Thorn Queen Chapter Eighteen

The village I'd passed earlier was called Marmant, and I had to get directions from Maiwenn's guards to make sure I didn't accidentally take some twisted Otherworldly path in my attempt to return. I rode there with troubled feelings, still replaying the events with Kiyo and trying to decide if our assorted arguments today had qualified as true fights. I soothed myself a little by reaching out and manipulating the air, creating gusts and eddies and attempting to see how big a blast I could make. At one point, I made a scrubby tree bend pretty far, but it tired me out. I had to practice more to sustain true gale-force winds, and lightning still remained out of my grasp. The people of Marmant greeted me with that same mix of fear and awe I had come to expect. Word of the changes being wrought in the land was getting around, so they were grateful and allowing themselves optimism at last. Yet, my fearsome reputation always lurked on the horizon, so they spoke gingerly around me, fearful of enraging the dangerous monarch who had forced this dangerous land upon them. â€Å"How is everything?† I asked, hoping I seemed concerned and nonthreatening. Rather than a mayor, this town had a council of five that made decisions, and they'd invited me inside for a private meeting. They were ordinary-looking men and women-still with that peasant feel so common in the Otherworld-but there was an air of competence around them. â€Å"You've got water and food now?† â€Å"Yes, your majesty,† said a middle-aged woman who seemed to be the speaker of the group. â€Å"Thank you, your majesty.† â€Å"Good. I'm sorry it's been so hard on you. Things should be better now.† There was a brief silence in the group, one heavy with unspoken meaning. I looked from face to face. â€Å"What?† â€Å"We don't want to trouble your majesty†¦Ã¢â‚¬  â€Å"Trouble away. It's what I'm here for.† This got another round of exchanged looks. It was still apparently an odd concept for these people. â€Å"Well,† began the woman, â€Å"near the outskirts of our town's boundaries, there have been some attacks.† â€Å"What kind?† â€Å"Bandits, your majesty.† â€Å"Son of a bitch,† I said. We'd known the group had moved, but they'd been quiet thus far, allowing me to hope I could take Kiyo up on his offer and deal with them before they caused more trouble. â€Å"We actually have many fighters and strong magic users,† she said with some pride. â€Å"But we could not stand against their monsters.† â€Å"You mean demons.† She gave a nervous nod. â€Å"Son of a bitch,† I said again. This had to be dealt with, and at this point, I really was willing to be a bastard and hold a gun to Jasmine's head. â€Å"Don't worry. They're going to be taken care of. Soon. Very soon.† The woman looked startled at the menacing tone in my voice, but her words were grateful. â€Å"Thank you, your majesty.† â€Å"Anything else I should know about?† This time, it was a man who spoke up. â€Å"We don't want to trouble you†¦Ã¢â‚¬  I groaned. â€Å"Just tell me what it is.† â€Å"We heard your majesty has been seeking missing girls.† I straightened up. â€Å"Yes. What about it?† â€Å"One of ours disappeared two days ago. My neighbor's daughter, Markelle.† A small, wry smile crossed his lips. â€Å"She's a wild one, often wandering off where she shouldn't. But she hasn't come back†¦and she always does†¦.† I felt my fists clenching and forcibly relaxed them. I didn't need to scare these people any further. â€Å"Aside from the bandits, have you seen anyone else lurking around? Humans, maybe?† He seemed even more afraid to discuss this topic. â€Å"We see humans sometimes, your majesty.† I think he thought mentioning my own kind would anger me. â€Å"It's not uncommon. Often there are humans who†¦ah, give chase to some of the denizens of this world.† Shamans like me, he meant. â€Å"Usually, they leave us alone once they've found their quarry.† I thought back to Jasmine. â€Å"Any soldiers or warriors of the gent-shining ones?† â€Å"Occasionally. I presume they're deserters from King Aeson.† Not a bad theory, actually. â€Å"But we see none of them regularly. There's no one in particular who keeps returning.† I leaned forward, some part of me feeling like everything was about to fall together. â€Å"But there is a human you keep seeing, isn't there? Especially since the girls began disappearing?† He nodded. It was here. Everything was here. â€Å"A man, right? A man with a red snake tattoo?† â€Å"No, your majesty.† â€Å"I-what?† I froze for a moment. â€Å"Then who?† â€Å"A woman, your majesty. A woman with graying hair that she wears in a long braid.† I stared at him for several seconds, and then I laughed. This seemed to scare them all more than if I had burst into a rage. â€Å"Abigail,† I said at last, more to myself than them. â€Å"Your majesty?† I waved a hand at them. â€Å"Never mind.