehensive guidance regarding the management of Schizophrenia (NICE, 2002b) a broad CMP was considered appropriate. The author used the prescribing pyramid to aid practice (NPC, 1999) and adhering to the first principle, considered a holistic assessment. The IP had already taken a thorough history and made a diagnosis, however the history taking was repeated by the SP to ensure that Alexanders presentation had not changed. Difficulties can arise if this occurs (evidence 2d). A CPA assessment was carried out (evidence 10), supplemented by a symptom analysis tool, namely Morton (1992). The assessment confirmed the original diagnosis. The National Service Framework for Mental Health (DH 1999a) reported that individuals suffering with this illness are nine times more likely than the general population to commit suicide and that the risk of death from other violent incidents is over twice as high. Government policy since this time has aimed to ensure that people with mental health problems are better able to access services and appropriate treatments in a timely manner, to prevent the aforementioned likelihoods. The author was keen to uphold these principles and treat accordingly. Theorists such as Wyatt (1991) and McGlashan and Hoffman (2000) have speculated that prolonged non-treatment of Schizophrenia can result in brain-damaging neurotoxicity and synaptic plasticity, respectively; however there is limited research into these theories (McGlashan, 2006). Findings from duration of untreated psychosis studies have lead to the recent development of Early Intervention Services which aim to ensure that people with mental illness receive timely treatment in order to prevent biological, psychological and social decline (Whitwell, 2001). Personal experience has further demonstrated that non-treatment of the illness results in further loss of insight, increased distortions of judgement and the possibility that the active phase will last indefinitely. This knowledge meant that the second principle of the prescribing pyramid was satisfied since the appropriate strategy was to issue a prescription. Alongside this, the author, working as care co-ordinator for Alexander highlighted interventions to address issues relevant to his quality of life and well-being including housing, finance and employment support etc as suggested by government policy (DH 1999a, DH 1999b). The third principle, consideration of product choice, was initially agreed via the CMP. This indicated use of antipsychotic medication; however the selection of agents was open for discussion between Alexander and myself. To aid the decision, referral was made to the NICE guidance for treatments in Schizophrenia (NICE 2002a). The guidance recommends use of atypical antipsychotics in the treatment of Schizophrenia. Evidence 12 explains typical versus atypical antipsychotics in further detail. Alexander previously had a good response to an atypical drug, namely Risperidone, however stopped it due to the adverse drug reaction (ADR) he suffered. Alexander developed retrograde ejaculation, a reasonably high reported adverse effect of this drug (Taylor et al, 2007). Alexanders G.P had been satisfied that the symptom was not caused by other conditions such as diabetes mellitus or multiple sclerosis; and as the symptom ceased following discontinuation of Risperidone, was satisfied that it was an ADR. Although evidence suggests that this effect is dose related (Raja 1999, Loh, Leckband, Meyer and Turner 2004), Alexander did not wish to recommence this treatment. In choosing the most appropriate treatment, the criteria was therefore further simplified to an atypical agent, where possible, with a low affinity for alpha1 adrenergic antagonism since this is thought to be the cause of retrograde ejaculation with Risperidone (Loh at al, 2004). From the atypical agents listed in the current British National Formulary (RPS BMA, 2007), the two with the lowest affinity for alpha1 adrenergic antagonism are Aripiprazole and Quetiapine (Loh et al, 2004). Alexander was also presented with information comparing antipsychotics in terms of other commonly experienced side effects (Appendix 4) and then given the opportunity to ask questions. Finally, Alexander and I agreed on Aripiprazole and a prescription was issued (evidence 11). In addition to the importance of the positive side effect profile, Aripiprazole also rated as less expensive than comparable treatment with Quetiapine (Taylor et al, 2007) and this is a factor which prescribers are directed to pay attention to (NPC 1999, NICE 2002). In terms of preparations, Aripiprazole is manufactured in tablet form, orodispersible tablets and as an oral solution. As Alexander was happy to take tablets, this was the preparation prescribed. Aripiprazole is described as having a uniquely robust pharmacology (Davies, Sheffler and Roth 2004), centred on it being a partial agonist at Dopamine D2 receptors. Evidence 12 provides a profile for Aripiprazole, which explains this in further detail. It is distinctive from the other atypical agents as it stabilises the spread of dopamine in two of the four major pathways (mesolimbic and mescortical) where the neurotransmitter Dopamine is found, as opposed to purely blocking dopamine receptors or working as an antagonist at D2 