Medical Marijuana Essay Example | Topics and Well Written Essays - 750 words - 2

Medical Marijuana - Essay Example I, therefore, agree with the medical findings on the use of marijuana for medical reasons and the benefits of medical marijuana. The use and legalization of marijuana have led to controversies in the society. These controversies consist of opposing views on medical marijuana; there are those who are in support of its use and legalization and those who are against its use and believe its use should be banned. According to studies done thoroughly by the medical research and studies, the use of marijuana does show positive signs of relief when used in the treatment of various medical illnesses. Diseases such as arthritis, depression, HIV, cancer and other chronic conditions affect a huge percentage of the society’s population today. With no treatment at all or few treatment and cures for these medical conditions, the use of medical marijuana has been a good alternative to alleviate the suffering faced by these people having these illnesses. Marijuana content contains ingredient referred to as tetrahydrocannabinol (THC) which is active. After smoking marijuana, this ingredient gives the individual a  "high† feeling. According to the American Cancer Society, the active ingredient in marijuana helps in reducing pain and other cancer symptoms. With these concrete research report, the FDA has agreed on the use of tetrahydrocannabinol in marijuana for therapeutic and medical purposes (Anderson, Hansen, & Rees, 2012). Despite the fact marijuana, use for medical reasons may have positive effects on some medical illnesses and conditions; on the other hand, it also has its negative effects. Most of the population in the society knows that marijuana is an illegal drug. Approximately seventy-eight percent of marijuana users in the society smoke marijuana for recreational purposes as well as personal enjoyment. For this purpose, this drug is made illegal in most countries. The law

Book report Essay Example | Topics and Well Written Essays - 1500 words

Book report - Essay Example The Author Ernest Miller Hemingway is an American author who had been actively writing between 1920’s and 1950’s. Due to his influence in modern literature, he had been awarded with a Nobel Prize in Literature in 1954. During that time, his work under study which is Across the River and into the Trees had already been published. Hemingway’s reputation can be attributed to the character of his works which belong in the identity of the 20th century works of literature, specifically fiction. His capability to present influential characters in his fiction works that can relate to people is considered to be one of his most notable capabilities (Bloom 25). Ernest Hemingway originated in Oak Park, III. He was born on July 21, 1899 and was observed to have an inclination in writing even at a young age. In the school paper, Hemingway already contributed notable articles. In 1925, after his career in the United States as a cub reporter and as a volunteer Red Cross ambulanc e driver, he moved to Paris which became the mark of his career as a novelist. He documented the said stage in his life and actively made important contributions to the literary world (Hemingway 1998, p. 27). Hemingway made and published the novel Across the River and into the Trees during the peak of his career. His main inspiration in writing the story was deeply rooted on the trip during the fall of 1948 when he visited Italy. Venice is the main location of the plot and the place of inspiration in the story (Hemingway 1998). The Plot of the Novel The novel is about the Richard Cantwell, who is a war veteran, scarred and experienced in battles. The story happened during the winter of 1949, in the post-war period in Venice, Italy and the surrounding area. The main character is a colonel who can be considered as a sad man. Although he is not that old, he had the sadness that is beyond his years due to the experiences that he had already been through (Hemingway 1959, p. 1; Kellman 7) . Colonel Cantwell, regardless of his character, fell in love with a young and beautiful Italian countess. The love and passion between the two characters can be considered as one of the most important factors of the story. This feeling in addition to torment, passion, courage and even the feeling of death are the main themes represented in the story (Hemingway 1950, p.1). The plot started as the main character Colonel Cantwell, a 50 year old man, went on a duck hunting trip in Trieste. This constituted the first chapter of the novel which was set in the present time. The scene wherein he rode a boat was dramatically expressed in a form that depicts parallelism of being in a war (Hemingway 1959, p.5). This can be attributed to the fact that the main character is continuously living in his past which is being part of a war. The next consecutive chapters dealt with the flashback of memories in the life of the protagonist. Through the 38 chapters, the life of Colonel Cantwell during th e early part of his life had been recounted. This is considered as one of the highlights of the novel since the author was able to present a realistic and affective presentation of events in the life of the protagonist. The message of the novel had been presented in an approachable manner through the narration of the main character which gives access to the inner self and brings the

Human Resource Management and Personnel Management Essay Example for Free

Human Resource Management and Personnel Management Essay Introduction 1. This report discusses the historical development of Human Resource Management (HRM), identifies the role and purposes of HRM, and also to distinguish between personnel management and HRM. The Chartered Institute of Personnel and Development (CIPD) defines personnel management as the part of management concerned with people at work and with their relationships within an enterprise. It aims to bring together, and develop into an effective organisation, the people within an business, having regard for the welfare of the individual and of working groups, to enable them to make their best contribution to its success. HRM may be defined as a strategic and coherent approach to the management of an organisations most valued assets: the people working there who individually and collectively contribute to the achievement of its objectives for sustainable competitive advantage. The Nature and Development of Personnel management 2. HRM obtained acknowledgment in the late 1970s in the USA, as a label for the way companies such as IBM were managing their people. These companies applied the principles outlined by David Guest (1989) to gain a competitive edge over their competitors. These four principles are listed below. a) Strategic integration -the ability of organisations to integrate HRM issues into their strategic plans, to ensure that the various aspects of HRM cohere and for line managers to incorporate a HRM perspective into their decision making. b) High commitment people must be managed in a way that ensures both their genuine behavioural commitment to pursuing the goals of the organisation and their attitudinal commitment, reflected in strong identification with the organisation. c) Flexibility HRM policies must be structured to allow maximum flexibility for the organisation, so it can respond to ever changing business needs: for example, by encouraging functional versatility in employees and by creating an adaptable organisational structure with the capacity to manage innovation. d) High Quality The notion of quality must run through everything the organisation does, including the management of employees and investment in high-quality employees, which in turn will bear directly on the quality of the goods and services provided. Personnel management can be traced back to second half of the nineteenth century when Victorian workers were hit hard by the industrialisation, and urbanisation of Britain. Companies such as Cadbury and Rowntree, initiated programmes for their employees managed on their behalf by industrial welfare workers, the philosophy