† Abigail. Fucking Abigail and Art. Working together to†¦what? Abduct gentry girls? But why? I'd toyed with the idea of Art as some kind of sick rapist, but where did Abigail fit in with this? Surely that would hold no interest for her. With a sigh, I pushed the questions to a small box in my mind, needing to wrap this up and get back to the human world. I needed to have that talk with Roland. â€Å"Anything else going on I need to know about? You've got copper nearby, right?† Finding water and food was naturally essential, but it was copper that was going to truly change things in the Thorn Land. It was what all our trade agreements were being based on. â€Å"How's the extraction going?† â€Å"Slowly until today, your majesty,† the woman admitted. â€Å"Our magic users are skilled in many things, but we have few who can work with metal. Much of our labor has been manual.† I frowned. â€Å"Why did things change today?† â€Å"Why,† she said in surprise, â€Å"because you sent the Oak King to us.† â€Å"The Oak-wait. You mean Dorian?† I exclaimed. â€Å"He's not here now, is he?† They were all clearly surprised at my surprise. â€Å"Yes, your majesty,† said the guy who'd spoken earlier. â€Å"He's out with the workers now. I thought you knew.† I stood up, still full of shock. â€Å"I have to see him. Excuse me.† They all murmured polite farewells and nearly knocked each other over with bows. I didn't stick around to return the formality. Instead, I headed back out into the bright afternoon sun, lightly jogging to where I'd seen the workers on the far side of the village. At first, I saw no indication of Dorian. Men and a few women were digging diligently, sweat rolling down their faces. Then, suddenly, I heard a slight rumbling, and the ground trembled. Huge chunks of rock rose from the earth, a few of them glinting in the sunlight. They lifted in a cluster and then slowly drifted off to the side of the work site, gently coming to rest on a pile of similar stones. Turning, I looked to the opposite side of the area and finally found Dorian, his hands moving in the air as he guided the ore. His clothes were simple today, but that hair burned and rippled in the sunshine like liquid fire. His face was filled with concentration as he watched the rocks, but once they'd come to a halt, he broke into a smile as he strode forward. â€Å"My lady Thorn Queen, what a delight.† I let him kiss my hand for the sake of appearances-seriously, why were the gentry so into that?-and then pulled him out of earshot of the others. â€Å"What the hell are you doing here?† I exclaimed. â€Å"Why, retrieving my copper.† â€Å"That's not what I mean!† He shrugged and wiped sweat off his brow. His devil-may-care expression aside, it was clear he was tired. I grabbed hold of his arm and led him back toward the town. â€Å"Come on, get something to drink before you get dehydrated. And start explaining.† â€Å"I heard there was some difficulty with your copper, and I decided to come help, seeing as it benefits me too. My sword is in need of replacement, you know-and that's not a metaphor. The metaphorical one is just fine. Besides, you don't honestly think I can let you take all the glory as being the most helpful monarch around, do you? You're making us all look bad.† â€Å"Dorian,† I groaned. Because there was really no other response. If people had fallen all over me when I arrived, the two of us together created quite the stir. Again, I was reminded of some celebrity tabloid couple. We returned to the council hall, at which point I used my queenly authority to get some privacy and some refreshment. It was a bit startling to see how quickly my orders were obeyed. Once we were alone and Dorian was sprawled in a chair, I truly got a good look at just how exhausted he was. â€Å"How long have you been out there doing this?† I asked, pouring him water from a pitcher. â€Å"Most of the day. And I'll take the wine, my dear.† He nodded toward a nearby decanter. â€Å"It'll dehydrate you further,† I scolded, handing him the cup of water. He scowled but drank it down eagerly. I watched him, still perplexed. â€Å"But why? You don't need the copper that badly.† â€Å"Perhaps not. But you do.† He finished the water, and I gave him a refill. â€Å"Thank you. Waited on by a queen-truly the dream of many a man.† I pulled over a chair of my own. â€Å"You didn't need to do it,† I protested. â€Å"You've practically killed yourself.† â€Å"Hardly. Give me and my stamina some credit.† â€Å"I still don't get it.† He finished this cup too and then gave me a look that was both exasperated and amused. â€Å"Eugenie, why do you keep having such a hard time believing I'd do things for you?† There was earnestness in his voice, and I realized we kept having this conversation over and over. Out of everyone in my life lately, it seemed like he was the only reliable one. â€Å"I don't know why. I'm sorry. I just run into few people who give something for nothing. Mining isn't going to get me into your bed.† â€Å"Well,† he said cheerfully, â€Å"nobody knows that for sure, but even if not? It doesn't matter. You need it. It makes you happy. End of story.