PTLLS Assignment 1: Roles and Responsibilities in the Teaching Cycle

1. Describe what your role, responsibilities and boundaries would be as a teacher in terms of the teaching/training cycle. My role as a teacher In her book Preparing to teach in the Lifelong Learning sector 2011 (P9), Ann Gravells explains that â€Å"Your main role as a teacher should be to teach your subject in a way that actively involves and engages your students during every session. † Beyond this, my role as a teacher of business management extends to firstly being an exemplar of good management practice, behaviour and conduct. I would need to be a positive role model to my students in interpersonal relationships, organisation, time management, leadership and other aspects of the role of a manager. My role as a teacher also extends to creating a positive, safe and encouraging inclusive learning environment that provides opportunity for learner collaboration and co-operation. My role is not just didactic but facilitative in enabling learning. My role would be ongoing in identifying barriers to learning whether academic, personal or otherwise. I would then apply appropriate interventions to support the learner in overcoming such barriers, with due regard for the professional boundaries of the role. Ultimately, my role is to successfully motivate and support my learners to attain their management qualification. Responsibilities throughout the stages of the teaching / training cycle The teaching / training cyle is in five stages: 1. Identify needs 2. Plan and design 3. Facilitate / deliver 4. Assess 5. Evaluate At each of the five stages of the teaching / training cycle there are many responsibilities countered by relevant boundaries. Responsibilities and boundaries in identifying learning needs At Stage 1, identifying learning needs, the process starts with the candidate’s eligibility for the training. This may be in terms of their academic ability in being able to achieve the Management qualification or in their background and experience in being able to apply the learning. My responsibility would be to explain the entry equirements and assesment criteria to any prospective students. Eligibility in terms of funding and other issues unconnected with the course itself might be addressed by the Course Administrator and would therefore be a demarcation boundary. Course dates and issues around availability would be part of my responsibilities, as I would need to ensure that I maximise attendance and provide timings and dates that were feasible and appropriate. Other responsibilities wou ld be in assessing the needs of the students prior to the learning. I would include, in any pre-course literature, questions around special requirements / reasonable adjustments so that I could make the environment inclusive, safe and learner-friendly. I would also include a learning styles questionnaire, either VAK (Visual, Auditory, Kinaesthetic) or Honey and Mumford which is based on Kolb’s experiential learning cycle. I might also include questions around levels of understanding / experience in the management arena. This information would then inform the development of course materials that catered for the range of learning styles and differentiation in learners’ abilities. I would also be responsible for arranging suitable accommodation for the training including a classroom layout conducive to learning and the resources necessary to support the course materials. In management training it may be appropriate to have PowerPoint presentations, case studies and management DVDs. In terms of working within boundaries at this stage I would need to ensure that timings, dates and literature were in accordance with diversity and equality policies and did not exclude potential candidates. I would also need to ensure the safe-keeping and confidentiality of anything dislosed in the completed pre-course questionnaires. Responsibilities and boundaries in planning and designing At Stage 2, Planning and designing, my responsibilities would include reviewing the ‘needs’ questionnaires to prepare and design the course. If the course was new, I would need to research the internet, consult management books and theory and source materials from colleagues. I might also purchase appropriate support materials such as management styles questionnaires, DVDs etc. If the course was an existing one, I would review the course content to ensure that it was inclusive, contextualised to the learners’ experience, compatible with the learning styles of the learners and at an appropriate academic level to both meet assessment criteria and meet the varying learning needs of the learners. If necessary, I would need to tailor the course providing additional support for the differing academic levels of the learners I might consult internal verifiers or other colleagues to ensure that my course content was appropriate and engaging for the learners. I have often piloted courses to test their effectiveness. My responsibilities at this stage also include preparing aims, objectives, lesson plans, schemes of work and assessments. I would also need to design flipcharts, posters and handouts. The boundaries at this stage include budgetary and time constraints which may affect the quality of the course materials. I must also again make any reasonable adjustments with materials e. g. font size on handouts / PowerPoint presentations adjusted to meet the needs of learners with a visual impairment. I once had to recruit a signer for a deaf learner. I must also ensure that my materials do not breach copyright and licencing requirements. Responsibilities and boundaries in facilitating and delivering learning At Stage 3, facilitating and delivering the learning my responsibilities are extensive. Using my personal presence, presonal example, charisma and tools such as ground rules, I need to create the right first impression to ensure that my learners are aware of their responsibilities within the learning environment. I try to create an environment of support, collaboration and mutual respect. I am responsible for ensuring inclusivity of the learners and celebrating their diversity. I have a duty of care in respect of my learners and should get advice and guidance from my fellow professionals in areas I am unsure of. The environment should be in accordance with Health and Safety requirements allowing free movement and access, no trip hazards, safe, tested electrical equipment. I need to create a psychologically safe environment without intimidation or disrespect. I would do this by challenging inappropriate behaviour and encouraging positive behaviour. I could also refer learners back to the ground rules. Depending on the learning needs / progress of individuals I might need to adapt and target some parts of the course content. I need to minimise jargon and adapt my language and style to the needs of the participants. I need to create opportunities for networking, self-development and experimentation. I must also be aware of any perceived or real barriers to learning and make appropriate interventions. To do this I would confer with teaching assistants or ‘privately’ discuss any issues directly with learners. My presentation style should be engaging, motivational inspirational and thought-provoking. I should keep the necessary records to evidence learner attendance and attainment. My exercises should cater for the varying learning styles of the group. I can employ the assistance of other professionals such as teaching assistants to provide learners with any learning / motivational support or personal care. This is another area of demarcation for the teacher. If there are personal issues creating barriers to learning, then I should know the boundaries of my responsibilities and when to refer to other professional bodies. Other boundaries would include maintaining a professional distance and not becoming too familiar with learners. The use of personal email addresses, personal mobiles numbers and social networking sites would overstep the boundaries of professional conduct. I should also be careful not to favour individual learners or discriminate or exclude learners adhering at all times to diversity and equality requirements / policies. I should maintain confidentiality, agreed as part of the ground rules. Records should be kept safe and confidential. Responsibilities and boundaries in assessing At Stage 4, Assessing, my responsibilities are to set appropriate assessments that comply with the criteria set by the examining board. I also need to comply with any requirements / adjustments advised by the external and internal verifiers. I have a responsibility to ensure that assessments are accessible, with any reasonable adjustments made. I need to ensure that any examinations are conducted appropriately in accordance with guidelines set by the examining board. I need to ensure objectivity, equality and fairness in my grading and marking of assignments. I also need to complete my marking in a timely manner to ensure that learners receive feedback as soon as possible. Feedback on assigments would be written or vebral if additional support was required. Feedback should be constructive, balanced, supportive and helpful. I need to follow the correct procedures for referring or failing students that do not meet the assessment criteria. I should ensure that assessment records are captured correctly and stored safely, ensuring confidentiality. The responsibility areas outlined above illustrate the boundaries that must be adhered to data protection, confidentiality, bjectivity, equality and fairness. Responsibilities and boundaries in evaluating Stage 5 is evaluation. As a teacher I need to review the course once it has concluded. Evaluation methodology employed might include post-course questionnaires, budgetary analysis, return on investment exercise, outputs from exercises and assessments, teacher observation, reflective diaries, peer ob servation, feedback from external and internal verifiers and ultimately the assessment results. I should analyse what went well and what needs to be improved. Boundaries at this stage would be my ability to be objective and barriers to receiving / accepting feedback. 2. Identify the key aspects of current legislative requirements and codes of practice relevant to your subject and the type of organisation within which you would like to work. In my former role as a trainer in the Civil Service, I was subject to the Official Secrets Act, the Civil Service code of conduct and to various HR policies. These governed my personal behaviour towards others, my integrity and my professionalism. Failure to comply might lead to grievances, disciplinary procedures and employment tribunals. In her book Preparing to teach in the Lifelong Learning sector 2011 (P9), Ann Gravells lists codes of practice and legislation relevant to the training arena. I have considered their relevance to my role and subject area. Code of Professional Practice 2008 by the Institute for Learning is a useful guide as to how teachers should behave and the professional boundaries that they should work within. This code covers such areas as integrity, respect, care, practice, disclosure and responsibility. Copyright Designs and Patents Act 1988 – I would need to ensure that the support materials used did not breach this legislation. I would need to acquire permission or purchase licences for relevant work that I wished to use. Data Protection Act 2003 – this governs the type of data kept about my students, information held should be restricted to what is relevant for my purposes and role. Data should be up-to-date and accurate. This also governs the security of information. Confidentiality and safe keeping being of the utmost importance. Equality Act 2010 – this legislation was designed to protect individuals from unfair treatment and discrimination and advance equality of opportunity. It protects individuals on the grounds of gender, race, ethnicity, religion, age, disability and sexual orientation. As a teacher I should be aware of my own prejudices and ensure that I do not exclude, discriminate or treat unfairly any of the learners in any way that contravenes this act. Further to the Equality Act, there are often organisational policies relating to Diversity which means that as a teacher I should accept and celebrate the diversity of the learners, enabling and valuing the contributions of individuals. Freedom of Information Act 2000 – this legislation is around the rights of the public to information held by authorities. This information could be anything that might be in the public interest to know. The ‘public’ therefore includes the learners. As a teacher I need to ensure that any records kept are accurate and relevant and contain nothing that I would not wish the learners to see.. Health and Safety at Work Act 1974 – relates to the responsibility of everyone in the workplace to take responsibility for ensuring the workplace is healthy and safe. As a teacher I would need to be aware of my responsibilities and ensure that learners are aware of their responsibilities. Responsibilities include interventions to rectify issues e. g. removing a trip hazard. Reporting accidents and near misses is another responsibility. Aslo reporting any issues that you are unable to address yourself. I would also add the requirement for a Public Performance Licence. This would be held by the organisation you work for. If you play recorded music or music videos in public – including radio or TV – you are legally required to have a PPL licence.