behind these people was that in the welfare tradition, the work and responsibilities of the personnel officer was directed to the employees, rather than to the strategic concerns of the organisation and its management. The programmes included facilities such as company housing, health care, education for workers families and so on. The motivation for these measures included, that they reflected a wider social reform, led by political and religious groups. In the USA groups like Quakers were abolishing slavery, and striving to increase business performance by the moral and social enhancement of their employees. Moreover, as more motivation to convert to these programmes, improved health and education for the workers and their families meant that these employers would have a better reputation with employees and consumers, employees would be more committed and motivated, also there would always be great demand for a job within the company. This can be linked to Maslows theory on the hierarchy of needs, in which he states that workers are motivated by five different needs. Physiological- pay, holidays (lower order need) Safety Health and safety measures, pensions (lower order need) Social formal and informal groups, social events (lower order need) Self-esteem power, promotion (higher order need) Self-actualisation challenging work, developing new skills (higher order need) These programmes and jobs would provide something for each of the lower order needs, therefore increasing motivation throughout the workforce. Furthermore, consumers would feel morally better as they were buying products that were helping the working classes. This could be considered very similar to the ideas linked with the popularity of fair trade products in modern day society. The demise of the working class was outlined at this time when the British government had problems recruiting troops for the Crimean and Boer wars, as many people failed the medical, and the health of the nations labourers was brought into the limelight. The need for negotiation, conflict resolution and the management of relationships between labour and management occurred in 1871 with the legislation of trade unions. This was recognised politically, with formation of the aptly named Labour Representation Committee in 1900, which was renamed in 1906 as the Labour party, which was largely funded by the trade union development. In 1911, the National Insurance Scheme created the first welfare provisions for workers in the result of illness, or unemployment. The establishment of the Ministry of Labour to address wider issues and representations quickly followed this in 1916. In the 1930s and 40s management theorists changed attributes of their theories, as scientific management which was in current use came under scrutiny for dehumanising employees. This is when the HRM approach began to appear, being backed by Maslow, Herzberg, and McGregor who shifted their attention to the higher order needs, as shown above on Maslows hierarchy of needs. The new key to motivation of the workforce involved job satisfaction, which it was then believed, could not be achieved just from maintenance factors like pay and working conditions. The governments influence on industrial relations, and the workforces continued until the mid 1970s in conjunction with social reforms in health and education. After this time the UK government did not interfere in collaborated relationships between the employer and employee, with the exception of trade union reform. In spite of that the latter half of the twentieth century saw extreme legislation in all sectors of employment. It was during this era that the industrial relations tradition suggests that the work and the responsibility of the personnel officer was to mediate and even arbitrate between the sides in industrial disputes, to facilitate collective bargaining, negotiation and compliance with the current industrial relations laws. As a response to the escalating speed of organisational expansion and alterations, the control of labour tradition suggests that the work and responsibility of the personnel officer is to support management by regulating the range of workplace activity. This includes job allocation, performance, absenteeism, pay, communication, training, and so on. The CIPD have endeavoured to establish personnel management as a career, by providing a programme of learning resulting in a qualification. However, many personnel managers do not posses this qualification and this is rarely seen as an obstruction within the career. It is safe to say that all personnel managers will use remnants of the welfare, industrial, and the control of labour traditions to become part of the professional tradition that is occurring today. The Role and Tasks of the Personnel Function 3. Personnel specialists can take various roles like line mangers, advisors, service providers, auditors, Co-ordinators and planners and in todays modern world of rapidly developing technology, ethics, and growing organisations in any business there is need for specialist advice on personnel matters, whether it is internal or external. This is because the practise of personnel management needs to be consistent, impartial, proficient and on course with organisational goals, as there are constant developments in this field that require expertise in the area of personnel management. The need for this specialist has several contributing factors including the need to comply with changing regulation and legislation, for example the personnel specialist may be used to recruit staff to avoid sex or racial discrimination. Constant changes within the labour market have also meant that policies need to be designed by someone with current knowledge on the matter. Moreover, trade unions, industrial tribunals, and the Advisory, Conciliation and Arbitration Service (ACAS) have a continuous role in employee relations; therefore having some one who is familiar with the legislation amongst other things that is used would be very useful. However, since there the existing role of the personnel manager is so diverse there are different models derived by different theorists. A popular model is that suggested by Tyson and Fell (1986). The three roles that they suggest are: * The clerk of works model all authority for actions is with line managers. Personnel policies are formed after the actions that created the need. Policies are not integral and are short term and ad hoc. Personnel activities are routine and involve day-to-day administration. * The contracts manager model Policies are established, often implicit, with heavy industrial relations emphasis. The personnel department will use fairly sophisticated systems especially with regard to employee relations. The personnel manager is likely to be a professional or experienced in industrial relations. They should take on the role of policing the implementation of policies, but does not create them. * The architect model Explicit corporate personnel policies exist as part of the corporate strategy. HR planning and development are important concepts. The head of the function is likely to be on the Board of Directors, and is therefore seen as a professional, making an important contribution to the business. Policies are often formed to assist in the personnel function to make sure that people are treated equally, and that laws and regulations are met. These can include equal opportunities, disciplinary policies, and safety policies. The policies are based upon legislation put in place by the Government and the EU in certain areas like safety. The values and philosophies of the business about how the employees should be treated and what kind of behaviour will enable them to work most effectively on the organisations behalf. The needs and wants of employees, and the organisations need to attract and retain the kind of employees it wants by its reputation of practice as an employer. The Shift in Approach Which Has Led to the Term HRM 4. Throughout history the social change has been reflected in personnel management, and which also changes in conjunction with the social needs. This is shown by the implementation