† I looked away. Dorian truly was my friend. â€Å"Thank you. It does make me happy. One less thing in a sea of problems today.† He handed me the cup. â€Å"Get me wine this time, and tell me what your problems are. You can even sit on my lap.† â€Å"No thanks,† I said, but I did get him the wine. â€Å"I saw you and the kitsune pass earlier, actually. Is that part of your problem?† He answered his own question. â€Å"Yes, yes. Of course it is.† I was a bit surprised to hear myself pouring my thoughts out to him again. I didn't even have the excuse of being drunk this time. â€Å"I saw the baby today.† â€Å"Cute?† â€Å"Very. And it just made me feel†¦I don't know. Kiyo thinks it's jealousy, but it's more than that. I just can't explain it.† â€Å"Kind of a questioning of your own life and the choices-or lack thereof-before you?† I looked up, startled, and met his eyes. They were unusually serious. â€Å"Yes, exactly.† Dorian remained silent, and I found myself rambling more. â€Å"He's having a hard time getting all of it lately-the magic, the girls, the demons†¦he doesn't like me spending time over here. Neither does Roland.† I couldn't help a smile. â€Å"Hell, neither do I. But†¦I have to. I have to put things right around here.† â€Å"I know you do,† he said, face serious. â€Å"Dorian†¦what would happen if I got a crown?† This made him a smile a little. â€Å"It would make you look even more beautiful.† â€Å"No, I'm serious. Kiyo says it's a bad idea. That it would make all this real.† â€Å"It's already about as real as it's going to get, my dear.† â€Å"That's what I told him! But I don't get the big deal. You never wear a crown.† â€Å"Not often. But I have one, and I was crowned and all my people swore fealty to me. That's what a crown would lead to. You want one for ornamentation? Sure, that's easy. But put one on and walk out among your people-especially in a city like Highmore-and say, ‘This is who I am, I am your queen†¦' Well, that's what the kitsune fears. You're already queen. No crown can affect that. But you accepting one and declaring your authority is when you truly believe you're a queen. And as far as Kiyo is concerned, that's where the danger is.† â€Å"Wow,† I said, nearly as surprised to have such a thorough explanation from him as I was by the content itself. â€Å"Are you afraid of it?† He snorted. â€Å"Hardly. I don't need a crown to know you're a queen. It radiates off of you. But I would like for you to know you're a queen.† If dealing with all the crap I had on my plate didn't make me think I was a queen, then I didn't really know what else would. I let the crown issue go and instead recapped my latest intel about the bandits and Abigail. â€Å"I can't figure out her role here. You mentioned before that Art's motives would be†¦uh, understandable. But why her? Unless she's just enough of a pal to help him score some gentry action.† Dorian was still in his pensive mode. He'd poured himself yet another glass of wine and handed me one too that I sipped sparingly. â€Å"Let me ask you this. Why do men of the shining ones so often abduct your women?† â€Å"Easy,† I returned. â€Å"Because we're more fertile. You guys might have sex in public, but it doesn't usually result in anything. A guy who wants a kid has better luck with a human.† Dorian nodded. I had a feeling he'd already made some leap of logic and was prompting me here to figure it out myself. â€Å"And what about humans? Are you hoping for children each time you make love?† I laughed, thinking of my stock of condoms and birth control pills. â€Å"Hardly. We go to a lot of trouble not to. Too easy for us.† He leaned toward me, green eyes shrewd. â€Å"Then think about it. You understand why we would want humans. Why would humans want us?† I studied him, trying to catch up to what he'd already thought of. A few moments later, I got it. â€Å"Because you'd fulfill the opposite need. A human could have sex with a gentry girl and not worry too much about her getting pregnant. Or getting a disease.† Gentry were healthier than us in that regard. It seemed to go along with them having such long life spans- â€Å"Oh God. That would be part of it.† The more I followed his logic, the clearer and clearer it became. â€Å"You guys live longer. Gentry girls would stay young and beautiful for a long time†¦.† The horror of it was setting in. Until that moment, I had thought there were few sexual crimes worse than gentry guys consistently trying to rape me to get me pregnant. As shocking as it seemed, I was wrong. If this were true†¦if this idea that Dorian was suggesting was true†¦well. That was worse. Gentry girls taken because they were the ideal sexual partners: young, disease resistant, hard to get pregnant-even with a human. I almost laughed. It was like Tim's poem about the maiden who'd come from another world, whose beauty and youth were so great that mortal men had coveted her. The question was, how did the gentry girls feel about this role? A lot of girls wanting to get pregnant might wholeheartedly embrace human lovers-literally and figuratively. But Moria's traumatized state suggested her stint with Art hadn't been welcome†¦ I stood up and rubbed my eyes. â€Å"Oh God,† I repeated. â€Å"The stuff†¦all the stuff†¦Ã¢â‚¬  â€Å"What?