Effective and Ineffective Communication

Effective and Ineffective Communication Lisa Brady Loyola University Effective and Ineffective Communication Where we come from, what we’ve experienced, our culture, our norms, our circle of friends, and our history all affect the ways in which we communicate with each other. What constitutes effective and ineffective communication? How do we assess what works as opposed to what doesn’t? Communication is vital not only to patient care but in collaborating as a team to ensure goals are achieved.In Contemporary Nursing, Cherry states that â€Å"effective communication is a foundational component of professional nursing practice. † (Cherry & Jacob, 2011, p. 381) When I think of communication in the clinical setting, two examples are always in my fore mind both of which happened in nursing school. I keep these experiences in mind because they have had a profound effect on the ways in which I communicate with my patients daily. My example of ineffective communicat ion stems from a rotation I did in the ICU. I was apprehensive about going to the ICU. Was I ready?The patients were so acute and I was so inexperienced. I was filled with doubts and insecurity. The short version of this story entails an ICU nurse who was not aware she was getting a student and a shortage of computer tablets, so medications were pulled via a written paper brought to the pyxis. A patient was upset with medications he didn’t understand and the doctor had to be contacted. The doctor yelled at the nurse, the nurse ran from the unit crying and when she returned the scene was set for a near fatal accident. The nurse took me and her piece of paper to the pyxis and began to pull her medications.Again for time and space, the shortened version explains that the nurse mistakenly pulled a night medication due at hour of sleep instead of the day medication. The nurse then instructed the nursing student to pass these medications. By the time the nurse realized she had pull ed the wrong dosage and the nursing student had given them, the patient had to be intubated; stomach pumped and could easily have died. During this emergency treatment the nurse yelled at the nursing student, â€Å"and this is why you always check the computer prior to giving medication. I cannot express to you the fear, anger and confusion I had over what had transpired. I felt â€Å"thrown under the bus†. What had just happened? What happened was a serious disconnect in communication and a hard lesson in patient safety. The patient lived and recovered. I learned to never completely give up my power and to trust my instinct. I have never since and never will give a medication unless I have pulled it and have all the resources in front of me to verify the information.The nurse later wrote on my evaluation that we both needed to learn our five rights. I was angry but in retrospect she was right. I may not have pulled those medications but she told me to give them and I obeyed . I was utilizing non-assertive communication. I have always thought communication was my strong suit. I strive to use the â€Å"I† statements that Cherry suggests. (Cherry & Jacob, 2011) I believe strongly in Jan Hargrave’s concept that â€Å"55% of what we say is non-verbal,†¦38% is in voice reflection and only 7% is in the actual words we say. (Cherry & Jacob, 2011, p. 385) The difficulties that arise in communication; it is dependent on a host of factors, including non-verbal communication and interpretation of the information. (Cherry & Jacob, 2011) I have since learned assertive communication techniques and am currently working on responding instead of reacting. It is a lifelong process. My second example is one of effective communication. A young mom with two babies arrived to the ER. She had no insurance, and her baby presented with fever and signs of pneumonia.The ER doctor and the nurses expressed she was from the city hours away and was mos t likely attempting to obtain free care. The doctor discharged the patient and the nurses discussed amongst themselves the patient and the problems with patients abusing the system. Once again my gut instinct told me there was more to this patient and her story. I went to the patient to express concern and to listen and discovered that the patient was not at this particular hospital to avoid payment. She was in a domestic violence shelter with her two young babies and was attempting to change her life.It upset me that she was pre-judged like this, when all it would have taken was a few minutes of building a rapport and trust to get to the truth of the matter. It has truly made a difference in how I work with my patients. I try to truly listen to what they are â€Å"not† saying. To work with our patients on a holistic level we must actively listen, validate their concerns and their feelings and earn their trust. In conclusion there is so much to take into consideration regardi ng how we express ourselves and interact with each other as professionals and with our patients.We must always consider cultural differences and be keenly aware of body language. How we communicate with individuals varies greatly and is dependent upon where that person is in their life and at that moment. Physical touch is another form of communication and again must be assessed dependent on the person. Some patients don’t mind if we touch their hand or shoulder reassuringly, others are bothered by this. I always make an attempt to ask a patient for example if they are crying; can I give you hug?It is so important to maintain open communication but at the same time keep boundaries. It is a gift to be able to care for our patients but it can be difficult to find the right path of communication for each person. In the end we do the best we can, utilizing the tools we’ve been given and making every effort to be authentic, genuine and in the moment. References Cherry, B. , & Jacob, S. R. (2011). Contemporary nursing issues trends and management (5th ed. ). St. Louis, Missouri: Elsevier Mosby.

The Problems Of Solid Waste In Turkey Environmental Sciences Essay

AbstractionMunicipal solid waste ( MSW ) is a major environmental job in Turkey, as in many developing states. Problems associated with municipal solid waste are hard to turn to, but attempts towards more efficient aggregation and transit and environmentally acceptable waste disposal continue in Turkey. Although rigorous ordinances on the direction of solid waste are in topographic point, crude disposal methods such as unfastened dumping and discharge into surface H2O have been used in assorted parts of Turkey. This article presents a brief history of the legislative tendencies in Turkey for MSW direction and the MSW duty and direction construction together with the present state of affairs of coevals, composing, recycling, and intervention. The consequences of several researches show that about 25 million ton of MSW are generated yearly in Turkey. About 77 % of the population receives MSW services. In malice of attempts to alter unfastened dumping countries into healthful landfills and to construct modern recycling and composting installations, Turkey still has over two 1000 unfastened mopess.Reappraisal of the Turkish legislative model in MSW directionIn 1983, the Ministry of Environment in Turkey published Environmental Law 2872 as the first phase in order to better the environmental state of affairs in the state. However, there was no consensus on the best option for MSW direction in the jurisprudence. In 1991, the Solid Waste Control Regulation came into force in order to pull off solid waste. The ordinance played a cardinal function in solid waste aggregation, storage, conveyance, and disposal. The ordinance has been continuously updated. In add-on, Turkey developed ordinances for medical waste in 1993 and for risky waste in 1995. The Medical Waste Control Regulation established a basic action line for medical waste direction based on the aggregation, storage, conveyance, and disposal or reuse of the waste by its proprietor. Some types of waste, such as r adioactive wastes, were excluded from that jurisprudence. The Hazardous Waste Control Regulation set the standards for the aggregation, conveyance, and concluding disposal of risky waste, including options for land filling or incineration, every bit good as the design standard and the operational regulations for healthful landfills and incinerators. The ordinance besides focuses on the minimisation of risky waste and encouragement of recycling. By legal definition, municipal solid waste includes all the waste originating from human activities that are usually solid and that are discarded as useless or unwanted. Municipal solid waste by and large consists of waste generated from residential to commercial countries, industries, Parkss, and streets [ 1 ] . In metropoliss in Turkey, community enterprises in solid waste direction are presently being supported by the municipal governments, who guide their activities harmonizing to the statute law and policies dictated by the Ministry of Environment and Forestry ( MEF ) . The model of duty and direction of MSW in Turkey is shown in Figure 1. MSW comes from commercial services, industries, health care installations, and citizens in Turkey. Some private endeavors are responsible for the aggregation and conveyance of solid waste and for the sorting of individually collected packaging waste. After screening, the packaging waste is directed towards the recycling industry [ 2 ] . Fig. 1. Model of duty and direction of MSW in Turkey.MSW coevals and composingUntil 1994, there were merely estimations of MSW coevals in Turkey because of the predomination of unfastened dumping and the trouble of entering MSW coevals. The absence of dependable informations and statistics for waste coevals and composing makes a regional and national rating of MSW direction hard. The Turkish State Statistical Institute has compiled statistics about MSW direction since 1994 [ 3 ] . In the 1960s, 3-4 million ton of municipal solid waste per twelvemonth was generated in Turkey. However, harmonizing to the Turkish State Statistical Institute ‘s 2004 database, about 25 million ton of MSW was generated yearly ( Figure 2 ) . Fig. 2. Sum of MSW collected in Turkey. Increasing population degrees, rapid economic growing, and the rise in community life criterions will speed up the hereafter solid waste coevals rate in Turkey. The sum of MSW per capita in the summer and winter seasons from 1994 to 2004 is given in Figure 3. The coevals rate per capita varies well from the summer season to the winter season. As seen in Fig. 3, in the 1990s Turkey generated a higher sum of MSW in the summer than in the winter. MSW coevals rates in summer and in winter are 1.30 and 1.29 kg/cap/day in 2004, severally. This is a consequence of the decreasing use of fossil fuel for day-to-day warming. Fig. 3. Sum of MSW per capita ( kg/cap/day )Technologies in usage for managing and intervention of MSWCollection and transit of MSWThere are 3225 municipalities in Turkey, and 16 of them are metropolitan municipalities. A sum of 3028 municipalities have solid waste direction services. The population having solid waste services from 1994 to 2004 is shown in Fig. 4. As can be seen, the per centum of the population having solid waste services increased from 71 % in 1994 to 77 % in 2004 ( Fig. 4 ) . Fig. 4. Percentage of entire population having solid waste services of Turkey. However, the per centum of municipalities roll uping and transporting solid waste in the municipalities is 95 % . In most of the colony units of Turkey, the aggregation and transit constituents of MSW direction are by and large good organized. The municipalities spend all of their attempts and budgets for these services. There are two types of aggregation systems in the municipal countries of Turkey [ 4 ] .Collection Systems of MSW1. Curb Side PickupThis system is operated in the cardinal parts