receptors. Despite this difference, a recent systematic review of Aripiprazole actually found that it did not have significant advantages over other atypical medicines, neither did it demonstrate increased efficacy over typical drugs (El-Sayeh and Morganti, 2004). Coupled with this, Aripiprazole was shown to instigate similar adverse effects as treatment with typical agents, with the exception of akathisia, which lead to improved compliance (El-Sayeh and Morganti, 2004). Aripiprazole has not been shown to cause elevation of prolactin levels, nor is it associated with the development of impaired glucose tolerance or weight gain, therefore in theory, monitoring of these factors is not required (Travis, Burns, Dursun, Fahy, Frangou, Gray, Haddad, Hunter, Taylor and Young, 2005). In fact, Travis et al (2005) purport that no specific monitoring is required outside of the basic screening advocated in NICE (2002b) i.e. monitoring for endocrine disorders and cardiovascular risk factors etc. Despite this, the NHS Trust for which the author works recommends extensive monitoring (Appendix 5). The author would therefore be compelled to work within the guidance of the employing authority. In negotiating a contract (stage four), because Alexander and I shared the decision to try Aripiprazole, it was hoped that concordance would be achieved. Evidence 14 highlights the implications of excluding service users from the decision making process. Delivering the choice agenda in mental health is considered key to an effective prescribing value base for nurses (Jones and Jones, 2007), however it must be identified that issues of capacity for individuals with mental health problems can jeopardise this. For individuals lacking capacity during an acute Schizophrenic episode, guidance recommends the use of oral atypical medications, prescribed after consultation with the individuals carer or advocate (NICE, 2002a). Government policy has stated that service users should be encouraged to compile an Advanced Directive (AD) as part of their care plan, highlighting their treatment choices (NICE 2002b), although in practice, the author has limited experience of this happening (evidence 13) and does not feel it is something that the Trust encourages. Concerns have been expressed that service users might draw up unrealistic and illogical plans, refusing all forms of treatment, however a recent study found evidence to the contrary of this (Papageorgiou, Mohamed, King, Davidson and Dawson, 2004). It is the opinion of the author that where possible ADs should be formulated, allowing the patient to be autonomous, however the author also acknowledges that there may come a point where decision-making is replaced by that of the prescriber. At present ADs can be over-ridden if the patient is subject to compulsory treatment under the Mental Health Act (1983). In Alexanders case, an AD was offered but refused. Alexander was considered capable of providing informed consent and therefore, following the principles of good practice (United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1996), the author communicated to Alexander, various details about the prescription. These included information on what the prescription was for, how long the drug would take to work, how long to take it for, what dose to take and the possible side effects. The UKPPG data regarding Aripiprazole was given to Alexander (Appendix 6). The fifth principle of the prescribing pyramid, review of the patient was dictated by the CMP. Weekly review was carried out in order to ensure that the treatment was effective, safe and acceptable. Had it not been, the broad CMP permitted use of alternative agents. The IP and SP reassessed Alexander as planned three months later. In this time however the IP and SP met frequently to discuss the progress of Alexander and record keeping was kept up-to-date using the eCPA system. At present, GPs are advised of supplementary prescribing arrangements and changes in these via Trust devised letters (see Appendices 7 and 8). In this instance the letters were compiled and sent within 24-48 hours in line with local policy. The author reflected on her prescribing decision as recommended by the final stage of the pyramid and is confident that neither patient pressure nor the action of pharmaceutical companies affected decision-making. In practice, the author has experience of nursing individuals on a range of antipsychotics and is aware that this may affect choice of drug in the future Conclusion The author has described and analysed an independent and supplementary prescribing experience and has attempted to meet the module learning outcomes in doing so. The author is confident that her rationale for prescribing decisions is based on sound comprehensive guidelines and practice experience. The author plans to base future decisions on the prescribing pyramid model, making a conscious effort to see outside of the prescriptive toolkit so as to remember the importance of other nursing interventions. It is the intention of the author to utilise the support and clinical supervision available in the practice area, including discussion about differential diagnosis and treatment options with the medical team following assessments. This will ensure safe practice, professional development and recognition of the contribution of non-medical prescribers within the team. Evidence 16 details the authors plans for continuing professional development in prescribing practice, both as an independent and a supplementary prescriber. These goals are important to ensure competency in prescribing practice is maintained. By ensuring that practice is updated, monitored and evaluated, service user experience is hopefully improved leading to increased concordance and better health outcomes