of legislation and rules, to stop discrimination and aid safety measures, as the social climate becomes more morally aware of the workforce. In the late nineteenth century it would not have been unheard of for people to die at work, even into the twentieth century there were still accident that occur to labourers working in primary industries, but this became more shocking, as with the development of technology it was publicised by the media and made safer by improvements, as a company realised that its image was very important. A political and economic change is also evident through out history, for example in the 1970s when the government would no longer interfere with some matters between employer and employee relations, this is because it was realised that full employment was not as important as controlling inflation and other economic factors. Also HRM has become common through out the business world and is thoroughly integrated into the organisational structure of a business. This is because it has been found that companies use this approach in different strengths to achieve a competitive edge over their rivals. Today companies like Marks Spencer, McDonalds, and even public sector businesses like British Gas are using various strengths of HRM. Recommendations 5. To draw conclusion, it is my recommendation that Phoenix Tannoy Ltd. consider establishing a HR department as it is shown in history that the use of HRM does give a competitive edge over rivals, by motivating employees. The reality is that by moving to a HR department Phoenix Tannoy will motivate its workforce by implementing policies and procedures that benefit all the staff. Motivated staff are then more committed to the organisation, and motivated into doing the best they can to help the business achieve its goals. Moreover, a HR department would remove the depersonalised face of the personnel department and make the company less bureaucratic.

The United States Constitution Its Strengths And Flaws Politics Essay

The United States Constitution Its Strengths And Flaws Politics Essay In the late 18th century, the United States Constitution was designed as a foundation to build a stable governing structure for the 13 states that composed the United States around that time. These states were relatively different and consisted on predominantly rural and agrarian societies. Moreover, the same document regarded by these states as the supreme law of the land, serves the exact same purpose today as it did back in the day. The 200 year old Constitution of the United States, by far the oldest charter of government in the world, faces a time of increasing urbanization and technological developments. Nonetheless, its effectiveness at guiding this nation and providing individual freedom, economic stability, economic growth and social development has proven to be substantially enduring over the years. The United States Constitution is often referred to as a living constitution, because of its adaptability to the emerging and ever changing political and social views, needs and demands of Americans. Moreover, its enduring nature in a world of continued change has served as a role model for the evolution of numerous governmental institutions and their respective constitutions around the world. Its self-correcting and self-regulating nature made possible through amendments, the constitutional supremacy it embraces, the bill of rights, the separation of powers and its simplicity of design are major strengths of the constitution. The Constitution is a timeless document due to the adaptability of its nature. It was designed so that it could be amended as the needs of Americans changed over time. However, the founding fathers were well aware that amending the constitution should require significant complexity to avoid the approval and ratification of ill-conceived amendments. Moreover, they made sure that amending the constitution was in the best interest of the majority as opposed to a select few by putting into effect a dual process that Amendments must undergo in order to be approved and ratified. Furthermore, amendments are subject to judicial review by the courts, a process that originated from the Marbury v. Madison case and allows the courts to review and revoke unconstitutional measures carried out by other branches of government. The Constitutions supremacy draws the boundaries along which state governments and congress adopt and ratify legislation. Despite its supremacy the Constitution is not entirely the absolute authority for it can be amended by the people through their participation in open elections aimed to provide political representation in the various structures of government. Appointed and elected officials are subject to be removed from office under the constitution if convicted of treason, bribery, or other high crimes and misdemeanors; which serves as an intensive to fulfill their constitutional duties, that is with the exception of lifetime appointees of the supreme court and/ or federal judges. The reasoning behind such exception is to eliminate the impact external influences often have on public officials. The establishment of a Bill of Rights in the Constitution serves as a mean to protect the natural rights of the people. It is composed of the first ten amendments added to the constitution which aimed to protect individual freedoms from the government. The first amendment is perhaps one of the most important since it addresses delicate issues such as the separation of church and state allowing for freedom of religion. Also, it establishes freedom of speech, press, the right to assembly, right to petition the government, and protects individuals not only from the government but from each other by restricting libel. Moreover, subsequent amendments address other issues such as the right to bear arms, search and seizures, prohibition of self-incrimination, the right to trial by jury and counsel, reservation of powers to the state and people powers, among others. In addition, it has a significant influence on laws and policy-making under the principle for the people and by the people. It is the Bill of Rights along with other factors that distinguishes the United States from other less successful democracies around the world. The separation of powers among the three dominant structures of government is another strength of the Constitution. It allows for the overlap of authority among all government institutions and hinders the concentration of power in one of these institutions. Foremost, the Constitutions simplicity of design outlines the government structures and designated functions. Yet, it does not specify how power is to be distributed among the government institutions, resulting in an ambiguity that has made it possible for the Constitution to successfully guide the United States in the desired direction. Nevertheless both of these have been a source of conflict and harshly criticized for the broadness of the power allocated to the structures of government. As can be appreciated, the United States Constitution is deeply flawed, to the point where some of its strengths represent major threats to its original purpose put forth by the founding fathers. Although federalism is vital to avoid the concentration of power in a single structure of government, it blurs the concept of the separation of powers by providing the national government with sufficient protection to surpass the power allocated to states. In the time being there is not an easy approach to deal with this dilemma; however, it is not terribly hindered to solve as to set it aside for another 200 hundred years. Therefore, one of the first measures to deal with the problem in question is to narrowly draw the jurisdictional boundaries in order to define the power reserved for each structure of government, so that no structure has an unfair advantage over another. Such a measure should address the insufficient protection given to the states as compared to the national government. Another weakness of the United States Constitution is Congressional stagnation. The absence of term limits in Congress has proven to be an issue of