of the metropoliss and big towns. In this aggregation system, a solid waste aggregation vehicle Michigans at each edifice to pick up the garbage, either in plastic bags or in kitchen bins. Where this system is operated, the waste is collected daily or twice a twenty-four hours. Some occupants use specially produced plastic bags, but most use packaging plastic bags of assorted thickness and sizes. The kitchen bins used by the occupants of most parts are non standard, either in size or in fabric ating stuff.2. Community Bin SystemThis system is normally practiced in little colonies and the ill developed peripheral parts of urban countries. Depending on the population of an country, community bins with assorted non-standard sizes and theoretical accounts are placed on the streets, and waste from these bins is collected by assorted types of vehicles, runing from tractors to compactors. The bins are by and large emptied or replaced in some municipalities two or three times a hebdomad. Due to the addition of population and rapid urbanisation, the roads in the peripheral parts in some urban Centres are really hapless, so the aggregation vehicles can non make the community bins in these countries during rainy periods and therefore the community bins can non be emptied on a regular basis. The MSW from these countries by and large contains high concentrations of putrescent affair, which makes them peculiarly prone to do aesthetic and environmental perturbations to neighboring popul ations, particularly when the community bins or poulet bins are non emptied within 48 H of adding the garbage to the bins. Medical waste from healthcare constitutions to other risky wastes are by and large put into the community bins alternatively of being collected individually by specially designed trucks and workers. However, some municipalities individually apply aggregation and transit systems, particularly municipalities with high populations. A little sum of medical waste is disposed by firing in Turkey. The infective solid waste, together with MSW, is by and large discharged to dumping countries of municipalities. Municipalities use their ain vehicles for solid waste aggregation and transit. Both the aggregation and transit services are performed by the same vehicles. By and large, transportation theoretical accounts are non used in Turkey. The aggregation and transit vehicles are by and large trucks with capacities of 3.5-7 ton. Tractors are besides used in many countries in big metropoliss.Disposal of MSWIn many metropoliss in Turkey, lacks in the proviso of waste services are the consequence of unequal fiscal resources, direction, and proficient accomplishments of municipalities and authorities governments to cover with the rapid growing in demand for services. Methods of disposal of solid waste, harmonizing to the Turkish State Statistical Institute ‘s 2004 database, are shown diagrammatically in Figure 5. Fig. 5. MSW disposal methods in Turkey There are 16 healthful landfills, five composting workss ( three of which are being actively operated ) , and three incineration workss in Turkey. In 2004 25,013,521 ton of MSW were collected, whereas 7,002,000, 351,000, and 8000 ton were disposed of in healthful landfills, composted, and incinerated, severally. A sum of 17,661,254 ton of waste was disposed of without any control. There are typically a big figure of scavengers at garbage bins in Turkey. The stuffs collected are subjected to some degree of intermediate processing, such as separating, rinsing and drying. The rescued stuffs re so sold to decline traders, who further separate the stuffs and sell them to allow processing/ recasting Millss and mills. It is estimated that about 10-15 % of MSW is recycled by scavengers.Agreements in Management Strategies and DutiesThe conventional waste aggregation and disposal system in Turkey consists of refuse trucks and unfastened dumping. However, the tendency for disposal of MSW is tow ards implementing waste recreation and making an integrated MSW direction system. An incorporate system requires many direction options, such as beginning decrease, kerb side recycling, material recovery, waste-to-energy, healthful land filling, and composting. Physical and chemical informations can be analyzed to find the physical makeup and the chemical content of the MSW watercourse consecutive, supplying of import information for MSW direction systems. Although the physical composing analysis may straight back up the appraisal of material recovery, kerb side recycling, and composting, the energy content may greatly back up the probe of the thermic intervention potency. Bettering the criterion of direction and operation of some bing installations at much lower cost may offer considerable betterment in environmental public presentation. Additionally, puting out a plan of planned closing and redress of the most contaminated garbage dumps will represent an early measure in the devel opment of the national waste scheme [ 5 ] . Co-disposal of MSW with risky medical and industrial wastes creates a great concern for public wellness. From this point of position, the execution of solid waste direction schemes will cut down the hazard of environmental pollution. In Turkey, a negligible sum of MSW is presently being recycled. Ill organized aggregation systems for recoverable wastes, deficiency of support, and low inclination of occupants to segregate waste are factors impacting the efficiency of recovery. If there are no recycling plans in metropoliss, it is of import for waste directors to find the per centum of recyclables in the waste watercourse, every bit good as what per centum of these recyclables is marketable. If metropoliss have had recycling plans, the sum of reclaimable stuff could supply valuable information by placing the gaining control rates in recycling Centres. Municipalities are responsible for guaranting that the waste generated y their occupants and constitutions is collected and dece ntly managed. A major job is the current hapless status of the economic system in Turkey. The sum of financess available from municipal budgets for MSW betterments should be increased.Costss and Financing of MSW Collection and Recovery OperationsCost informations on solid waste direction in Turkey is normally extremely controversial and complicated due to the nature of the topic. The cost informations is farther complicated by the particulars of the Municipal Region and the cost accounting methodological analysis employed. In order to give an thought of how dearly-won the MSW intervention is, an illustration from a recent survey is given below [ 6 ] . In this case, two separate Municipal cost analyses have been conducted. The first one covered Municipal aggregation and conveyance costs whereas the other one is basically an economic public presentation analysis of two small-medium scale stuff recovery installations. The first set of information was collected from 24 selected Municipa lities from the Aegean Coast of Turkey. The set of informations includes merely the aggregation and conveyance costs of municipal solid waste ( Table 1 ) . Table 1. Cost informations for municipal solid waste aggregation and disposal Table 2. Cost appraisal for a medium sized metropolis broad recycling programme for Turkey Premises: Population: 1.0 million, MSW: 1000 tons/day, % reclaimable waste: 20 % sum recycable waste: 200 tons/day, engagement rate: 45 % , material recovery: 90 tons/day. In order to do comparative appraisal and derive some commercial penetration towards the separate aggregation programmes, cost informations has been gathered from separate aggregation programmes in Turkey. The information on cost of aggregation and sorting has been summarized in Table 2 for a medium-to-large metropolis. An mean population is estimated to be 1.0 million. Based on the elaborate waste analysis, a cost/revenue analysis for a metropolis broad recycling programme is made. The analysis given in Table 2 indicates that grosss are sufficient to cover the general operational costs of material recovery installations if operated at full capacities. Depending on the beginning composing or depending on the aggregation method employed, a comparatively acceptable commercial net income can be retained. In Table 2, costs points are categorized with different types of aggregation methodological analysis. Collections through bring-centres outputs comparatively high investing costs and low operational costs, whereas door-to-door aggregation of reclaimable stuffs by plastic bags has the lowest investing cost. However the go oning ingestion of plastic bags outputs comparatively higher operational costs.Decision and SuggestionsBased on the consequences of TURKSTAT [ 7 ] , it can be concluded that MSW direction is a major job confronting municipalities. The one-year waste coevals additions in proportion to the rise in the population and urbanisation, and issues related to disposal have become ambitious as more land is needed or the ultimate disposal of solid waste. Open mopess can be damaging to the urban environment. In malice of attempts to alter unfastened mopess into healthful landfills and to construct modern recycling and composting installations, Turkey still has over 2000 unfastened mopess. The Solid Waste Control Regulation is applied decently in the phases of aggregation and transit, but the chief job is the readying of healthful landfills and rehabilitation of unfastened mopess because of deficient funding. Currently, electricity production from waste incineration is instead low in Turkey. This is because several of incineration workss lack the capacity to bring forth electricity. Determining methods of concluding waste disposal requires an apprehension of the makeup of the MSW watercourse. A MSW decision- support system based on incorporate solid waste direction should be developed for metropoliss in Turkey. The sum of solid waste collected in Turkey in 2004 was 25,013,521 ton ; 27.99 % , 1.4 % , and 03 % of MSW is disposed of in healthful landfills, composted, and incinerated, severally. This indicates that 70.57 % of the entire sum of MSW was disposed of without any control. In Turkey, MSW is largely composed of domestic residues, and its composing varies by season. Solid waste generated by and large consists of a high organic fraction because of high ingestion of veggies and fruits. In rural countries, the ash content is higher due to the usage of ranges for heating intents in the winter. In Turkey, as in many developing states, there is a deficiency of organisation and planning in MSW direction due to deficient information about ordinances and due to fiscal limitations. In the short term, the best policy might be to go forth disposal methods without any controls, and utilize the resources available to upgrade them with environmental protection systems. In the long term, the building of new healthful landfill countries, composting, and incineration installations could be planned. Public engagement and consciousness are besides of import issues in accomplishing the ends of the suggested direction system, but it is hard and takes a long clip to do people cognizant of the importance and of the rules of the proposed direction system and to consequence their engagement. The reappraisal of municipal and family solid waste statistics in Turkey indicates that mean family waste coevals per capita is 0.6 kg/day and mean municipal solid waste is 0.95 kg/day. The composing of municipal solid waste varies by the beginning of waste ; nevertheless in all instances organic components histories for more than 50 % of municipal solid waste. Detailed cost analyses indicate that stuff recovery installations are normally self sufficient if operated at their established capacities, whereas initial investing to put up large-scale aggregation and recovery strategies still remains to be the major barrier that the municipalities have to get the better of.