My Philosophy of Teaching :: Education Traveling Personal Narratives Essays

Philosophy of Education As people we all have experiences that are unique to only ourselves and it can be argued that it is through these experiences that we mold individual personalities. Not all of these experiences can be positive or enjoyable ones. Sometimes the hardest of all experiences are the ones in which we take memories and tools that make ourselves stronger people. Thankfully the experience that I am going to depict that had specific value to me was both enjoyable and positive in how it shaped my future. It was a year long trip that I took with my parents that spanned all the way across my eighth grade year of school, and reached nearly every continent of the world. This experience not only brought me to new places but also brought me to new realizations about the world that surrounded me. Though despite all of its glories this experience taught me a hard lesson as well which is what it means to be truly grateful. If one is not grateful towards his or her own belongings then it is im possible to really appreciate and enjoy the possessions and connections that can make life wonderful live. After a long drawn out seventh grade year where hormones and puberty hit me like a ton of bricks I felt like I needed some time off to clear my head. Fortunately my parents had the same idea but instead of just taking a little time off they, as well as myself, were willing to do something extraordinary that none of us would forget any time soon. It was set. My eighth grade year would be spent not in public school, but rather through home schooling. The greatest part is that my schooling would not take place at home and would continue as we were traveling. The continents we traveled to included Africa, Australia, Europe, and parts of South America and Asia. The countries we visited within those continents are numerous except each one was fun and interesting in its own way. All of the continents we visited are very different from each other and we had a blast at each one doing various things based on what that continent had to offer socially and geographically.

The Thought Process of Shakespeares Hamlet Essay -- William Shakespea

The Thought Process of Shakespeare's Hamlet "If Hamlet from himself be ta'en away, And when he's not himself does wrong Laertes, Then Hamlet does it not, Hamlet denies it. Who does it then? His madness. If't be so, Hamlet is of the faction that is wrong'd; His madness is poor Hamlet's enemy." (V.ii.230-235) Hamlet's self-description in his apology to Laertes, delivered in the appropriately distanced and divided third-person, explicitly fingers the greatest antagonist of the play†¹consciousness. The obligatory cultural baggage that comes along with Hamlet heeds little attention to the incestuous Claudius while focusing entirely on the gloomy Dane's legendary melancholia and his resulting revenge delays. As Laurence Olivier introduced his 1948 film version, "This is the tragedy of a man who couldn't make up his mind." By tracking the leitmotif of "thought" throughout the play, I will examine the conflicts that preclude Hamlet from unified decisions that lead to action. Shakespeare is not content, however, with the simple notion of thought as a mere signifier of the battle between the mind and the body. The real clash is a conflict of consciousness, of Hamlet's oscillations between infinite abstraction and shackled solipsism, between recognition of the heroic ideal and of his lim ited means, between the methodical mishmash of sanity and the total chaos of insanity. I repeat "between" not only for anaphoric effect, but to suggest Shakespeare's conception of thought; that is, a set of perspectivally-splintered realities which can be resolutely conflated, for better or worse, only by the mediating hand of action. Any discussion of Hamlet, a work steeped in contradictions and doubles, necessitates inquiry into passages ... ...ble that someday the legendary cultural baggage that accompanies Hamlet will be lost, and future generations may wish to judge the play on its dramatic merits and not on its required-reading position. If that is the case, they may very well "make" the play "bad" through their different perspective, one which we cannot yet appreciate, and Hamlet, already four centuries old, may disappear from our cultural consciousness. As the prince himself might say, perish the thought. Works Cited: Fredric Jameson, Postmodernism, or, The Cultural Logic of Late Capitalism (Durham: Duke University Press, 1991). Franco Moretti, Modern Epic (New York: Verso, 1996). Marjorie Nicolson, "The Breaking of the Circle" (Illinois: Northwestern University Press, 1950). William Shakespeare, The Arden Shakespeare: Hamlet, ed. Harold Jenkins (England: Methuen & Co. Ltd, 1982).