high debate among politicians. It seems reasonable to argue that term limits in Congress would result in inexperienced individuals taking roles which have been adequately fulfilled by previous political officers and that the degree to which they represent their constituents as well as their ability to do is questionable. Nevertheless, it is crucial to point out that a large majority of incumbents, that is those currently in office, get reelected [INSERT STATS] to a point where most Congress representatives have rather established a career in Congress. Their reelection is primarily due to the low turnout of elections since the public is less involved in these elections as compared to presidential elections, name advertisement and credit obtained from the service provided to their constituents. Because elections take place every two years, reelection is the main drive for incumbents, which includes obtaining name recognition among their constituents and service credit within their districts. Incumbents aim to meet the interests and demands represented by the majority of constituents, which has proven to be very problematic due to the emerging concerns regarding whether they act as puppets to secure their seat or act in the faith of making a difference for their constituents by having their voices heard. Either way, incumbents enjoy unfair advantages over competitors since they are allotted higher campaign funds than subsequent competitors, for instance through free mail. Additionally, due to the large sums necessary to fund a successful campaign and the diminished chances of election when running against incumbents, the number of candidates is inconsequential, limiting the choices of voters. Lastly, the long term retention of office by legislators may result in corruption, through the means of lobbyists seeking that legislators address their cause which may not be related or benefit by any means the constituents that such legislator represents. The need to have checks and balances for Congress is evident; which constitutes the reason why term limits should be implemented in Congress. The power to establish term limits is delegated to the states and the people and further protected under the 10th amendment. Therefore, a state can propose an amendment by obtaining a two-thirds majority of state legislators to call for a constitutional convention, after which legislators must ratify the amendment with a three-fourths majority. Similarly the house and senate members can propose such amendment, which is very unlikely to occur due to the fact that the ratification of term limits will affect their personal interests. On similar grounds, the Electoral College has been harshly criticized since the purpose it served 200 years ago is viewed as rather outdated today. This election system is not only compelling in terms of its design but also the extent to which it is representative of the popular vote in presidential elections. For instance, in the 2000 election featuring George W. Bush running against Albert Arnold Gore for the presidency, Al Gore won the popular vote; however he did not win the election. Therefore, it is legitimate to question how accurately do outcomes of the Electoral College reflect the will of the people. Moreover, because the number of electoral votes allocated to states relies primarily on the number of district and house representatives of the states, it gives larger states the power to influence the outcome of presidential elections. Since larger states are delegated such power, most presidential candidates focus their campaign and attention on the states with the most elect oral votes; therefore, smaller states have a disadvantage regarding their political involvement in presidential elections and the value of their vote as compared to larger states and voter turnout can be further discouraged. The Electoral College can also result in a minority president being elected It is not terribly difficult to acknowledge that the removal of the Electoral College is by far the best strategy to solve the present situation. Nevertheless, the difficulty lies in designing a system that accurately represents the people. Some politicians argue that providing a representation of the electoral vote proportional to that of the popular vote would ease the problem at stake. However, it is very likely to raise new concerns, especially if both candidates running for office win 50% of the electoral vote, then a method for splitting the vote must be addressed, which complicates the nature of the Electoral College and furthermore defeats the initial purpose of correcting the flawed design of such institution. One way to do this without further complications is by establishing a direct vote system in which all individuals have an equal say in presidential elections and are equally pursued by the candidates running for office. Please discuss the suitability of the Constitution as a governing document for the contemporary United States. What are the strengths of the Constitution?   What are some of its weaknesses?   Should we attempt to reform the Constitution?   If so, why?   If not, why not?   You should rely heavily on course materials, but feel free to use any outside material that will help your argument. Is it public officials or government officials? Are supreme court justices and federal judges public officials too as compared to senators and house members? Paragraph about the separation of powers. Am I making my point clear enough, since its rather a transition into the weaknesses? Purposely chose it.. As can be appreciate ità ¢Ã¢â€š ¬Ã‚ ¦Is this contradicting somehow?

Native Son :: essays research papers

Character Actions Defines Their Individual Personalities and Belief Systems Richard Wright's novel, Native Son, consisted of various main and supporting characters to deliver an effective array of personalities and expression. Each character's action defines their individual personalities and belief systems. The main character of Native Son, Bigger Thomas has personality traits spanning various aspects of human nature including actions motivated by fear, quick temper, and a high degree of intelligence. Bigger, whom the novel revolves around, portrays various personality elements through his actions. Many of his actions suggest an overriding response to fear, which stems from his exposure to a harsh social climate in which a clear line between acceptable behavior for white's and black's exists. His swift anger and his destructive impulses stem from that fear and become apparent in the opening scene when he fiercely attacks a huge rat. The same murderous impulse appears when his secret dread of the delicatessen robbery impels him to commit a vicious assault on his friend Gus. Bigger commits both of the brutal murders not in rage or anger, but as a reaction to fear. His typical fear stems from being caught in the act of doing something socially unacceptable and being the subject of punishment. Although he later admits to Max that Mary Dalton's behavior toward him made him hate her, it is not hate which causes him to smother her to death, but a feeble attempt to evade the detectio n of her mother. The fear of being caught with a white woman overwhelmed his common sense and dictated his actions. When he attempted to murder Bessie, his motivation came from intense fear of the consequences of 2 "letting" her live. Bigger realized that he could not take Bessie with him or leave her behind and concluded that killing her could provide her only "merciful" end. The emotional forces that drive Bigger are conveyed by means other than his words. Besides reactions to fear, his actions demonstrate an extremely quick temper and destructive impulse as an integral part of his nature. Rage plays a key part in his basic nature, but does not directly motivate the murders he commits. Rage does not affect Bigger's intelligence and quick thinking and it becomes evident during the interview with Briton. The detective makes Bigger so angry that the interrogation becomes a game to Bigger, a game of logic and wills, of playing the stupid negro, and telling the man exactly what he wants to hear.