Dark Pools Case Study Example | Topics and Well Written Essays - 3000 words

Dark Pools - Case Study Example They are known to be trading in a dark pool. Thus, the concept of Dark Pool was introduced much back in 1980. This was initiated when many few of the institutional investors and traders got involved in trade in a secure place, away from the interfering eyes of the brokers or public exchanges. Their main aim was to sell or buy large amount of the stocks without being affected by the market fluctuations and achieve a better price than that provided by the public exchanges (â€Å"Definition of Dark Pools†). It was noticed that around 2005, the dark pools was successful in capturing 3-5% of the total market activity. After that, the situation had started to improve when the Security and Exchange Commission (SEC) passed a new regulation, called the Reg NMS (Regulation National Market System). In this regulation, there were provisions which had increased the level of competition among the exchanges. However, it got rid of the rules that confined manual quotations which are generated by the stock exchanges. It allowed the investors the option to avoid the exchanges, if they are unsatisfied with the price and receives better price and convenience elsewhere. Dark Pools The dark pools can be defined as the name that is given to the networks which enables the traders to sell or buy huge orders without bearing the risk of other traders and their price of selling the orders. Thus, they are criticized for the lack of transparency that the later possesses. The unavoidable fragmentation of trading can lead to less competent pricing in the conventional open stock exchanges. In the dark pools, the pre-trade prices of the shares that are open for sale are not detectable to the public. The participants are also not aware of the prices at which the shares are traded. The prices are revealed only when the trade is done (â€Å"What the Heck is a Dark Pool and Why are People Trading in Them?†). The Reg NMS gave an opportunity to the brokers and the dealers to start their own automated trading, thereby creating dark pools. The institutional investors and the banks which generate huge money, started to head towards these dark pools in order to save their trading costs. The recent statistics indentify that there has been 12% trading in the dark pool accounts in United States (â€Å"What are dark pools?†). The main benefit of trading in dark pool can be recognized as the price improvement. The benefit can be explained through an example. Suppose the bid price of a stock on an exchange is $10.00 and the asking price is $10.10. The dark pool will set the price at $10.05 which is in the midpoint of ask and bid price. The investors like the activity of the dark pool and thus, prefer to invest there. The equity markets in United States and worldwide are prospering at an increasing rate. The participants work on a certain model which allows the people, interested to trade display the sell or buy price and ask or bid price. In the exchanges, the displa yed prices by the brokers are seen in the Tier II quotes (â€Å"What the Heck is a Dark Pool and Why are People Trading in Them?†). The opposite of the displayed prices are the dark pools. It refers to the place where the trading liquidity

Learning Organizations & Effectiveness Research Paper

Learning Organizations & Effectiveness - Research Paper Example However, this does not come easily as there are important aspects that come with learning and which organizations must conform to in order to effectively adapt the learning. In this regard, it is paramount for organizations to clearly define their visions and mission statements which act as guiding principles. With statements clearly stipulated, strategic plan with a clear learning strategy should lay a foundation for effectiveness of organizational learning. Characteristics of an ideal learning organization and their observable behaviors Learning strategy: It is argued that for any organization to thrive, learning is necessary. However, learning has to be strategized in order to achieve desired objectives. Therefore, learning strategy constitutes characteristics of an ideal learning organization. Organizations are expected to endorse both learning innovation as specific goals, and learning strategy (Denton, 2002). One of the strategies is the ability for the organization to learn fa ster than other competing organizations. This is the surest way to maintain competitive advantage. To achieve this, organizations need to put learning at the top of the list of priorities (Buckler, 1996). Once learning strategy has been adopted by an organization, it is apparent that this becomes a habit, which becomes an everyday occurrence. Flexible structure: After setting learning strategies, it is vital for ideal organizations to streamline a structure that would foster learning within the organization. To affect this, organizations need to create teamwork by the formation of small, core workforce (Yang, Watkins, and Marsick, 2004). Actually, a flexible structure should dispose of traditional operations like rigid job descriptions. In fact, it is believed that flexible structure encourages cross-functional cooperation which enables organizations improve the organization’s operations. Organizations that use flexibility structure tend to reduce bureaucracy and restrictive job descriptions. Blame-free culture: It is believed that learning organization should provide an ideal climate, through which learning is prioritized and valued (Denton, 2002). When mistakes are identified, they need to be viewed as a chance to learn and perk up. In fact, it is argued that learning organizations that uphold blame-free characteristic encourage employees to experiment, and in the process, they learn from the experience and become innovative. For organizations that practice blame-free culture, learning becomes automatic. Vision: The concept of a learning organization goes hand in hand with shared vision. A shared vision is needed to overcome authoritative forces that hold up the preservation of the status quo (Denton, 2002). Besides, learning cannot occur without stipulating specific objectives of the learning. Shared vision gives an overview of organization’s commitment to achieving its objectives. An organization with a clear vision would tend to establish ov erarching goals, which forms the basis of encouraging the workforce to speak in one voice. Knowledge creation and transfer: It is apparent that in a learning organization, the concept of creation of new knowledge forms the foundation of development. Knowledge may come from several directions ranging from within the organization and outside the organization (Yang, Watkins, a