Essay --

Designing Fear: A Brief History of Hate Crimes at Elmhurst College Elmhurst College is a small, private, four-year college. Though affiliated with the United Church of Christ, the college seeks to educate its students for life in the global society. As such, Elmhurst College welcomes students of many faiths. At the heart of the college’s spiritual life is the college chaplain’s office, which offers worship programs, community service opportunities, and spiritual guidance for students from all faith traditions. To ensure that the college can represent, embrace, and engage all of the religious communities on campus, the chaplain’s office employs nineteen co-chaplains and interfaith advisors. Leading the charge as the campus’s primary chaplain is the Rev. H. Scott Matheney. In the fall of 2008, Rev. H. Scott Matheney had been the chaplain of Elmhurst College in Elmhurst, Illinois for 11 years. A graduate of Whitworth College and Princeton Theological Seminary, Matheney arrived at the Elmhurst College with having already served for many years as the Presbyterian and United Church of Christ Chaplain at Columbia University and New York City. In his first decade at the school, Matheney had played a key role in the establishment of the NAACP Chapter on campus, spearheaded the annual Holocaust Education Project and Habitat for Humanity projects, instituted the Religious Lecture Series to explore different faith traditions, and provided significant outreach to all religious groups on campus—particularly the Muslim community. Matheney was proud of the progress made on key religious issues on campus, and felt that the campus was successfully fostering an environment that allowed individual members of the community to learn from each other... ..., curtains, and other items that make the space friendly and welcoming to all. â€Å"If there’s any good that has come from things like this—Safia, the things they see at the Interfaith Youth Core, even September 11, I think it’s two-fold,† Matheney says. â€Å"First, there’s been a dramatic movement of interfaith agendas and issues. And second, there’s a recognition that the Muslim community has to step into the public square and not be a quiet minority on our Christian campus—or in our Christian nation—anymore. They’ve had to become able to become a force that defends, defines, and differs themselves as they engage society. There has been a noticeable uptake in their engagement here since Safia left, even if things did slow down for a while. They, and we, are coming to terms with what it means to become a part of U.S. society. And we’re learning from each other every day.†

Organising people to achieve objectives Essay

Organising people to achieve objectives Within our company of facilities management, most of the day to day running is based around organising and delegating tasks to our supply chain. This takes a lot of different considerations as to who we send the tasks to. All of our suppliers are vetted thoroughly through our system before any works can be issued to them. Not only do they have to have the necessary legal information available i.e. insurances etc. but we also have to vet their engineers. We have to ensure they are all CRB check. (Criminal Records Bureau) However, there is also other elements of information we require from them to assist us within day to day running. Suppliers have to identify within their initial registration what disciplines they are able to cover showing that they have engineers with the associated skill sets, qualifications etc. They also have to identify which regions within the country they have coverage for. Once the suppliers have completed their registration form (Please see example attached in appendix) it is sent to a director for approval. Once approved, the supplier will be set up on our system. We as a company then have to ensure that all of the helpdesk staff know exactly what suppliers are on our books, what disciplines they cover and what areas in the country they cover. A client will send a task through  to the helpdesk. This can be via phone, email or portal. A helpdesk member of staff is then expected to ascertain what discipline the task should be logged under and also decide what priority the job should go on. Once this is complete, they then have to send the task to a supplier. This is where the information from the supplier’s registration shows its importance. The helpdesk member would have identified, when logging the task, what the discipline is and what region the site is in. They can then filter through the suppliers to see which is most capable of completing the work satisfactory. Therefore it is extremely important that we make effective and efficient use of the registrations, to ensure we get the task complete effectively through organising and delegating to the suppliers. One technique used to schedule and allocate work to suppliers is our PPM planner. (Planned preventative maintenance programme) This planner is set up for every client to ensure that any assets within the buildings that we look after are registered and maintained on a schedule. This includes compliance items. (Please see example attached in the appendix) When planning these works, we have to identify which supplier is appropriate to be assigned to carry out the works. For example: if we are planning in an annual fire extinguisher test, we need to ensure we use a su pplier who has demonstrated that they have engineers qualified to complete this test providing a compliance certificate where appropriate. This will apply across all disciplines within the planner. Human resources play a very important role within the company. They assure output and quality. They ensure that our any staffs put forward to be a potential candidate appears capable for the position following their curriculum Vitae. They will then identify training and development needs with the staff in the company. Later they will help to conduct appraisals and reviews. Human resources are able to work with KPI implementation within the staff. However, our HR will offer incentives too. Hr will ensure that we have key staff members capable of doing the positions above them. The reason this is important is if a staff member