Comapring Father/Daughter Relationships in King Lear and A Thousand Acr

Father/Daughter Relationships in King Lear and A Thousand Acres   Ã‚  Ã‚   The bond between a father and a daughter stands as one of the strongest emotional bonds present within many families. From the moment their little girls emerge from the womb to the moment their young women marry, the father reigns as the head of the household, the controller, and the protector. Though this rings true for many families, sometimes Daddy's little girls make all the rules. They possess the ability to acquire what they want through their incessant whining, crying, and batting of their eyelashes. Daddy's little girls assert control over most situations and possess negotiating skills that rival those of the best Wall Street stockbrokers. Pulling at Daddy's heart, Daddy's little girls play their fathers like puppets. Daddy appears as the head, but everyone knows who reigns as the boss. Though a father takes on the leadership role as the male figure head of the family, the role of protector makes the father-daughter bond particularly strong. Fathers protect their little girls from all harm so they proclaim. What happens when something shatters the respect and trust within the father-daughter relationship? What happens if the father hurts the daughter or vice versa? William Shakespeare's King Lear and Jane Smiley's A Thousand Acres delve into the subject of father-daughter relationships. Both works of literature carefully examine the father-daughter theme, but, in King Lear, Lear receives the sympathy and not his sinister, evil daughters, Goneril and Regan, while in A Thousand Acres Larry Cook emerges as the villain, the daughters, Ginny and Rose, emerge as the heroines.      Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   In every family resides the favorite. The favorites get eve... ...es stand as the ones that survive through the storm that rages in their lives. Although some of the heroes ultimately die, Lear of King Lear and Ginny and Rose of A Thousand Acres establish themselves as examples of total self-respect. Though people disrespect them, they persevere and live their lives to the best of their abilities emerging as the only true, heroic characters.    Works Cited Harbage, Alfred. " King Lear: An Introduction." Shakespeare: The Tragedies: A Collection of Critical Essays. Englewood: Prentice-Hall, 1964: 113-22. Knight, Wilson. "King Lear and the Comedy of the Grotesque." Shakespeare: The Tragedies: A Collection of Critical Essays. Englewood:   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Prentice-Hall, 1964: 123-38. Shakespeare, William. King Lear. New York: Scholastic, 1970. Smiley, Jane. A Thousand Acres. Thorndike: Thorndike Press, 1991.

Pressure Ulcers

Feature Strategies to improve the prevention of pressure ulcers Judy Elliott describes a project that sought to improve tissue viability during the patient journey from admission to discharge Summary This article outlines the actions taken by one acute trust to implement evidence-based, best practice recommendations for pressure ulcer prevention. Initially, an exploratory study identified specific areas for practice development, particularly improving early risk assessment, intervention and focus on heel ulcers.Further actions included recruiting tissue viability support workers to promote a pressure ulcer campaign. Prevalence audit results demonstrated improved prevention and reduced prevalence of hospital-acquired pressure ulcers by 6 per cent and heel ulcers by 4. 9 per cent. Further work is required to ensure prevention strategies are consistent and documented. Keywords Best practice, evidence base, pressure ulcer prevention ( Institute for Innovation and Improvement 2009), there fore it is important to seek further initiatives to eliminate avoidable pressure ulcers from NHS care.Tissue damage A pressure ulcer is defined as (European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP) 2009): ‘†¦ localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. ‘ Healthy individuals are continuously moving and readjusting their body posture to prevent excess pressure and shear forces. Reduced mobility or sensation interrupts this natural response, rendering an individual vulnerable to tissue damage.Eurther susceptibility is influenced by an individual's intrinsic risk factors reflected by their tissue tolerance (Bonomini 2003). Individual risk factors include immobility, malnourishment, cognitive impairment, acute and chronic ulness (National Institute for Health and CUnicad Excellence (NICE) 2005). Pressure ulcer preventio n involves the modification of an individual's risk factors by the whole multidiscipUnciry team (Gould et al 2000). Risk assessment Identification of vulnerable individuals can be challenging.Designated risk assessment tools have been found to lack reliability and validity with a tendency to overestimate risk (Pancorbo-Hidalgo et al 2006). The NICE (2005) guideline emphasises the importance of early assessment, within sbc hours, using clinical judgement. Vanderwee et al (2007a) found skin inspection more reliable compared with an assessment tool, with 50 per cent fewer patients identified as requiring intervention cuid no significant difference in patient outcomes. The skin should be assessed for early signs of tissue damage, which November 2010 | Volume 22 | Number 9PRESSURE ULCERS have potentially devastating consequences for patients, hospitals and the overaU hecdth economy. An estimated 5 to 10 per cent of patients admitted to hospital develop pressure ulcers, resulting in incre ased suffering, morbidity and mortaUty (Clark 2002, Redelings et al 2005) and depleting NHS budgets by 4 per cent, or more than ? 2 billion ? mnually (Bennett et al 2004). Prevention is a complex, multifactorial process and although it is accepted that some pressure ulcers are unavoidable, most are considered preventable.Acknowledging the difficulty in establishing national comparative prevalence data because of variances in methodology and settings (Calianno 2007), a prevalence of 21. 9 per cent of patients affected was reported in a pilot study of UK acute hospitals in 2001 (Clark et al 2004). Pressure ulcer prevention is a nursing quality indicator and high impact action for nursing and midwifery (NHS NURSING OLDER PEOPLE Feature Figure 1 I Illustrations showing a correctly fitting chair to ensure sufficient I pressure redistribution and poor sitting posture 1.The patient should be seated with hips and knees at right angles, feet flat on the floor and arms/shoulders supported. Th e patient's weight is evenly displaced through the feet, thighs and sacrum. 