† asked Dorian, understandably confused. Dropping my hands, I looked back at him. â€Å"These shamans, Abigail and Art. They live well. They have more possessions†¦nicer things than they should for the jobs they have.† Art's giant house in an upper-class neighborhood. The shiny SUV. Abigail's luxurious-albeit messy-apartment. Her extensive jewelry collection. â€Å"I don't know how, but they're making money off it. Off these girls.† I slumped against the wall. â€Å"And I don't know what to do about it.† Dorian rose and came to stand by me. â€Å"You'll stop them.† I shook my head. â€Å"It's not that simple. Art was right-there's no shaman council. I can't report them to anyone, certainly not human authorities. There's no accountability, no laws that apply here.† â€Å"They're breaking your laws,† he said, leaning toward me. â€Å"Therefore you have every right to stop them. Treat them as you would any other criminal in your land. Kill them.† â€Å"I can't!† I exclaimed. â€Å"I'd have to actually catch them here, and so far I haven't been able to. And I'm certainly not going to go to Texas and kill them there.† â€Å"Why not? If a murderer from my kingdom killed someone in yours, I wouldn't bat an eye if you came to slay him.† â€Å"It's different. They're†¦Ã¢â‚¬  â€Å"Human?† I hated to admit, but yes, there it was. I had chased Otherworldly monsters from my world back to this one and never hesitated to kill them or banish them directly to the Underworld. But somehow, the thought of intentionally tracking humans and killing them†¦ I didn't need to voice my answer for Dorian to understand. Exasperation flared on his face, this time mixed with†¦anger. â€Å"Damn it, Eugenie. You just told me you had to put things right! Which is it? Or does it only depend on what's easy at any given time? What your mood is? Who you like better that day?† â€Å"It's not that easy!† I exclaimed. â€Å"You don't understand. You can't understand. I'm caught between two worlds here, with two sets of loyalties. I've spent my entire life being human-being part of that world. You can't expect me to throw all that away and betray my own kind.† He opened his mouth to retort and was interrupted by a faint roll of thunder. Whatever words he'd been about to utter disappeared, and he laughed. â€Å"Do you hear that? That's you, Eugenie. Your anger.† I shook my head. â€Å"I can't control thunder and lightning yet.† â€Å"Not control, no. But you can summon it unconsciously. Do you think there's anything in this land that isn't tied to you?† He gestured around us. â€Å"All these people here†¦all the people in this village looking at you with adoring eyes†¦they are your own kind too. This is what I meant when I said you're the only one who doesn't seem to realize you're a queen yet! All these people are looking to you to protect them and do what's right. If you can't do that, then you might as well back off and do what the kitsune and your stepfather want you to do.† â€Å"Dorian, I can't kill in cold blood!† He gripped me by the arms, voice calm but infused with anger. â€Å"You can do whatever it is you have to do! You are a queen. Forget all this talk about Storm King's grandson. Right now, you are his heir. You are on the verge of becoming one of the most powerful rulers in this world, which means you don't have the luxury of being squeamish. You can rule with love, but you have to rule with ruthlessness too. You are going to go down in history, Eugenie, as one of the greatest monarchs we have ever seen. And it is going to start with this-this wrong that you're going to right. If you can't do it, if you can't stop those who are hurting your people, then you might as well stop the rest of this charade. Go out there and tell those people you can't do anything for them, that you can't feed them or protect them because they aren't your kind and aren't worth bloodying your hands for!† He was shouting now, breathing heavily. I stared at him, eyes wide, filled with a little of that fear I always got when his temper rose. Moments like these reminded me of just how powerful Dorian was physically and magically. His lazy, lean appearance was deceptive; I'd seen him fight. Between that and the power he wielded, I hoped there would never come a day when we were truly antagonists. Outside, I heard thunder again. It took me several seconds to muster an answer, and when I spoke, my voice was very small. â€Å"I can't,† I said. â€Å"I can't tell them that.