Marketing question Essay Example | Topics and Well Written Essays - 250 words

Marketing question - Essay Example This is because customers could prefer buying commodities from his premises which could intern increase his sales volumes and returns revenue. The Wallmarts everyday pricing strategy was reported to be a successful pricing strategy and was adopted by numerous businesses in the United States. The strategy was applied by most business to consumer /goods such as tooth paste, toilet papers to mention just but a few of the products (Matthews, pp.1-2). Wallmarts everyday pricing strategy has been reported to have some disadvantage. Among that disadvantage include; low product quality perception. This means that customers may perceive that cheaper goods may mean low quality goods. Further, price reduction by Wallmarts could mean that sometimes the company may be forced to sell goods and services at a loss in order to remain competitive in the market. It has been discovered that Wallmarts everyday low pricing strategy may detriment its operations (Soderquist, p.211). This means that this strategy reduces Wallmarts profit margin. Therefore, instead of concentrating on everyday low pricing strategy Wallmarts should employ other marketing strategies such as segmentation, distribution and market expansion strategies to remain competitive (Cheng, paras.

Class student dicussions answers Assignment Example | Topics and Well Written Essays - 500 words - 2

Class student dicussions answers - Assignment Example You also provided a simple ‘what to do’ measures in order to eliminate the risk of viruses affecting the computer. It is a good insight that you gave about training the new users on how to detect scam emails and not click on the provided unknown links, and also executing an anti-malware or anti-virus scan whenever accessing an external memory drive. You could have also added not auto-executing flash drive programs or executables. Another thing that I feel should be a part of training for novices should be proper usage of trusted sites for downloads security features available in the browsers. Brain, you defined what Kevin said. You explained how a honeypot is implemented outside the main network and it sacrifices itself for the protection of the main, critical network. The best things that you told about the honeypot networks in general, are the disadvantages of implementing them. Cost was always a default factor but yes it would take more toil on the system administrator to monitor and look after this network’s resources. I would partially agree with the last comment you made on comparing advantages and disadvantages. For critical data organizations, we do need these honeypots but for smaller organizations, we cannot afford to have such a high cost. You also specifically mentioned what intrusion detection systems and firewalls we can use for information security. As opposed to Kevin, you have provided specific details on three main techniques of ensuring information security within the organization. You also made good points on differentiating how software and hardware security systems work in unison to provide maximum security to the organizational data. I completely agree that software based security is either algorithmic or rule based but hardware based security is almost rule based. The explanation of how routers work

How has social media influenced Apple market Dissertation

How has social media influenced Apple market - Dissertation Example The emergence of the social media platforms has led to a dynamic shift in how people interact and build a communicative space for communication and information. The Internet is the basic infrastructure on which the social media platforms are based. In the initial stages, the internet guaranteed equal distribution and access and over time it has been further developed that enables data to be transported through ‘tethered applications’, or ‘applied services’ such as Apple’s iTunes to download songs or Facebook to channel social contacts (Dijck, 2012). While this may have been possible due to technological advancements, it has now expanded into the realm of the social and cultural spheres to the extent that these social platforms affect interactions and reciprocal relationships. Social media has been described as an online platform that facilitates content sharing, collaboration and interactions (Coyle, Smith and Platt, 2012). It is a platform where participants can freely send, receive and process content for use by others (Aula, 2010). Social networking applications also enable creating and managing digital expression of people’s relationship or links. As the social media has enhanced social interactions and relationships, it is also extensively been used by marketers as one of the platforms for marketing and promotion. As such it is used by companies to engage the customers. Companies such as Starbucks and CNN use it to build brand awareness and brand equity (Palmer & Koenig-Lewis, 2009). The number of Facebook users and Tweets has reached such a state that consumers and their virtual networks drive conversation, thereby posing challenge for businesses. Companies have become engaged and try to keep their customers engaged through the social media because they believe that if they do not do so, â€Å"they will be out of touch† (Baird & Parasnis, 2011). While many companies have started using the social media platform it is not known how many actually engage and how many have derived benefits from this platform. It is not possible for this study to evaluate the performance of several companies through the social media. Apple Inc is in the field of computer hardware, software and consumer electronics. Their electronic consumer products such as the iPhone, iPad and iPod have particularly changed the way people use the social media. Apple is one of the most valuable brands in the world and has been generating billion dollar revenue figures for over a decade (Statista, 2013). This study would focus

Mussolini's War Speech Essay Example | Topics and Well Written Essays - 1000 words

Mussolini's War Speech - Essay Example Such regimes flourished during the politically uncertain period in Europe following the First World War. Italy and Germany were the most important centers of such fascist governments. The arguments that are provided by Mussolini for the war against Ethiopia, a country which they had failed to subdue for around a century are not scientifically valid. Economically and as far as military might was concerned, Italy would not have been able to hold up against the might of the Allied powers alone, who supported the League of Nations, which had condemned the attack on Ethiopia (Italy in the Second World War). Mussolini’s claim that â€Å"to acts of war†, he would â€Å"reply with acts of war† (Mussolini Justifies War Against Ethiopia) is thus, based on his needs to rouse his countrymen and gain their support rather than a scientifically legitimate claim on his part. The text talks of the need to invade Ethiopia at a point of time when the sentiments of the international community were against such an invasion. Italy did not really have the ability to stand against such opposition as was proven in a disastrous manner by the Second World War. Mussolini’s claims are based on hope and intuition and not on reports of diplomatic understanding. They are also directed at invoking the intuitive nationalist sentiments of the Italians rather than an appeal to their sense of rational understanding. Mussolini reasons with himself about the chances of his victory- while talking of France and Great Britain, he speaks about the improbability of their doing so. This is a case of inductive reasoning whereby he uses particular examples to prove that a certain event would not come about. He also rejects responsibility for any act of violence that may follow an act of violence upon Italy. This is an example of causal reasoning whereby he talks of retribution on the part of the Italians would be the effect of violence on the part of others. Mussolini here shies away from responsibility and this was one of the important characteristics of the fascist regimes that developed during the interwar years. The regimes that came up during this period led their people into war; they were, however, unable to ensure that their people would come out of the war unscathed. Italy and Germany spent many years following the Second World War trying to recoup from its effects. The process of rebuilding took great efforts on the part of the German and Italian people. When Mussolini says that the people of Italy had been impressed by the work of the fascists, he means it to be an example of deductive logic. When he says that fascism was a spectacle that history had not seen till then, he means it to be the premise that along with the premise of the effectiveness of fascism led to the twenty million people of Italy gathering together in support of Mussolini and the institution of fascism. The techniques of logic and reasoning are employed in a very effective and convincing manner by Mussolini. The power of oratory that shines through his entire speech was a feature that was very important in his journey to success. This was important in the consolidation of his power of Mussolini over the people of Italy. The Italian people were swayed in a manner that was similar to the way in which the Germans were swayed by Adolf Hitler in later years. The promise of economic development was a major reason as to why people were misled in

Sociology of Prostitution Essay Example for Free

Sociology of Prostitution Essay Prostitution is one topic in which the causes have been debated by many. There are three theories that I will discuss throughout this paper. The theories include a functionalist, feminist, and social psychological view of the subject. The argument that appears more correct is a matter of opinion. The functionalists believe there are two main reasons why a person would become a prostitute. The first reason deals with sexual morality. To break it down further the argument is that our sexual morality system, while condemning prostitution, actually and inadvertently encourages it. We live in a society that encourages the belief that sex with a spouse is â€Å"meaningful† while sex with a prostitute is â€Å"meaningless. † This idea may actually encourage men to seek sex with a prostitute if all they want is meaningless sex. Additionally certain sex acts, such as oral copulation or anal sex, are considered immoral by our society. This means that the common belief among society is that these acts should not be done with their spouse. This may motivate men who desire these acts to seek the services of an immoral prostitute. Another reason proposed by the functionalist is the belief that prostitution actually serves to strengthen sexual morality. Basically the sex industry keeps the â€Å"respectable† women pure because men can satisfy their immoral sexual desires elsewhere. There is some evidence to support the functionalist view of prostitution. Studies have shown that in certain societies such as traditional Asian societies where prostitution is prevalent, respectable women are less likely to engage in immoral sex acts. Read more:  Essay on Prostitution On the other hand many western societies where prostitution is less common, respectable women are more likely to engage in immoral sex acts. Now let’s look at the feminist view. Feminist believe that the functionalist theory is nothing more then a reflection of our society’s sexist views. They believe that the men partaking in the acts are just as immoral as the prostitutes themselves. They take their argument a step further by suggesting that the topic of prostitution is a small part of the larger patriarchal system in which men dominate the exploited women. Feminist also argue that society teaches boys to dominate girls and are expected to continue this behavior into adulthood. On the other hand society teaches girls to be submissive to boys, and to remain that way into adulthood. To prove this the feminist point out that prostitution is more prevalent in societies in which there is a greater presence of gender inequality. The basic idea is that prostitution and a male patriarchy support each other. This is because prostitution supports and encourages the idea that all women can be bought or are less valuable then men. Finally let’s look at the Social Psychological Theory. This theory argues that there are three main reasons why some women become a prostitute. First are predisposing factors such as parental neglect, child abuse, or some other traumatic event. Attracting factors such as the belief that a women can have an easy life or make allot of easy money as a prostitute. And precipitating factors, such as unemployment, peer pressure, or other outside influences. While predisposing factors may cause a women to consider becoming a prostitute, it is unlikely she will actually become one without some of the other listed factors. In my opinion each theory states a very convincing argument. It is difficult to remain unbiased when thinking of this topic due to our personal beliefs. Although the supporters of each theory may not want to admit it, the fact is that if you look close enough you will see they all say the same basic thing. This one thing is the fact that prostitution is not merely an issue that involves prostitutes; it involves all of society and many outside influences.