2. The chair is too low; the patient's upper legs are not supported, and weight is increased onto the buttocks leading to greater risk of pressure damage. include observable discolouration and palpable tissue changes such as localised bogginess, heat or cold (NICE 2005). International guidelines (EPUAP/NPUAP 2009) advise a structured approach to risk assessment using a combination of all three techniques.Ecirly intervention Once risk is identified immediate action is imperative to minimise risk of pressure ulcer development. As evidence is weak for specific interventions a number of areas should be addressed, involving ecirly initiation of preventive action, improving tissue tolerance and protecting from the adverse effects of pressure, friction and shear (Calianno 2007). Nutrition and tissue loading are two areas of nursing influence. Strategies to ensure optimal nutrition should be used and the provision o f oral nutritioneil supplements has been associated with reduced tissue breakdown (Bourdel-Marchasson et al 2000).Tissue loading may be addressed by manual and mechcinical repositioning, mobuisation and exercise. Strategies to minimise shear forces include addressing posture, moving and handling techniques and use of electric profiling beds (Keogh and Dealey 2001). Positioning and repositioning Research has not established an optimeil frequency of patient repositioning (Defloor et al 2005). Repositioning should be undertaken on an individual basis in Une with ongoing skin evaluation, avoiding bony prominences (NICE 2005).The skin shoiUd be closely monitored to ensure effectiveness of the regimen and further actions taken if ciny signs of tissue damage occur. November 2010 Volume 22 Number 9 A flatter position distributes body weight more evenly. Semi-Fowler (semi-recumbent) and prone positions yield the lowest interface pressures with sitting cind 90-degree side-lying the highest (S ewchuk et al 2006). Repositioning using the 30-degree tuted side-lying position (alternately right side, back, left side) or prone position is advised (EPUAP/NPUAP 2009).The repositioning regimen should be agreed with the patient and will require adaptation to ensure concordance with comfort, symptoms and medical condition. Prolonged chair sitting is impUcated with greater risk of pressure ulcer development (Gebhardt and BUss 1994). Chair sitting should be Umited to less than two hours at ciny one time for the acutely ul at-risk individual (Clark 2009). A correctly fitting chair is important to ensure sufflcient pressure redistribution (Figure 1).Poor sitting posture may cause posterior pelvic tilt (sacral sitting) or pelvic obUquity (side tUting onto one buttock), with the ideal chair allowing feet to sit flat on the floor, with hips and knees at 90 degrees and arm/shoulders supported (Beldon 2007). Support surfaces High specification foam mattresses have demonstrated improved perf ormance in pressure ulcer prevention (Defloor et al 2005), leading assessme Low risk †¢ Use static foam mattress. †¢ Reassess if patient's condition changes. Medium risk †¢ Use static foam mattress. †¢ Implement repositioning regimen. Check skin at least daily. †¢ If any signs of pressure damage request dynamic (air) mattress. †¢ Reassess if patient's condition changes. High risk (contraindicated if patient weighs more than 39 stone (refer to guidelines), has a spinal injury (refer to trauma and orthopaedics) or unstable fracture). †¢ Use dynamic (air) mattress. †¢ Implement repositioning regimen. †¢ Check skin at least daily. †¢ If any further signs of pressure damage increase repositioning programme. †¢ Reassess and step down onto static mattress as patient's condition improves.Remember to apply heel protector boots for patients at risk or with heel pressure ulcers. NURSING OLDER PEOPLE Feature to replacement of standard mattr esses by most hospital trusts. There has also been considerable investment in mechanical (dynamic) support surfaces, where air is pumped through the mattress via alternating pressure or low air loss. However, the benefits of these devices remain unclear in terms of clinlccd and cost effectiveness (Reddy et al 2006). Pressure ulcer incidence rates of 5 to 11 per cent have been reported in studies, with longer use associated with greater risk (Theaker et al 2005).These devices should be considered m conjunction with other support surfaces as delayed or inconsistent use may negate the benefits. Multiple strategies A number of studies have attained favourable outcomes using multiple interventions. Examples include introducing a multidisciplinary working party, improving management of pressure-relieving equipment, educational programmes and developing new guidelines (Gould et al 2000, Catania et al 2007, Dobbs et al 2007). Variations in approach suggest the commitment of practitioners is vital to success. For example, a support surface . howed improved outcomes only when used In conjunction with an educational programme for registered nurses (RNs) (Sewchuk et al 2006). Factors identified as impeding pressure ulcer prevention include lack of time, staffing levels and staff knowledge (Moore and Price 2004, Pancorbo-Hidalgo et al 2006, Robinson and Mercer 2007). Skill mix may also influence outcomes. Horn et al (2005) investigated staffing levels in a nursing home and found fewer pressure ulcers were associated with more direct RN care for each resident. heels' protocolj Apply heel protector boots to patients at high risk of heel ulcers when on bed rest.Assessment criteria include limited mobility and: †¢ †¢ †¢ †¢ I Is patient immobile, heavily sedated or unconscious? Can patient lift his or her leg up in bed? Is there any evidence of heel tissue breakdown, blistering or ulceration? Does the patient have diabetes, vascular or renal disease? experie nces highlighted the challenges in delivering timely, optimal preventive care. Opportunities to improve preventive care during the patient journey from admission to discharge were identified. These processes were influenced by the level of communication and collaborative care.Practice development