† â€Å"I know you can't,† he whispered. And then, still gripping me, he leaned down and kissed me. More astonishingly, I kissed him back. It seemed like all the emotions that had consumed me recently-all the rage and confusion-were poured into that kiss. My teeth bit against his lips, and when he shoved me against the wall, I welcomed the brief pain. Our hands were all over each other as we kissed, mine running the length of his body while his more aggressively hiked up the dress I'd earlier regretted wearing. In a matter of seconds, it was pushed over my hips, leaving my legs bare. With one hand still holding the skirt up, his other pushed between my thighs, slipping underneath the thong I'd put on this morning in the hopes of getting intimate with Kiyo. Those clever fingers slid into me, stoking a wetness I hadn't thought could come on so fast. My small exclamation was muffled in his crushing kiss as he alternately thrust his fingers into me and pulled out to tease and dance with my clit. It was the latter he eventually settled on, circling and stroking as heat built between my legs and made all my muscles tense up. Then, the burning flood of sensation exploded, and I came with another cry that his kiss smothered, a cry that faded into a moan as my body trembled and spasmed from the shock waves of heat and electricity still shooting through me from his touch. My orgasm created no pause in the action, though. The hand that had just brought me such pleasure moved from between my legs to his pants as he began to unfasten them. His mouth finally left mine, moving on to my neck, his kisses hot and fierce. He shoved his pants down, and I felt him against me, hard and ready as he pressed his hips to mine. My hands were tangled in his hair as I tilted my head back to receive his kisses, but his hands, busy as always, were prying off my underwear. The reality of what was happening sank in. â€Å"Wait†¦Ã¢â‚¬  I murmured, lost as his mouth bit against my skin. â€Å"No, we can't†¦I can't†¦Ã¢â‚¬  â€Å"You can,† he breathed in my ear. â€Å"Let me†¦let me do it. Let me bury myself in you. Let me spread your legs and take you like I did before. We are gods in this world, Eugenie, with no other lovers who are our equals. No others who are worthy of this joining.† The thong was on the ground now, and I could feel his erection pressed against my skin, so, so close to sliding in and doing all the things he promised. He rested his hands under my thighs and hoisted me up against the wall so that my legs wrapped around his hips. â€Å"Dorian†¦Ã¢â‚¬  I gasped. â€Å"I'm with Kiyo†¦.† â€Å"So? You're a queen. Do you think you can't have as many lovers as you like?† â€Å"It's†¦it's wrong. We can't†¦Ã¢â‚¬  â€Å"We can,† he said, voice low and full of promise. â€Å"And when we do, this land will be reborn†¦.† Afterward, I would never be entirely sure if I would have let him do it. I like to think I would have stopped him. I was in love with Kiyo, after all, and loyal to him. Surely I would have said no and shoved Dorian aside. I wasn't in love with him†¦or was I? In those moments before we'd kissed, I'd felt like he truly got me and understood the things in my head. I think I'd probably loved him since around the time we'd met; I certainly never lost the attraction. Still, that didn't make cheating on Kiyo right. Whatever decision I would have made was taken from me when there was a knock at the door. I jerked away from Dorian and hastily shoved my skirt down. He more casually turned away to pull his pants back up, seeming in no particular hurry. The door opened, and the lead councilwoman stuck her head in. Even with Dorian's back to her and me dressed, it had to have been obvious what was going on-particularly with my underwear on the floor. If she found it shocking, though, she didn't show it, and I recalled how free the gentry were in public. â€Å"Your majesties,† she said politely, â€Å"there's a storm coming in, and the workers were wondering what the Oak King wanted to do.† Dorian, decent once more, turned around and gave her a laconic, charming smile. â€Å"A storm? Really? How truly unexpected. Well, tell them to bring as much of the ore as they can into storage before the rain and cover the rest up. I'll come check on it in a moment since I have a feeling the Thorn Queen is about to depart with some haste.† The woman gave a quick curtsey and shut the door once more. â€Å"You're right,† I said, jerking my thong back on. â€Å"I'm leaving.† â€Å"Yes,† he agreed, still smiling. â€Å"Because that's your normal course of action when something happens that you don't know how to process.† â€Å"That's the thing,† I growled. â€Å"Nothing happened here, okay? None of this did.† His eyebrows rose. â€Å"Really? Because I could have sworn that something happened when my hand was between your-â€Å" â€Å"No!† I would have approached him with clenched fists to drive home my threat but was afraid of what would happen if I was close to him again. â€Å"This didn't happen. This was anger and confusion and me in a weak place, okay? I appreciate what you've done here with the copper-really. And for the advice on the girls. But that's it.† I turned, not wanting to look into those green eyes or see that smirk anymore. I didn't want to admit that loving two men was just like the rest of my life, ripped into two worlds. I needed to get out of here and get back home-though I wasn't sure which home I meant. Dorian didn't try to stop me, but his voice rang out after me as I hurried out and rain began to fall outside. â€Å"Don't forget what I said, Eugenie. Crown or not, you are a queen, so don't be afraid to do what you have to do. Love and ruthlessness. Those are the keys.†