How Learned Helplessness Can Impact Patient Satisfaction Nursing Essay

How Learned Helplessness Can Impact Patient Satisfaction Nursing Essay Ever since To Err is Human did patients really start to care about the quality of care they received from their physicians, hospitals, and healthcare organizations. However, healthcare organizations had already recognized the importance of patient satisfaction several years earlier. Many organizations started measuring patient satisfaction as a way to judge the perceptions of how their patients viewed their experiences while under their care. There are many facets to measuring patient satisfaction but to date the concept of learned helplessness has not been incorporated into the mix. Learned helplessness is a phenomenon occurring in many places in our society. It affects how we work, interact with others, conduct our business, and employ our thoughts and views on healthcare. When experience with uncontrollable events leads to the expectation that future events will also be uncontrollable, disruption in motivation, emotion, and learning may occur. That phenomenon has been called learn ed helplessness (Cemalcilar 2003). Armed with a better understanding with how learned helplessness plays a role in patient satisfaction healthcare settings will be better able to alleviate this discomforting phenomenon and thus should raise patient satisfaction scores. This paper serves as a vehicle to investigate the concept of learned helplessness combined with a review of patient satisfaction and provide guidance for research to further our understanding of the relationship between the two. Literature review: Learned helplessness came about by accident in 1965 by Martin Seligman and his team while studying the relationship between fear and learning. Seligman observed an unexpected behavior while investigating Pavlovs theory on stimulus and response. Seligman didnt pair the bell with food but rewarded the dog with a small shock while restraining the dog to keep it from running away. The researcher thought that the dog would experience fear after hearing the bell and would try to run away or display some other type of behavior. After this the dog was placed into a box with two compartments divided by a low enough fence that the dog could see the other side and escape if the dog so desired. To their amazement, after the bell was sounded the dog didnt try to run away but instead just laid or sat on the one side of the box. The researchers repeated the test but instead of sounding the bell they gave the dog a small shock. As was the case with the bell the dog decided to stay on its initial sid e of the box. The test was repeated with a dog that had never been subject to any of the previous experiments and when given the shock the dog took flight and jumped over the small fence to escape. What was decided was that the first dog, while being restrained, learned that trying to get away from the shock was pointless and the dog had no control over its destiny and was therefore helpless. Some researchers have contended that the dog just thought he was being punished for some act of wrongdoing or that the end of the pain from the shock was indeed the reward. However, this behavior has been used in a variety of situations which will be explained here in an effort to learn more about this phenomenon. Learned helplessness has detrimental effects on children. They develop a lack of self-confidence in challenging tasks which result in deterioration of performances (Dweck, Davidson, Nelson, Enna, 1978). These children do not develop good problem solving strategies and can suffer from lack of attention and think that all of their efforts are fruitless. Children like this are often held back a grade in an effort to bolster their social and academic skills. In the end, they get a message that they are worthless and hopeless (Berger, 1983). These children may be inadequately prepared to take on new learnings and perform out of the ordinary tasks. Failure become synonymous in these childrens vocabulary and repeated efforts may do little to change their outlook. In Eriksons view, he suggests that children with few successes will become inferior which leads them to have a low self-esteem (Berger, 1983). Most learned helpless students give up trying to gain respect through their academic pe rformance so they turn to other means for recognition. They may become the class clown, bully or tease. When they begin adolescent years they try to gain respect through antisocial behaviors (Berger, 1983). With learned helpless children, competence is almost entirely destroyed. They lose confidence within themselves because they experience failures, leading them to believe they are failures. They might feel competent about something at first but if they fail in that activity they wont bother to try it again for fear of failure. Autonomy is also faint in a learned helpless students life. They feel as though they have no control over their environment because no matter how hard they tried in the past, they never succeeded. As for relatedness, learned helpless students feel as though they dont belong because they believe that they dont relate to the environment. This is why they become the class clown, bully or tease in order to get their recognition. These results may include becomin g an antisocial individual during their adolescent years or earlier. These three factors are all detrimental to an individuals growth and development in our social world today. There have been a few scales conducted and measured trying to use this construct in a variety of situations. The majority of these studies utilized learned helplessness as a secondary construct in explaining either complaint behavior (Lee and Soberon-Ferrer 1999) and measuring the relationship between empowerment and learned helplessness (Campbell and Martinko 1998). The study showed that there were many differences between empowerment and learned helplessness. Another study was conducted in a hospital setting with a reported reliability of 0.85. It had a positive relationship with Becks hopelessness scale (r=.252) and a negative correlation with Rosenbergs Self-Esteem scale (r=-.622) (Quinless 1988). Another way it can affect people is through different emotions such as pessimism, futility, risk aversion, depression, and self-esteem. It has been defined in people as a state of which the consumer cannot control their destiny or outcomes and therefore relinquish control over a certain situation. What research to date has been conducted to study patient behavior with learned helplessness? Raps et. al (1982) found that the longer a patients length of stay was the worse the patient performed on cognitive tasks that index learned helplessness. First, they determined this because of a perceived loss of control by the patient. Second, increased hospitalization resulted not only in increased deficits but also in increased vulnerability to identical deficits produced by minimal amounts of uncontrollable noise, suggesting that the process underlying the deficits in the no-noise conditions is learned helplessness produced by hospitalization. Third, increased hospitalization disrupted performance at the problem-solving tasks, but not at the verbal intelligence test-replicating the previous results from laboratory studies of learned helplessness and suggesting that the deficits of our subjects were not a general deterioration but instead a more specific difficulty with new learning (Rap s et al. 1982). Fourth, increased hospitalization produced increased depressive symptoms that covaried with poor performance both across and within conditions. This pattern suggests again that perceptions of helplessness caused the observed deficits, since depression involves a diminished sense of efficacy (Raps et al. 1982). Faulkner (2001) set out to investigate the relevance of learned helplessness and learned mastery theories in the respective development of dependence and independence in older hospitalized people. Faulkners experiment shows how an exposure to uncontrollable or disempowering circumstances potentially places patients at risk of developing learned helplessness. This condition has the potential to retard self-care performance in the absence of supervision, direction, or active personal assistance thus rendering patients dependent (Faulkner 2001). Moreover, this dependence may not remain specific to the task within which LH was induced, but may generalize to affect patient performance in other activities. To date the accepted scale to use when measuring learned helplessness is the LHS scale developed by Quinless and McDermott-Nelson. A conceptual definition is necessary in order to further explore this phenomenon. Learned helpless can be defined by a state in which a person thinks that they cannot control their own destiny and the life experiences which happen to them. This definition incorporates the key elements found throughout the research: loss of control, depression, low self-esteem, pessimism, and defeat. Learned helplessness can have the potential for explaining some variation in patient satisfaction scores. In order to further explore how the two are interrelated, an investigation into patient satisfaction must be employed. Patient satisfaction: With the effectiveness of medical care being increasingly measured according to economic as well as clinical criteria, the inclusion of patients opinions in assessments of services has gained greater prominence over the past 25 years (Sitzia Wood 1997). As health care budgets come under scrutiny, so consumers in the West have become more critical of the health care provided, organizing and claiming rights as active participants in the planning and evaluation of health services (Sitzia Wood 1997). An increase in interpersonal relationship interest sparked the development for a need to understand the patient-physician relationship which gave rise to patient satisfaction measurement. Consumer advocate groups such as the National Consumer Council produced Patients rights, which influenced the rise of consumerism in healthcare. The term patients rights became the rallying cry for Patients to have more control and say about the care that was extended to them. What then determines what pa tient satisfaction is? Linder-Pelz (1982) approached a definition of patient satisfaction through five social-psychological variables proposed as probable determinants of patient satisfaction with health care. These are outlined as: Occurrences-the event which actually takes place, and perhaps more importantly, the individuals perception of what occurred; valueevaluation, in terms of good or bad, of an attribute or an aspect of a health care encounter; expectationsbeliefs about the probability of certain attributes being associated with an event or object, and the perceived probable outcome of that association; interpersonal comparisonsan individuals rating of the health care encounter by comparing it with all such encounters known to or experienced by him or her; and entitlementan individuals belief that s/he has proper, accepted grounds for seeking or claiming a particular outcome. Ware et al. (1983) gives a more definitive taxonomy with eight dimensions: interpersonal mannerfeatu res of the way in which providers interact personally with patients (e.g. respect, concern, friendliness, courtesy); technical quality of carecompetence of providers and adherence to high standards of diagnosis and treatment (e.g. thoroughness, accuracy, unnecessary risks, making mistakes); accessibility/conveniencefactors involved in arranging to receive medical care (e.g. waiting times, ease of reaching provider); financesfactors involved in paying for medical services; efficacy/outcomes of carethe results of services provided (e.g. improvements in or maintenance of health); continuity of careconstancy in provider or location of care; physical environmentfeatures of setting in which care is delivered (e.g. clarity of signs and directions, orderly facilities and equipment, pleasantness of atmosphere); and availabilitypresence of medical care resources (e.g. enough medical facilities and providers). CMS has mandated the HCAHPS measures of patient perception of quality of care as a c ondition of Medicare participation (Griffith White 2007). CMS (Medicare) states the supplier shall conduct beneficiary satisfaction surveys and make the results available upon request and/or listed on their Internet website (if applicable). The supplier shall document and review on a quarterly basis a percentage of beneficiaries satisfied with services. These surveys include questions that are divided into five groups: Your care from nurses, Your care from Doctors, The hospital environment, Your experiences in the Hospital, When you left the Hospital, Overall rating of the Hospital, and Demographic questions. These questions must be incorporated into commercial patient satisfaction surveys and publicly reported. In some cases referring physicians may act as agents for their patients and are concerned with clinical outcomes, patient satisfaction and cost. This is important because if they are not satisfied with their patients responses, they may divert their patients elsewhere. However there are some concerns for those that dont buy into patient satisfaction scores. These fall into the category of social-psychological artifacts. LeVois et al. (1981) states that Social desirability response bias argues that patients may report greater satisfaction than they actually feel because they believe positive comments are more acceptable to survey administrators. Similarly, ingratiating response bias occurs when patients use the satisfaction survey to ingratiate themselves with researchers or medical staff, especially if there are any reservations over the anonymity of respondents (Sitzia Wood 1997). Why then study patient satisfaction? Typically patient satisfaction surveys are after the services have been rendered and the patient has left the hospital or physicians office. Most of the surveys use a 5 point Likert scale with 5 indicating excellent or highly satisfied and 1 being poor or highly dissatisfied. Most managers think that getting an average of 4s is very good or good enough and trying to achieve a 5 rating is too costly or time consuming. This is not the case. Many managers also think that they should focus on unsatisfied customers but research has shown that no matter how much time, effort, and money they invest, there will always be a small percentage of patients that are dissatisfied. Managers should then focus on moving those four ratings to fives. When it comes to customer loyalty, excellent has a different meaning from the other rating categories (Otani et al. 2009). Highly satisfied customers are the ones that are loyal and return for their next encounter or recommend others to the same physician o r facility. This usually comprises of about 75% of the physicians business so it is imperative that they keep this group happy and highly satisfied. In an emerging competitive market such as healthcare, managers should focus on achieving excellent ratings to distinguish their organization from others (Otani et al. 2009). Patients that are merely satisfied will seek care elsewhere and look for other providers. Even though the cost of switching hospitals is quite high, patients have more choices now than they did in previous eras. What are some other reasons to highly satisfy these patients? Satisfied patients tend to comply with prescribed medical treatments (Ford, Bach Fottler 1997). Due to an increase in chronic conditions, it is more imperative that patients follow the treatment process prescribed. This can reduce length of stays and lower readmission rates thus reducing costs. Also, it decreases switching. When a patient changes physicians, he or she may be required to retake te sts, which increases the patients costs and may hurt the patient (Otani et al 2009). Another factor is patient satisfaction is now considered a key part of the healthcare quality improvement initiative (Shortell and Kaluzny 2000). Many managed care organizations use patient satisfaction data to determine reimbursement rates to healthcare providers, and many leading companies will not contract with health plans that do not require a patient satisfaction survey. Providers with positive patient satisfaction survey results may receive more financial incentives than providers with poor patient satisfaction survey results (Kongstvedt 2001). In addition a 1 standard deviation point increase in the quality of pt/physician interaction equals a 35% lower chance of a patient complaint for the primary care physician, and a 50% lower chance of a patient complaint for a specialist (Saxton et al. 2008). Saxton (2008) also reports that a one standard deviation decrease in patient satisfaction equal s a five percent increase in the physicians risk management. Compared to physicians in top satisfaction scores: Physicians in middle 1/3 of scores had malpractice lawsuit rates 26% higher while Physicians in bottom 1/3 of scores had malpractice lawsuit rates of 110% higher. According to Saxton (2008) the top five patient priorities are: Response to concerns/complaints during stay, Degree to which hospital staff addressed patients emotional needs, Staff effort to include patient in decisions about their treatment, How well the nurses kept the patient informed, and Promptness in responding to the call button by the patient. One issue not investigated thoroughly is the billing activities of the hospital or caregiver. Richard Clarke, HFMA CEO and President has stated the best care, and great customer service provided during the patients hospital encounter can be destroyed quickly by confusing, complicated, or incorrect billing afterwards (Swayne et al. 2008). According to Swayne (2008, the top five hospital bill features that irritate customers the most are: confusion about what the patients insurance company has paid, confusion about the balance the patient owes the hospital once the insurance company pays its share, use of medical terminology that the patient does not understand, sending a bill to the patient before the insurance company has processed the patients claims, and inability to determine exactly what services the hospital has provided and what the patient is being charged for the service. Follow-on activities are also another area that the physician or caregiver can alter patient satisfaction scores. Many providers think that once the patient is out the door the experience ends there. After a patient has been seen by a physician or is leaving the hospital after surgery, there is a likely need for further services: a child with an ear infection has to return in 10 days for another check-up to make sure the infection is no longer present; after hip surg ery a patient may need to be relocated to a rehabilitation facility to learn to walk again (Swayne 2008). All of these additional services are value adding service activities. All of these factors play a role in learned helplessness as the patient may become frustrated by not having an excellent experience throughout the visit or after the visit. Proposed study: This paper shall utilize the current learned helplessness scale (LHS) and apply it to see how it moderates patient satisfaction scores. Method of study: The proposed model for this study is: Patient Satisfaction Scores Internal State of patient Patient Experience Learned helplessness Learned helplessness This research was consistent with the often used S-O-R paradigm. This paradigm assumes that environments contain stimuli (Ss) that cause changes to peoples internal or organismic states (Os), which in turn cause approach or avoidance responses (Rs) (Mehrabian and Russell 1974). It is anticipated that higher levels of learned helplessness will negatively impact patient satisfaction scores. The area most anticipated are those consistent with loss of control in fulfilling the needs of the patient, like care from the nurses, care from the physician especially in information sharing, and billing issues from either the hospital or the insurance company. The construct will be viewed as a moderator. In general terms, a moderator is a qualitative (e.g., sex, race, class) or quantitative (e.g., level of reward) variable that affects the direction and/or strength of the relation between an independent or predictor variable and a dependent or criterion variable. Specifically within a correlation al analysis framework, a moderator is a third variable that affects the zero-order correlation between two other variables. In the more familiar analysis of variance (ANOVA) terms, a basic moderator effect can be represented as an interaction between a focal independent variable and a factor that specifies the appropriate conditions for its operation. (Baron Kenny 1986). Data collection: Data collection shall be the most challenging facet of this study. It is important to gather rich data that will either support or disprove the theory that learned helplessness lowers patient satisfaction scores. A large enough sample is to be gathered in order to fully demonstrate this phenomenons capability. The LHS will be distributed along with the chosen hospitals patient satisfaction survey and patients will be asked to complete them. It may be necessary to delay the distribution of the survey so the patient has ample time to be contacted or experience learned helplessness form billing issues that may arise. After a sufficient number of surveys have been returned to the author, statistical regression methods will be employed to assess statistical significance as it relates to learned helplessness and patient satisfaction scores. Different factors can be cross-tabulated to see if there are any generalized effects on the scores like age, race, financial, and educational positions . Model fit could be assessed using SEM or other methods to ensure proper allocation and model assessment. Limitations As stated before data collection shall be difficult in performing this study. Hospitals may be reluctant to allow a researcher, independent of the organization, access to their patients and their satisfaction data. This reluctance could be over a variety of factors including patient privacy, fear of inappropriate scores released to the public, and a general distrust for academic research. It may be necessary to conduct this study as a joint venture so the hospital may learn from this study as well as the researcher. Another limitation is patient recall. This is always a factor since consumer recall plays a role in remembering perceptions, actions, and behaviors that occurred in the hospital or caregivers office. Since billing is an issue with learned helplessness, the delay in presenting the surveys may affect memory recall. The last limitation may be that of the construct being studied itself. Since there is little research on learned helplessness as it relates to patient satisfacti on or patient experience it may be difficult to determine how strong a score on the LHS scale must be to fully realize an effect on patient satisfaction. Conclusion: This paper has outlined the construct of learned helplessness and how it potentially could interact with patient satisfaction scores. Patient satisfaction scores are of the upmost importance to hospitals and caregivers as it affects their quality ratings, their allocation from CMS, and their reputation in general. While this project is a major undertaking, the author feels that it is worthy of such time and effort as patients and caregivers seek to further understand the patient experience in healthcare settings. This paper has outlined a course of action and while this project needs to be further investigated, it lays the necessary framework for a study worthy of journal submission. Future research could fully implicate different ways that learned helplessness is formed in different healthcare settings allowing for richer analysis into how patients react to different perceived outcomes. Hospitals and caregivers should be able to use information from this study to redesign their pati ent satisfaction surveys to allow them to gather richer data and use this to improve satisfaction scores which ultimately affect the bottom line. In this new age of healthcare reform, it is imperative that healthcare organization strive in every effort to raise the bar of patient outcomes, not only physical outcomes but mental outcomes as well.