recommendations included: †¢ Improve early risk assessment and intervention. †¢ Direct resources to the start of the patient journey. †¢ Prevent heel ulcers. Further actions were taken during 2009/10 to develop practice in line with these recommendations. Method Tissue viabUity support workers were recruited for each hospital site to focus on pressure ulcer prevention, in particular managing pressure-relieving equipment. They reclaimed dynamic mattresses and recurected them to admitting areas to enable immediate access ‘at the front door'.They were entrusted with keeping a ‘float' of mattresses in a clean library store and helping with maintenance, decontamination eind training. In September 2009 a trust-wide pressure ulcer campaign was launched. This focused on three Interventions: support surface, positioning and repositioning and heel offloading: 1. Risk assessment within six hours and appropriate support surface (Box 1). A simple flow chart was disseminated highlighting a structured patient pathway, based on NICF (2005) best practice recommendations.Initial risk assessment was encouraged using clinical judgement to help early assessment in the emergency admitting areas. A more detailed assessment was requested during the following 24 hours using the Waterlow assessment tool (Waterlow 1988) to provide risk status confirmation and identify individual risk factors. Patients were assessed as low risk (fuUy mobile and minimal risk factors/Waterlow score 20). All trust static mattresses consist of high specification foam offering protection to all admitted patients. The trust has purchased November 2010 Volume 22 BackgroundAn exploratory study of pressure ulcer prevention was undertaken in the project hospital trust during 2007/08. The trust includes three acute sites covering a large geographical area consisting of more than 1,200 beds and serving a predominantly ageing population. A case study meth(3dology was used to consider the topic from a range of perspectives using quantitative zind qualitative data (Yin 2003). A reduction in overall and hospital-acquired pressure ulcer prevcdence since 2001 was found. Steady reduction in sacral ulcers was observed with the heel emerging as the most common site for hospital-acquired pressure ulcers by 2008.Increased prevalence observed in 2009 reflected revised data collection methods and improved reuabuity with thorough skin inspection. Data were also generated from focus group interviews with multidisciplinary clinicians. Their NURSING OLDER PEOPLE Feature more than 350 dyncimic mattresses and local recommendations prioritise patients at high risk, unless contraindicated. 2. Im plementation of revised positioning cind repositioning documentation. Revised documentation included a visual care plan/ regimen, repositioning chart and skin evaluation for all vulnerable patients. 3. F*revention of heel ulcers.The ‘hecilthy heels' project ran concurrent to the Ccimpaign cind was undertaken from October 2009 to March 2010. Funding was procured for regular provision of heel protector boots that ‘float the heel' and offload pressure to augment the repositioning and positioning programme. A protocol was disseminated aiming to protect patients with high risk factors such as diabetes or early signs of tissue damage located at the heel (Box 2). The annual prevalence audit methodology was revised to improve reliabUity of data collection cind undertciken in Februcuy 2009 and repeated in February 2010.Data was collected by tissue viabibty nurses at the bedside including skin inspection eind related preventive interventions. Previously, ward nurses supplied the d ate using vcirious collection methods. Data analysis was undertaken by the trust's clinical audit team. ulcers as some patients hav e more than one pressure ulcer. Audit results from Februciry 2010 showed a reduction in hospital-acquired pressure ulcer prevcilence by 6 per cent and a reduction in total pressure ulcer prevalence by 4. 7 per cent (Table 1). Prevalence of patients with pressure ulcers had reduced from the previous audit by 2. per cent to 13. 4 per cent (Table 1). More than half of the total inpatient population was assessed as vulnerable to pressure dcimage. This information enables comparison with similar populations and indicates a 2 per cent increase in the population at risk from the previous year. There was also a reduction in all grades/ categories of hospiteil-acquired pressure ulcers (Table 2). The grade (category) of ulcer is used to assess depth of tissue damage, with grades 1 to 2 affecting the top skin layers and grades 3 to 4 including the deeper underlyin g tissues (EPUAP/ NPUAP 2009).The origin of some pressure ulcers was not fully established, mainly because of lack of documentation and appearance of the ulcer (Table 2). There were observable improving standards in best practice and patient comfort and care on the wards. Repositioning care plcinning documentation had improved by 7 per cent but ongoing documented repositioning had reduced by 1 per cent (Table 3). Further improvements are required to meet best practice standards in both cases. Although the heel remained the most common site for pressure dcimage, there was a reduction in hospital-acquired heel ulcers by 4. per cent. Results Benefits beccime apparent during the campaign with observable improvements in patient access to equipment cind eeirly intervention. The results were analysed in terms of patient prevalence (percentage of patients with one or more pressure ulcer) and pressure ulcer prevcilence (percentage of pressure ulcers). The prevalence of pressure ulcers is usu ally greater than the prevalence of patients with pressure Prevalence of pressure ulcers Discussion The tissue viability support workers were instrumental in raising awareness of prevention 009 Number Number of patients Population at risk Prevalence of patients with pressure ulcers Prevalence of pressure ulcers Pressure ulcers acquired in hospital Pressure ulcers present on admission Origin not known (unsure/not completed) Percentage Number 2010 Percentage Change Percentage 976 497 151 242 132 930 51 15. 5 24. 7 13. 5 492 125 186 53 13. 4 20. 0 7. 5 6. 8 5. 7 T2. 0 i 2. 1 J. 4. 7 J. 6. 0 i 0. 8 I2. 2 70 63 53 75 35 7. 6 3. 