left who was highly dependable upon, we need someone who is capable of slipping in there to cover and so not to leave us exposed. At the same time, this shows that member of staff good promotion aspirations. Human resources are also responsible for protecting the company legally. Ensure that we are all up to date with compliance and legislation. However, it is important to remember  that HR are there to support the employe es as well as the company. Delegating to achieve objectives After supplying the training, recently I delegated the responsibility of a particular task to one of the helpdesk members. I emailed through the lift insurance reports for a client’s estate of 127 buildings. I asked the staff member to take the responsibility of thoroughly reading through the entire reports identifying any defects that have been highlighted. I then instructed the staff member to upload these documents to the assigned buildings. I then instructed them to extract the defects from the report and log them on the system assigning them to the lift supplier. At this time, I also attempted to empower this member of staff by explaining that this will be their responsibility from now on. I went on to explain that by reading these reports, she would learn to understand a bit about lifts and therefore would be able to assist account managers on lift project works. There are sometimes barriers to delegating within my organisation. One of the most common barriers I personally face is a self-imposed obstacle of â€Å"it is quicker and easier to do things myself† this obviously can also be deemed as â€Å"I do not completely trust my employees to get the job done to the expectation†. However, we do have many mechanisms to support delegation within our workplace. Our suppliers are required to sign a contract and SLA (Service level agreement) during the stage of registration. This supports our delegation, expectation to suppliers. To monitor the outcome of this, we conduct contractor/supplier reviews quarterly. We will discuss their SLA’s and KPI’s (Key performance indicator) at this meeting and if necessary, provide support to achieve their best. We also use a similar method for our staff members in the office. They are obviously presented with a contract which includes their job role expectations before the commencement of work. We conduct 6 monthly appraisals with staff to monitor their work. Feedback, recognition and reward techniques are all extremely effective within our workplace. When receiving feedback, normally it is generally very helpful and supported. We will always use good feedback and attempt to elaborate on it and action. Negative feedback can always be very useful also as it gives us areas to improve. We always try to give recognition to our employees where necessary as we have a good history of proving that this is a very  good motivational technique. Obviously by motivating the staff, we are more likely to get their best performance. This motivation also is apparent when using reward techniques. Reward techniques can be a variety of things for example: promotion, new responsibilities, financial rewards etc. All of these prove very effective within the workplace.

Crimes Essay

Crime prevention is a major responsibility of law enforcement organizations. It is necessary to promote and maintain peace and order to the community by executing measures that lessens or diminishes crime rates as impacted by lawbreakers in society. Several solutions bring about the decrease in crime rates in the community. These solutions do not only depend on the roles and responsibilities expected to be carried out by law enforcement agencies, but also require cooperation from the people in communities and the government. Crime prevention should be a group effort because the will to prevent crime is everyone’s concern. With this in mind, one possible solution for crime prevention is motivating the community to be vigilant and cooperative in responding to criminal offenses. Law enforcement agencies cannot prevent crime without the help of other members of the community. In this case, the roles of victims, witnesses, and whistleblowers are magnified. When victims, witnesses, and whistleblowers experience criminal offenses of any gravity or kind, they should report it to the police. This catches the attention of law enforcement agencies allowing them to respond to the situation in a timely and apposite manner. Aside from experiencing criminal offenses, people should be able to inform the police of concerns regarding potential offenses observed in the community. Staying one step ahead is better, and by informing the police of concerns or observations, law enforcement agencies are able to plan ahead to prevent crimes from happening. Another way to prevent crime is by being cautious or vigilant about oneself and his surroundings. People should take safety measures in order to protect themselves, their property, and other people from the harmful nature of offenses. This includes following tips on safety precautions as advised by the state, law enforcement agencies, and concerned citizens or private organizations (HCSO, 2008). Engaging in a joint effort by the neighborhood, such as the establishment of neighborhood watch groups, is also one possible way to reduce or eliminate crime. Crime prevention does not only necessitate cooperating with the police, but also with other members of the community. Neighborhood watch groups are composed of people from a neighborhood who are concerned with the community’s safety and are willing to provide assistance to law enforcement agencies for crime prevention. Through collaboration and teamwork, people in the neighborhood are able to counter crime by evaluating their neighborhood and determining what steps to take in order to increase peace and order in their area. (Solutions for America, 2003) Technology and innovation also play a major part in reducing or eliminating crimes committed by offenders in the community. Law enforcement agencies use information technology in order to prevent crime and capture offenders. Crime rates, data sheets, and other background information about crimes, criminals, usual victims, and environments where crimes take place, etc. re