An Overview of Consent and Restraint

An Overview of Consent and Restraint Consent, Deliberate or implied affirmation; compliance with a course of  proposed action. Consent is essential in a number of circumstances. For example,  contracts and marriages are invalid unless both parties give their consent. Consent  must be given freely, without duress or deception, and with sufficient legal  competence to give it (see also INFORMED CONSENT). In criminal law, issues of consent  arise mainly in connection with offences involving violence and *dishonesty. For  public-policy reasons, a victims consent to conduct which foreseeably causes him  bodily harm is no defence to a charge involving an *assault, *wounding, or  *homicide; in other cases the defendant should be acquitted if the magistrates or  jury have a reasonable doubt not only as to whether the victim had consented but  also as to whether he thought the victim had consented. Restraint,  assault and  an intentional or reckless act that causes someone to be put in fear of  immediate physical harm. Actual physical contact is not necessary to constitute an  assault (for example, pointing a gun at someone is an assault), but the word is often  loosely used to include both threatening acts and physical violence (see BATTERY).   Words alone cannot constitute an assault. Assault is a form of *trespass to the  person and a crime as well as a tort: an ordinary (or common) assault, as described  above, is a *summary offence punishable by a *fine at level 5 on the standard scale  and/or up to six months imprisonment. Certain kinds of more serious assault are  known as aggravated assaults and carry stricter penalties. Examples of these are  assault with intent to resist lawful arrest (two years), assault occasioning *actual  bodily harm (five years), and assault with intent to rob (life imprisonment).   battery The intentional or reckless application of physical force to someone  without his consent. Battery is a form of *trespass to the person and is a *summary  offence (punishable with a *fine at level 5 on the standard scale and/or six months  imprisonment) as well as a tort, even if no actual harm results. If actual harm does  result, however, the *consent of the victim may not prevent the act from being  criminal, except when the injury is inflicted in the course of properly conducted  sports or games (e.g.rugby or boxing) or as a result of reasonable surgical  intervention. Duty of care, The legal obligation to take reasonable care to avoid causing damage. There is no liability in tort for *negligence unless the act or omission that causes  damage is a breach of a duty of care owed to the claimant. There is a duty to take  care in most situations in which one can reasonably foresee that ones actions may  cause physical damage to the person or property of others. The duty is owed to  those people likely to be affected by the conduct in question. Thus doctors have a  duty of care to their patients and users of the highway have a duty of care to all  other road users. But there is no general duty to prevent other persons causing  damage or to rescue persons or property in danger, liability for careless words is  more limited than liability for careless acts, and there is no general duty not to  cause economic loss or psychiatric illness. In these and some other situations, the  existence and scope of the duty of care depends on all the circumstances of the  relationship between the parties. Most duties of care are th e result of judicial  decisions, but some are contained in statutes, such as the Occupiers Liability Act  1957 Negligence and  Carelessness amounting to the culpable breach of a duty: failure  negligent misstatement 328 329 NHS Trust  to do something that a reasonable man (i.e. an average responsible citizen) would do, or doing something that a reasonable man would not do. In cases of professional negligence, involving someone with a special skill, that person is expected to show  the skill of an average member of his profession. Negligence may be an element in a  few crimes, e.g. *careless and inconsiderate driving, and various regulatory offences,  which are usually punished by fine. The main example of a serious crime that may  be committed by negligence is *manslaughter (in one of its forms). When negligence  is a basis of criminal liability, it is no defence to show that one was doing ones best  if ones conduct still falls below that of the reasonable man in the circumstances. See  also GROSS NEGLIGENCE. 2. A tort consisting of the breach of a *duty of care resultingà ‚  in damage to the claimant. Negligence in the sense of carelessness does not give rise  to civil liability unless the defendants failure to conform to the standards of the  reasonable man was a breach of a duty of care owed to the claimant, which has  caused damage to him. Negligence can be used to bring a civil action when there is  no contract under which proceedings can be brought. Normally it is easier to sue for  *breach of contract, but this is only possible when a contract exists. Generally, fewer  heads of damage can be claimed in negligence than in breach of contract, but the  rules limiting the time within which actions can be brought (see LIMITATION OF  ACTIONS) may be more advantageous for actions in tort for negligence than for  actions in contract. See also CONTRIBUTORY NEGLIGENCE; RES IPSA LOQUITUR.   vicarious liability   Legal liability imposed on one  person for torts or crimes committed by another (usually an employee but  vicarious performance 526 527 violent disorder  sometimes an *independent contractor or agent), although the person made  vicariously liable is not personally at fault. An employer is vicariously liable for  torts committed by his employees when he has authorized or ratified them or when  the tort was committed in the course of the employees work. Thus negligent  driving by someone employed as a driver is a tort committed in the course of his  employment, but if the driver were to assault a passing pedestrian for motives of  private revenge, the assault would not be connected with his job and his employer  would not be liable. The purpose of the doctrine of vicarious liability is to ensure  that an employer pays the costs of damage caused by his business operations. His  vicarious liability, however, is in addition to the liability of the employee, who   remains personally liable for his own torts. The person injured by the tort may sue  either or both of them, but will generally prefer to sue the employer.   Vicarious criminal liability may effectively be imposed by statute on an employer  for certain offences committed by an employee in relation to his employment. Thus  it has been held that an employer is guilty of selling unfit food under the Food Act  1984 when his employee does the physical act of selling (the employee is also guilty,  though in practice is rarely prosecuted). Likewise, an employer may be guilty of  supplying goods under a false trade description when it is his employee who  actually delivers them. For an offence that normally requires mens rea,an employer  will only be vicariously liable if the offence relates to licensing laws. For example, if  a licensee has delegated the entire management of his licensed premises to another  j:letson, and that j:letson has committed the offence with the nec~ssatymens YeQ, th~  licensee will be vicariously liable.   Vicarious liability for crimes may be imposed in certain other circumstances. The  registered owner of a vehicle, for example, is expressly made liable by statute for  fixed-penalty and excess parking charges, even if the fault for the offence was not  his. If the offence is a regulatory offence of *strict liability, the courts often also  impose vicarious liability if the offence is defined in the statute in a way that makes  this possible.   Scope of practice (the legal and professional boundaries imposed upon you as a nurse)   Advocacy (the nurses role as an advocate for the client)   Documentation   Open disclosure   The Coroner   An officer of the Crown whose principal function is to investigate  deaths suspected of being violent or unnatural. He will do this either by ordering an  *autopsy or conducting an *inquest. The coroner also holds inquests on *treasure  trove. Coroners are appointed by the Crown from among barristers, solicitors, and  qualified medical practitioners of not less than five years standing.   Colour. The normal colour of urine is pale straw or light yellow.   It is mainly due to the pigment urochrome and partly to urobilin.   Womens urine is slightly lighter.   If the quantity of urine is increased or there is a diminution or dilution of urinary pigments, it becomes lighter and rendered very pale as in excessive drinking, nervousness, anaemia, chlorosis, diabetes, hysteria, epilepsy, poluria, in general debility and in chronic interstitial nephritis. The colour of the urine will depend on the degree of concentration; the more concentrated-the darker; the greater the quantity of water -the lighter.   Acid urine is slightly darker than alkaline urine. Urine becomes deeper in colour, like orange or dark yellow or brownish red generally known as high coloured or concentrated urine and is due to uroerythrin and urobilin produced by increased haemolysis, as in. fevers, after journeys, in hot days, in nervous excitability and after bodily exercises. N ormal urine on standing for a time will have a white or sometimes a bluish white scum on the surface due to contamination and putrefaction.   Urine glairy, whitish in colour indicates admixture with pus or leucorrhceal discharges. Urine coloured smoky, brown, reddish, brownish black or black indicates admixture with blood and denotes haemorrhage. Urine coloured greenish yellow or greenish brown indicates admixture with bile and denotes jaundice and other affections of the liver. Urine coloured milky indicates admixture with fat or pus and denotes chyluria or any purulent disease of the genitourinary tract.   Urine coloured blue indicates typhus fever, admixture with methylene blue or when there is excess of indigogens. Many drugs after absorption colour the urine, such as yellowish orange by santonin and chrysophanic acid; reddish or orange brown by senna and rhubarb; dark olive green or black by carbolic acid and other coaltar derivatives while antipyrin reddens the u rine. Odour.   When just voided urine is faintly aromatic but after a few minutes its characteristic odour is urinous.   The odour of urine is due to phenol.   It becomes pungent in concentrated urine, when urea is liberated in excess.   It becomes ammoniacal and putrescent and the reaction becomes alkaline after sometime when this excess of urea takes up water and is converted into ammonium carbonate.   It occurs quickly in urine from chronic cystitis or from suppurating diseases of kidney and bladder i.e., when urine is mixed with pus; blood or excessive phosphates.   The odour of urine in diabetes and in acetonuria is slightly sweetish.   The characteristic odour of garlic, sandal oil, cubebs, copaiba are given off when they are taken internally.   Turpentine gives an odour of violets. Appearance, physical character or transparency is the naked eye appearance of urine. Normal urine is always clear when voided but when allowed to stand for sometime it becomes slightly hazy or turbid due to suspended particles or from a slight cloud of mucus and epithelium. After sometime there may be sediments at the bottom due to gravity. If the urine is ammoniacal or decomposed a white turbidity forms due to sedimentation of phosphates or from bacterial activity. The turbidity or sediment is due mainly to the following suspended particles:- Urates. Uric Acid. Albumin. Phosphate. Mucus. Oxalate. Pus. Blood. Micro-organisms. To distinguish one from another, first of all fill three fourths of a test tube with urine and very gently heat the upper portion of the urine, holding the test tube by the bottom.   Now note whether the urine becomes clear or a cloudiness appears in the boiled portion, comparing with the lower unboiled portion of the test tube.   If the urine is turbid and clears up on heating then it contains Urates.   If the urine is clear and becomes cloudy with heat, before boiling point, then it is Albumen.   If the urine is clear and becomes cloudy at the boiling point, then it is Phosphate.   To distinguish between albumin and phosphate add 3 or 4 drops of acetic acid on the cloudy urine.   If the cloudiness disappears, then it is phosphate; but if the cloudiness remains or thickens, then it is albumin.   Lastly to distinguish between albumin and mucin add 2 drops of nitric acid, if the cloudiness disappears, then it is Mucin, but if the cloudi ness still persists, it is albumin. The turbidity of carbonates will clear up with effervescence on addition of nitric acid whereas heat and acid increases the turbidity due to albumin. To distinguish between phosphate and oxalate take some fresh urine and add ammonia, when there will be a precipitate. If on the addition of a few drops of acetic acid, the precipitates disappear, then it is phosphate, if it remains it is Oxalate. Failing the heat test take some urine in a test tube, preferably from the bottom and add a few drops of Liquor Potassae. Mix it thoroughly and if it clears up, then it is mucus; but if it becomes gelatinous or ropy, it is Pus. Next, if the deposit is coloured then take some urine in a test tube, preferably from the bottom and add a few drops of caustic potash and gently heat a little.   If it is dissolved, then it is Uric acid but if there is a precipitate, note the colour of the coagulum; if it is reddish brown or bottle green, it is Blood. If the urine is turbid and there is no change either by heat or by addition of caustic potash and heat, then the turbidity is due to Micro-organisms.   They generally clear up on the addition, of watery solution of ferric chloride and ammonium hydrate and then filter the urine.   Sometime the character, colour and reaction will roughly denote the element. Urates-They look like moss and are yellowish white or pink in colour.   Reaction is generally acid. They deposit when the urine becomes cold.   Uric Acid-It is crystalline and reddish brown in colour, resembling a shower of cayenne pepper grains. Reaction is moderately acid.   Phosphate-It forms a thin deposit and is white or yellowish white in colour.   Reaction may be slightly acid, alkaline or neutral.   Mucus-It is a cloudy or woolly looking white deposit. Reaction is slightly acid.   Oxalate-It is soft, shining and white in colour. Reaction is generally slightly acid. Pus- It looks like a ropy or creamy deposit, and is white in colour.   Reaction is slightly acid or  alkaline. Blood-It is clotted or thready and is red smoky or brownish in colour.   Reaction generally alkaline or may be slightly acid. Micro-organisms-The deposit is slightly hazy and white in colour.   