5 1 November 2010 Volume 22 Number 9 NURSING OLDER PEOPLE Feature in the admitting areas and improving early access to dynamic mattresses.Previously, dynamic systems were often a late intervention, once pressure damage was appeirent, cind competing demands from the wards impeded availability. A structured approach supported fairer allocation, prioritisation by pat ient need and improved availability. The support workers also improved processes by fostering good teamwork with support staff, hospital management teams and nursing departments. Their presence in the ward areas improved preventive care, related protocols and provided a link with the tissue viability nurses.Our experiences suggest that further education and communication are essential to reach a staff. The ‘healthy heels' campaign demonstrated the effectiveness of heel protectors in a prevention strategy. These devices were used for prevention and treatment to ‘float the heel', with resolution of superflcial tissue damage often achieved through continued use. This included the treatinent of superficial necrosis (black heels), which in many cases were kept dry cind allowed to slough off retaining viable deeper tissues, as recommended by EPUAP/NPUAP (2009).The audit results mirror previous reports of less than 10 per cent of hospiteil patients having documented adequate pr eventive care (Vanderwee ef al 2007b). Some nurses expressed concems over time constrEiints and extra paperwork, which may have contributed to a reluctance to adopt revised positioning and repositioning documentation. Communication and education Achievement of best practice standar Best practice standard quired pressujmJceyar^ajeiKe by grad Grade of pressure ulcer Grade 1 Grade 2 Grade 3 Grade 4 Total 2009 Number 59 54 7 12 2010 Number 35 24 6 5 70 Percentage Change Percentage Percentage 6,0 5. 3,7 2,5 0,6 0,5 i 2. 3 4-3. 0 0. 7 1. 2 i 0,1 1 0,7 132 Origin not known (unsure/not completed) Grade 1 Grade 2 Grade 3 Grade 4 16 15 2 2 1. 6 1. 5 0,2 0. 2 23 23 7 0 2,4 2. 4 0. 7 T0. 8 i 0,9 IO. 5 _ Total 35 † 1 issues were other possible factors. The trust operates a link nurse system for tissue viability education that may limit dissemination to all nursing staff. In an audit of 44 UK hospitals Phillips and Buttery (2009) also found a lack of documentary evidence of risk assessment on admission and C2ire planning, together with the need to improve immediate allocation of appropriate resources.Early risk assessment and immediate intervention may also be hcimpered by the focus on emergency care in admitting areas. Robinson and Mercer (2007) identified contextual barriers to pressure ulcer prevention in emergency departments as use of a stretcher and a lack of basic care provision for older Patients having a documented pressure ulcer risk assessment within six hours of admission. Patients with documented risk assessment at time of audit. Patients nursed on appropriate mattress.Patients with a high or medium risk of developing a pressure ulcer with documented evidence of a positioning and repositioning regimen. Patients with a high or medium risk of developing a pressure ulcer with documented evidence of repositioning. Use of heel protectors and offloading techniques (of total number heel ulcers). Ulcers with resolving/treated infection. Prevalence of patients wit h hospital-acquired heel ulcers. 75 79 88 13 T9 11 33 2 7,9 10 4. 1 36 0. 2 3,0 I3 Improved by 1. 8 i 4. 9 NURSING OLDER PEOPLE November 2010 Volume 22 adults.The improvement of resources and processes in admitting cireas is crucial to prevention. Technological advances may cdso have created a culture focused on dynamic systems as the primary intervention. Eurther difficulties may cuise in maintaining individual repositioning schedules in busy hospital Wcirds where competing demands often require a more immediate response. Hobbs (2004) demonstrated improved outcomes when regular repositioning schedules were re-established. Eurther work is required to place the emphasis on patient mobilisation and prevention and away from equipment and treatment.Education and leadership are peiramount to generate this culture shift and rebalance these nursing priorities. Conclusion A comprehensive review of previous and current prevention activity was invaluable in identifying appropriate areas for i mproved intervention. The recruitment of tissue viability support staff assisted with early risk assessment and intervention, particularly in terms of pressure-relieving equipment. A pressure ulcer campaign was useful in raising awareness of three interventions: early risk assessment and intervention, positioning cind repositioning regimens eind ‘healthy heels' project.Audit results from Eebruary 2010 showed a reduction in hospital-acquired pressure ulcer prevalence by 6 per cent and a reduction in total pressure ulcer prevalence by 4. 7 per cent. Heel offloading using heel protector boots was an effective strategy for prevention and treatment of heel pressure ulcers. Although the heel remained the most common site for hospital-acquired pressure ulcers, there was a reduction in prevcilence by 4. 9 per cent. Improvements are indicated in the provision of documentary evidence to support prevention, particularly in terms of risk assessment, positioning and repositioning programme s.This project has demonstrated that responding to organisational specific factors can produce encouraging results in pressure ulcer prevention and identify' areas for continued effort. Dedicated leadership, education, teamwork and commitment are fundamental to continue to improve standards and ensure best possible patient outcomes. Online archive For related information, visit our online archive of more than 6,000 articles and search using the keywords Find out more Copies of the positioning and repositioning regimen can be obtained by emailing the author at: Judy. [email  protected] nhs. ukThis article has been subject to double-blind review and checked using antiplaglarism software. For author guidelines visit the Nursing Older People home page at www. nursingolderpeople. co. uk Judy Elliott is lead tissue viability nurse. East Kent Hospitals NHS University Foundation Trust, Canterbury References Bcldon P (2007) Silting safely to prevent pressure damage. Wound Essentials. 2, 10 2-104. Bennett G, Dealey C, Posnetl J (2004) The cost oi pressure ulcers in the UK. A^e and Ageing. 33, 3, 230-235. Bonomini J (2003) Effective interventions for pressure ulcer prevention. 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