stored electronically in a database managed and maintained by law enforcement agencies. Through this system or database, law enforcement agencies are able to share or view this information whenever needed for reference when it comes to predicting criminals patterns of potential risks that may cause the rise in crime rate in a particular situation. (SCRA, 2008) Continuous research and innovative techniques are being employed by private organizations in order to improve technologies that are being used by law enforcement agencies. For instance, the National Law Enforcement and Corrections Technology Center or NLECTC is active in research and experimentation in order to improve the quality, features, and functions of law enforcement technologies, making them more suited for crime prevention and criminal capture. Since technology demands high fees, it is the role of the state or federal government to allocate funds for this cause because technological advancement improves the performance of law enforcement agencies. Using technology automates law enforcement work, making it more efficient and timely in crime prevention. SCRA, 2008) Some of the gadgets that law enforcement use that assists in reducing or eliminating crimes committed by offenders include lightweight body armors, drug-recognition tools (through pupil scanning), cars (such as the Lotus Exige S which increases road safety for police officers especially when in pursuit), gunshot location technologies (computer that supervises specific areas to detect gun shots), video intelligence softwares for computers (may be used in houses, business companies, etc. or surveillance purposes), LED Incapacitator (it is a flashlight which emits LED light that restrains individuals when they look directly at it), and armed robots (apparently, some robots are utilized by law enforcement agencies by arming it with taser guns. (Gizmag, 2008) Focusing on rehabilitating crime offenders is also a plausible way in preventing criminal offenses. Restorative Jus tice is one way of rehabilitating criminals in order to reintegrate them back into society. It includes motivating jailed offenders to contribute to the community as a form of penalty. Restorative Justice also focuses on restoring damages to the victim and the community as a result of criminal actions taken by offenders. As a way to pay for crime offenses committed by offenders, they should be able to take necessary actions to patch up the relationship between the victim and the community to the offender. Through the penalties imposed to criminals, they are able to learn how to become responsible and cooperative citizens who area belt to make the right decisions. Moreover, restorative justice eliminates recidivism because it provides offenders the chance to correct their mistakes and become a valuable and accountable part of society.

The Beatles and the Rolling Stones in the 1960’s

â€Å"If you want to know about the sixties, then listen to the music of the Beatles†. This quote sums up the impact of the Beatles, who have become unaccountably linked with the sixties decade and all that it involved. The appeal of groups like the Beatles and the Rolling Stones has transcended the generations and created an interest among young people today. Is this purely an interest in reminiscence or are there other factors, which have continued to attract fans? At every stage in history, there are a number of forces that contribute to creating the climate for change, and the 1960's were no exception. For the Beatles and the Rolling Stones in the 1960's one of these factors was the baby-boomer generation. This was when there was a big increase in the quantity of children being born. This was due to people putting off having children during the war, but now it was over they were able to do so. This meant that there were more teenagers during the 1960's than usual. So any trends or fads that became popular with youngsters became loved by hundreds. Another factor is that teenagers were starting to have more of an impact in the society and culture at the time. This was mainly because they had more money to spend on clothes, magazines and records etc, so they had more power on what was going to be popular at the time. This resulted in the Beatles and Rolling Stones music being bought and listened too much more, compared to if no one had any money. A further big factor was the advances in new technology at the time, for example television and radio. This meant that everyone could listen to the new music that was appearing and they were able to be the first to find out who was number one – which was essential at the time. There was also the transistor radio, which allowed people to listen to music wherever they were. A cause for the two bands being successful was also about being in the right place at the right time, pure luck. If they had released their singles in the 1950's, they may not have been so successful because of the popular cultures present at the time. The Beatles and the Rolling Stones also helped to â€Å"knit together a youth sub culture†. They were the ones who encouraged them to live their lives as they wanted too, and not how they were always being told to live, by their parents – they taught them to be independent, and that it was acceptable to be independent. The Beatles and the Rolling Stones brought a new energy and a distinctive sound to their performances, which helped them to match the moods of the 1960's. The Beatles had an enormous ability to satisfy their fans, and they had a great freshness in each single that they released. The image that youngsters were seeing from the Beatles was young and vibrant – exactly what they wanted to see. They were clearly normal people, with qualities such as humour, charm, wit, inventiveness and cheek. The Beatles also had regional accents – which has not been seen before! They were regular guys trying to make it big – and they did! These characteristics can be seen clearly in some interview footage that we watched, with Paul's humour and George's cheekiness, showing that everyone loved them. The people of the sixties loved these characteristics; they felt that they could connect with the Beatles, as they were no different to