They generally stick to the sides of the glass. COMPLICATIONS OF FRACTURES The majority of fractures heal without complications. If death occurs after a fracture, it is usually the result of damage to underlying organs and vascular structures or from complications of the fracture or immobility. Complications of fractures may be either direct or indirect. Direct complications include problems with bone infection, bone union, and avascular necrosis. Indirect complications are associated with blood vessel and nerve damage resulting in conditions such as compartment syndrome, venous thromboembolism, fat embolism, rhabdomyolysis (breakdown of skeletal muscle), and hypovolemic shock. Although most musculoskeletal injuries are not life threatening, open fractures, fractures accompanied by severe blood loss, and fractures that damage vital organs (e.g., lung, heart) are medical emergencies requiring immediate attention. Compartment Syndrome Compartment syndrome is a condition in which swelling and increased pressure within a limited space (a compartment) press on and compromise the function of blood vessels, nerves, and/or tendons that run through that compartment. Compartment syndrome causes capillary perfusion to be reduced below a level necessary for tissue viability. Compartment syndrome usually involves the leg, but can also occur in the arm, shoulder, and buttock. Thirty-eight compartments are located in the upper and lower extremities. Two basic causes of compartment syndrome are (1) decreased compartment size resulting from restrictive dressings, splints, casts, excessive traction, or premature closure of fascia; and (2) increased compartment contents related to bleeding, inflammation, oedema, or IV infiltration. Oedema can create sufficient pressure to obstruct circulation and cause venous occlusion, which further increases oedema. Eventually arterial flow is compromised, resulting in ischemia to the extremity. As ischemia continues, muscle and nerve cells are destroyed over time, and fibrotic tissue replaces healthy tissue. Contracture, disability, and loss of function can occur. Delays in diagnosis and treatment cause irreversible muscle and nerve ischemia, resulting in a functionally useless or severely impaired extremity. Compartment syndrome is usually associated with trauma, fractures (especially the long bones), extensive soft tissue damage, and crush injury. Fractures of the distal humerus and proximal tibia are the most common fractures associated with compartment syndrome. Compartment injury can also occur after knee or leg surgery. Prolonged pressure on a muscle compartment may result when someone is trapped under a heavy object or a persons limb is trapped beneath the body because of an obtunded state such as drug or alcohol overdose. Clinical Manifestations. Compartment syndrome may occur initially from the bodys physiologic response to the injury, or it may be delayed for several days after the original insult or injury. Ischemia can occur within 4 to 8 hours after the onset of compartment syndrome. One or more of the following six Ps are characteristic of compartment syndrome: (1) pain distal to the injury that is not relieved by opioid analgesics and pain on passive stretch of muscle traveling through the compartment; (2) increasing pressure in the compartment; (3) paraesthesia (numbness and tingling); (4) pallor, coolness, and loss of normal colour of the extremity; (5) paralysis or loss of function; and (6) pulselessness, or diminished or absent peripheral pulses. Collaborative Care. Prompt, accurate diagnosis of compartment syndrome is critical.17 Perform and document regular neurovascular assessments on all patients with fractures, especially those with an injury of the distal humerus or proximal tibia or soft tissue injuries in these areas. Early recognition and effective treatment of compartment syndrome are essential to avoid permanent damage to muscles and nerves. Carefully assess the location, quality, and intensity of the pain (see Chapter 9). Evaluate the patients level of pain on a scale of 0 to 10. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Pulselessness and paralysis (in particular) are later signs of compartment syndrome. Notify the health care provider immediately of a patients changing condition. Because of the possibility of muscle damage, assess urine output. Myoglobin released from damaged muscle cells precipitates and causes obstruction in renal tubules. This condition results in acute tubular necrosis and acute kidney injury.   Common signs are dark reddish brown urine and clinical manifestations associated with acute kidney injury (see Chapter 47). Elevation of the extremity may lower venous pressure and slow arterial perfusion. Therefore the extremity should not be elevated above heart level. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome. It may also be necessary to remove or loosen the bandage and split the cast in half (bivalving). A reduction in traction weight may also decrease external circumferential pressures. Surgical decompression (e.g., fasciotomy) of the involved compartment may be necessary (Fig. 63-15). The fasciotomy site is left open for several days to ensure adequate soft tissue decompression. Infection resulting from delayed wound closure is a potential problem after a fasciotomy. In severe cases of compartment syndrome, an amputation may be required. DEFINITION Compartment syndrome is a condition that  occurs when elevated pressure within a limited  space compromises the circulation, with  increased risk of irreversible damage to its  contents and their function. Acute compartment  syndrome is a surgical emergency.   ICD-10CM CODES 958.90 Compartment syndrome unspecified   958.90 Compartment syndrome, not  otherwise specified T79.A0 Compartment syndrome,  unspecified, initial encounter   M79.A11 Nontraumatic compartment  syndrome of right upper extremity   M79.A12 Nontraumatic compartment  syndrome of left upper extremity   M79.A19 Nontraumatic compartment  syndrome of unspecified upper  extremity   M79.A21 Nontraumatic compartment  syndrome of right lower extremity   M79.A22 Nontraumatic compartment  syndrome of left lower extremity M79.A29 Nontraumatic compartment  syndrome of unspecified lower  extremity   M79.A9 Nontraumatic compartment  syndrome of other sites   T79.A19A Traumatic compartment syndrome  of unspecified upper extremity,  initial encounter   T79.A21A Traumatic compartment syndrome  of right lower extremity, initial  encounter   T79.A22A Traumatic compartment syndrome  of left lower extremity, initial  encounter   T79.A29A Traumatic compartment syndrome  of unspecified lower extremity,  initial encounter   EPIDEMIOLOGY   DEMOGRAPHICS   Occurs most commonly after acute trauma,  especially with long bone fractures, comprising  75% of cases.   It usually occurs in persons Incidence is higher in males.   It can occur in other parts, such as the foot,  thigh, gluteal region, and abdomen.   Supracondylar fractures in children can commonly  lead to compartment syndrome.   6% to 9% of open tibial fractures are complicated  by compartment syndrome.   It is seen in all races and ethnicities.   PATHOPHYSIOLOGY   Compartment syndrome occurs when the blood  flow is less than the tissue metabolic demands,  causing tissue injury. It occurs when the intracompartmental  pressure increases limiting  venous outflow with rising venous pressure,  resulting in compromise of the local circulation  and tissue hypoxia with decreased arteriovenous  pressure gradient. Venous congestion additionally  leads to tissue edema and interstitial pressure,  and the compartment pressure continues to  increase. Compartment pressure ranges between  10 and 30 mm Hg of diastolic pressure are able  to cause the condition.   Different conditions are known to cause compartment  syndrome:   Conditions that limit compartment volume, such  as when patients have fracture casts, when  sedated or comatose patients lie on a limb for  a prolonged period, or when patients have tight  dressings that are applied externally.   Conditions that cause increased compartment  content, such as bleeding in the compartment  from vascular injury or diathesis, fractures or  finger injuries, reperfusion after ischemic injury  such as embolectomy and arterial bypass  grafting, severe bruising of muscle, and thermal  or electrical burn injuries.   Other injuries, such as extravasation of intravenous  fluids, injection of recreational drugs,  and snake bites.   PHYSICAL FINDINGS CLINICAL   PRESENTATION Signs and symptoms are usually apparent but  can be unreliable and can lead to delayed  diagnosis. Acute compartment syndrome can  worsen within hours; therefore serial examination  is important in a patient with suspected  compartment syndrome. Patients with tense  painful limbs are considered to have acute  compartment syndrome; however, diagnosis  is confirmed with the assessment of elevated  compartment pressure. Clinical signs and  symptoms include the following:   Pain disproportional to injury (the earliest sign)   Constant deep pain and pain that is referred  to the compartment on passive stretching  of the muscles of the affected compartment   (Fig. E1C-84, A) Reduced sense of touch or sensation (hypesthesia) within the territory of the nerve passing the compartment (in acute anterior  compartment syndrome, the patient may  have hypesthesia in the territory of the first  webspace)   Tense and swollen compartment (Figs. E1C-  84, B and 1C-84, C)   Muscle weakness   Paresis (late finding) that suggests permanent  muscle damage   Capillary refill can be slow but normal.   Peripheral pulses that are normally palpable  even in severe conditions   Tingling and numbness in the affected limb.  Hypesthesia or paresthesia should be evaluated  with pinprick, light touch, and two-point  discrimination tests.   Difficulty moving the extremities.   DIAGNOSIS Diagnosis is based on clinical signs and  symptoms along with compartment pressure.   Compartment pressure testing may be unnecessary  if the diagnosis is clinically obvious.   DIFFERENTIAL DIAGNOSIS Muscle strains   Cellulitis Gangrene Peripheral vascular injury Necrotizing fasciitis Stress fractures Deep vein thrombosis and thrombophlebitis Tendinitis Muscle contusion Tarsal tunnel syndrome Posterior ankle syndrome Popliteal artery impingement Claudication Tumor Venous insufficiency LABORATORY TESTS Diagnosis is based on clinical findings and  the measurement of compartment pressures.   Laboratory values are not useful in the diagnosis  of compartment syndrome but are important  for other diagnoses or associated conditions.   CBC with differential for evaluation of infection   Creatine phosphokinase (CK) levels, which  can rise as muscle injury develops   Metabolic panel for the assessment of electrolytes  and renal function   Coagulation profile for bleeding diathesis   Urinalysis for rhabdomyolysis   Urine and serum myoglobin levels   Compartment Syndrome   A B FIGURE 1C-84 C: A, Severe calf swelling due to  anterior and posterior compartment syndromes  after ischemia-reperfusion. B, Appearance after  emergency fasciotomy. Note edematous muscle  and hematoma. (Courtesy Michael J. Allen, FRCS,  Leicester, UK. From Floege J et al: Comprehensive  clinical nephrology, ed 4, Philadelphia, 2010,  Saunders.) http://internalmedicinebook.com   Compartment Syndrome 307 Diseases and Disorders IMAGING STUDIES Direct intracompartmental pressure measurement  can be done by handheld manometer,  wick or slit catheter technique, and simple  needle manometer system. Compartment   syndrome is diagnosed when the difference  between diastolic blood pressure and compartment  pressure (Ά pressure) is à ¢Ã¢â‚¬ °Ã‚ ¤30 mm Hg.   Ultrasonography can be used to rule out deep  vein thrombosis, or Doppler ultrasonography  can be used to evaluate blood flow to the  extremity. Arteriography should be used to  evaluate the adequate blood flow through a  compartment. Near-infrared spectroscopy and technetium-  99m methoxyisobutylisonitrile scintigraphy  can also be used.   Radiography can be used on the affected  limb for fracture or foreign body evaluation.   TREATMENT   Treatment goal is to keep intracompartmental  pressure low and prevent tissue injury (Fig.  1C-84, D). NONPHARMACOLOGIC THERAPY Immediate relieving of all external pressure  on the affected compartment   Removal of casts, splints, and dressings   Placing limb at heart level to avoid decreased  or increased blood flow   ACUTE GENERAL Rx   Analgesics for pain Hyperbaric oxygen Hypotension can worsen tissue ischemia and  thus should be treated with IV isotonic saline. Fasciotomy of the affected compartment  is indicated if there has been >6 hr of  limb ischemia, or immediate decompression  should be performed when the compartment  pressure > 30 to 35 mm Hg.   Measurement of compartment pressure is  not necessary to perform fasciotomy if clinical  suspicion is high depending on history  and clinical examination.   When compartment pressures are trending  downward, it is often safe to delay emergent  fasciotomy, provided the Ά pressure is also  improving. CHRONIC Rx   Aftercare of fasciotomy wound: Wound is  inspected after 48 hours and dead tissue is  removed.   Wounds are left open, requiring later skin  grafting or delayed wound closure.   Opsite sheet and boot lace techniques are  also used for closing fasciotomy wounds.   Concomitant fractured bones should also be  stabilized with plating, external fixation, or  intramedullary nailing.   DISPOSITION With early diagnosis and treatment, the prognosis  is excellent for recovery of the muscles and  nerves inside the compartment. The following  conditions can be prevented:   Permanent nerve damage/paralysis   Muscle contracture Gangrene Amputation Muscle necrosis Fracture nonunion Rhabdomyolysis that leads to renal failure Compartment syndrome that can occur in  open fractures Permanent nerve injury, which can occur after  12 to 24 hr of compression; mortality rates in  patients who need fasciotomy is à ¢Ã¢â‚¬ °Ã‹â€ 15%. REFERRAL Patients with suspected compartment syndrome  should be referred promptly to orthopedic  and general surgery. PEARLS CONSIDERATIONS Universal precautions and aseptic measures are necessary for patients undergoing fasciotomy because the risk of local and systemic infection is high with the procedure. Invasive monitoring techniques should be undertaken with adequate analgesia so that patient immobility is ensured while the pressure is measured. Injection of local anaesthetics into the compartment can increase the pressure and pain and therefore should be avoided. Patients with fracture casts should be informed about the risks of swelling, and patients should also be encouraged to wear appropriate equipment while playing sports. A history of coagulation disorders and the use of anticoagulants should be mentioned in a patients medical history. Assault Assault has two different interpretations. 1. Traditionally called common assault and consisting of the making of an unlawful and intentional (or possibly only reckless) threat to inflict imminent force against the person where the victim was aware of the threat.   A distinction was previously maintained at common law between common assault and battery.   Increasing codification of criminal law has resulted in abandonment of this distinction and in Australia assault now commonly refers both to common assault and actual infliction of force.   Statutory provisions for the different states are numerous and terminology varies (e.g. offences of causing injury or threatening). 2. One of three ma