them. Every song of the Beatles was written by one of the band members, as was the music, which accompanied the lyrics. This meant that they had unique sound and were original, compared to others around at the time. Each song released by the Beatles was enthusiastic and participatory for their audiences, whatever their age, meaning there was not a soul that didn't like what was being drummed into their ears. This can be seen through the song â€Å"Yellow Submarine† – the fans wanted Ringo to write a song and perform it, so he did. He knew that he wouldn't be successful performing the song, so he wrote a humorous song. This also shows the characteristics that he had. It furthermore shows that the Beatles were so popular, that they didn't mind releasing a single that could end in a complete disaster, because whatever they did release was loved! Previous music that had been released was mainly by solo artists, whereas the Beatles was a band, the first â€Å"boy band†. They, along with other bands around, like the Rolling stones, marked the move away from the individual style to the importance of the group. One thing that can be said about the Beatles is their distinctive style. When Brian Epstein became their manager he changed the way they looked, with new, fashionable haircuts and an innovative style of clothes. This meant that they were appealing to every class in the UK – nobody considered them to be too posh or too poor, they were just right, meaning no one had objections to them – not even the older generation who were very much against the changes in culture that were currently taking place. This meant that the Beatles were popular with everyone, meaning they impacted everyone's lives, with people beginning to follow the style of the Beatles, and the Rolling Stones. The Beatles and the Rolling Stones would never have made it without the phenomenal amount of help they received from their managers, from advertising and commercial success. Andrew Oldham made the Rolling Stones what they were. He was a very dominating manager, and liked to be in control of everything that they were doing at any one time. This can be seen from when he locked the band in a room till they had their own music and lyrics, this seems a cruel thing to do, however it made the Rolling Stones produce original and unique music, which everyone loved. Andrew Oldham was also responsible for the rebel image that the Rolling Stones had during the sixties, this encouraged people to follow in the footsteps of their image ideas, it also encouraged the youth of the century to become rebels and independent. Brian Epstein changed the Beatles from common looking boys to professional looking men. He cleaned up their image, changing it from jeans and T-shirts to suits. This impacted the Beatles in a big way, as it meant that older people, who were previously against the Beatles, were now agreeing with the band, condoling the band and buying their music. This growth in the age range that they were selling to caused a huge increase in their profits, purely because of a change of clothes, instigated by Brian. The Beatles also changed to ensure that they were the profile that the record company wanted, so they would be able to continue producing excellent music. Brian Epstein also encouraged a mass amount of the fans that the Beatles had in the beginning, to bring others to like them. Brian decided that to make the Beatles look massive from the beginning he would give money to people to buy their merchandise and pay girls to scream – resulting in everyone following what these people were doing, known as Beatle mania. This was a very wise move for Brian; at it meant the Beatles became enormous in no time. Brian also set rules for the band that would make more people think they were appropriate, such as don't smoke in public and always keep your girls in the background. He furthermore had a part to play in who was actually in the band, he was the one who chose the final band, with the last member being Pete Best – Ringo Starr, even though he had no personality Brian thought he fit the band well, and he was correct. In addition to doing all the background work for the band, he produced money for them in times of need; this made the band successful as it meant they were able to do what needed to be done to become big, due to their amazing manager. Brian basically decided where they went, who they saw, whom they spoke too and created advertising deals for them! Without this great input into their career, they would be nowhere. Another major person in the success of the Beatles is George Martin, their record producer, without him their music wouldn't have sounded like it does. He was the one who sat for hours and listened to the raw music which the band produced and mixed it and made it fit, resulting in it sounding amazing. George also ensured that new sounds were brought into their music regularly, he's the one responsible for keeping them fresh throughout their careers. He furthermore holds a vast amount of the responsibility for the band being so successful, as he's the one that actually decided which songs would be released, and which songs would be binned. Without the expertise of George Martin the music of the Beatles wouldn't sound like it does today! Without the amazing input of George Martin the Beatles wouldn't have had that fresh, unique sound to their music, it wouldn't be the greats material it is considered today! The increasing amount of Television ownership and advertisement played a huge part in the fast success and impact of the Beatles. The Television brought the Beatles to a wider audience, on shows such as Juke Box Jury and Top of the Pops. Without these programmes, the Beatles wouldn't have been known by so many people so rapidly. The Television also meant that the Beatles were impacting more into people's lives, with live performances of their songs, with their styles and with the attitudes that they are showing their viewers. The mass amount of advertisement that the Beatles received meant that people assumed they were excellent, because they were everywhere, resulting in people buying their music, whether they liked it or not. Without the huge input of advertising on Television and Radio the music of the Beatles wouldn't have been known throughout the country so much, and wouldn't have been loved by everyone. The impact of the Rolling Stones and the Beatles was greatly due to their ability to adapt to the changing moods and culture in the sixties. One thing that the Beatles were excellent at was changing with time. They were continually innovative in their music and their appearance, for example; their change in clothing style with the hippies and the change in music style with the increase in drug use – Lucy in the Sky of Diamonds. This resulted in them being loved by everyone, and influencing them on what they were wearing and what they were physically doing. The music of the Beatles and the Rolling Stones was constantly eclectic, experimental and extremist, they were not afraid of the results of their music! For example: the Beatles during the era of drugs released two songs basically telling people to take them: Lucy in the Sky of Diamonds and Strawberry Fields. This showed that they were not afraid to release what they wanted too, and they were experimenting with a different style. They later released Black Birds, supporting the civil rights movement – showing they care about important matters in the world -, which is a great difference to the drug songs they had previously released. Also, to try and bring peace to the world once again they released ‘Back in the USSR', which was a pro communist song. This shows that they are not afraid of being different from the other bands around; they are willing to take a risk and broadcast what they are feeling. The people of the sixties loved this about the Beatles, and the Rolling Stones, hence their huge impact on their lives, as no matter what the song words were the song was loved. The Beatles and the Rolling Stones were also constantly breaking down barriers in their society, which was a constant feature of the trends of the 1960's. Barriers such as parents and older people being against anything new, different or independent for the youth of the sixties, but the Beatles and the Rolling Stones were so good that they even managed to get these generations on their side. Other artists that were around at the time were still providing easy to listen to music, but the Beatles and the Rolling Stones took the risk and released what they wanted, rock music! Older generations were initially against this, but because of the factors previously mentioned they managed to get this generation on their side, meaning they were impacting everyone's lives, and were valued by everyone. Both the Rolling Stones and the Beatles were at the front of new modes of self-presentation, which was a feature of the trends of the 1960's. The Rolling Stones and the Beatles had their own, unique fashion throughout their careers, both having great influences on fashions at the time. The Beatles were suited, clean-cut boys with mop-top haircuts and The Rolling Stones showed the opposite image; messy, and posing for publicity photographs. This made them very popular to many girls for their bad boy image; this soon made them a teen idol group. The behaviour that they were showing on and off stage began to shock many people in society. One example of this is that they were taking drugs. In February 1967 a raid occurred during one of the regular parties, and police discovered a moderate amount of cannabis. The raid also served as the start of made-up stories, mainly about the appearance and behaviour of Mick Jagger's girlfriend Marianne Faithful, which only served to increase their reputation for their bad behaviour. It was also rumoured that the raid was delayed on police instructions to allow Beatles guitarist George Harrison to leave, who was among the guests. Richards was charged and a few months later stood trial for allowing drug use in his home. Jagger was charged with possessing amphetamine tablets. Richards was sentenced to a year's imprisonment and Jagger to four months, prompting this created even more publicity for them. So their actins were starting to create many shocked reactions among the public. This created a great impact, especially on the youth of the sixties. The two biggest bands at the time encouraged them to rebel against parents, relatives, etc and to take drugs. Many saw this as the bad part of their careers, however it all depends on your personal opinion. The Beatles also had a magnificent achievement during their careers, and this was that they were the first British band to break into the American market, successfully transporting â€Å"Beatle mania† to the USA. During 1964 the Beatles swept through the great US cities, drawing tens of thousands to airports just to get a mere glimpse of them. They played for no more than half an hour at each concert, however this hard work guaranteed them star status. A British band conquering America was also a sign of international cultural exchange, and it marked the first of many exchanges between the two countries. The Beatles also made a stand for what the believed in, as they refused to play in segregated audiences, this influenced the people as they saw that it was ok to stand up for what you believed in, and it encouraged different races to mix and become one. The Rolling Stones also made a stand, as they decided to provide music for both their black and their white audiences. In conclusion, both the Beatles and the Rolling Stones had an enormous impact of the people in the 1960's. They encouraged people to relax and live life as they wanted to. Many things influenced their continuing success, including their normality, their style, their music and their behaviour throughout their careers. The Beatles success can be seen clearly through Beatle Mania, wherever they went Beatle Mania followed. They couldn't help this; it was a form of real love for them. George said many years later: â€Å"The world used us as an excuse to go mad, and then blamed it on us†, but there is a parallel theory that it was time for the world to go that sort of mad – get down a bit, loosen up and have some fun. This amazing change in the people of the world was hugely down to the distinctiveness, uniqueness and influential music that the Beatles and the Rolling Stones wrote and released.