Critical Response on “One Flew Over The Cuckoo’s Nest” Essay

There have been many struggles in history between authority and those who oppose it. The most obvious and most common example is revolutions against governments. We live in a society where stability and assimilation are not just recommended, but also enforced. We have the right for civil disobedience, so long as it is non-violent and within reason. In the book, One Flew Over the Cuckoo’s Nest, R.P McMurphy, a â€Å"brawling, gambling man† enters a mental asylum in Oregon, and begins to wage war â€Å"on behalf of his fellow inmates†. However he finds himself at odds with Nurse Ratched, a strict, manipulative and methodical woman who runs the ward like a â€Å"precision-made machine†. The book follows McMurphy’s actions that constantly clash with the Nurse, and what she represents: authority. By the end of the book, there are many examples of struggles against the higher power, and it is in my opinion that the statement â€Å"when authority and indi viduals come into conflict, authority always wins out† is incorrect, because individuals do not have to win the physical conflict to win the battle of brains. From day one, the reader finds that McMurphy is out to cause trouble. Gambling is illegal in the ward, but McMurphy declares that he was sent to the institution â€Å"to bring [the inpatients] some fun an’ entertainment around the gaming table†(p. 16). He starts interrupting daily meetings, which the Nurse treats with much importance. And whenever he is reprimanded for something, he laughs. The laughing is the most important part of his self-defence, as it is the only legal way he can fight back against authority. It is a symbol of defiance, and a sign of McMurphy’s freedom. It shows that, no matter what the institution does to him, he still has his mental independence. As the reader progresses further on in the story, McMurphy makes a bet that he can â€Å"get [the Nurse’s] ‘goat'†. When he finds he has no ward-clothes (p. 79), he runs around in a towel, threatening to drop it at times, while the distressed Nurse tries, in vain, to make him get dressed. Then, the same morning, he takes bets on his accuracy about throwing butter at the clock (p. 85). McMurphy wants to watch the World Series, and takes a vote from all the saner patients. While all of them vote to watch it, the Nurse shuts the  idea down, even when McMurphy gets the majority. When airing on television (p. 114), he stops work and proceeds to turn on the television, sit down, and watch the game. When the rest of the men decide to stop work and join him, and the Nurse turns the power off, they continue to watch, just to show that her power and authority has nothing over them. This is an example of individuals fighting against authority. They might not be successful in the real world (having to wear clothes, not being able to watch the baseball game), but inside they’re freer than they’ve ever been before. Being downtrodden and strict by the Nurse forced them to become less Things begin to grow bigger and more important as the story progresses. McMurphy realizes that his release is dependent on his good behavior, and tones down his obnoxious acts. However, he still finds that Nurse Ratched is going to keep him in the hospital for as long as she wants. He tries to be subdued, and in doing so, another rebellious inmate called Cheswick, who had tried very hard to be like McMurphy, kills himself, because he thinks that McMurphy has been defeated (p. 136). Nurse Ratched sees the change in McMurphy, and to gain total control of the ward, she demands penance for the insubordination during the World Series. McMurphy smiles and nods, but destroys the glass that separates the nurses’ room from the ward, to show his true feelings (p. 155). He excuses himself, saying that the window was â€Å"so spick an’ span [that he] completely forgot it was there†. This shows how he is standing up to authority, and while he doesn’t change anything in the real world, it shows the inmates and himself that inside they are free. Part III describes McMurphy’s fishing expedition. He takes the men on an excursion on a fishing boat, much against the Nurse’s wishes, but by tricking the doctor to come along, he succeeds. While there is not much about Nurse Ratched in that part, Chief Bromden, the narrator of the story, notices that the Combine is working on the outside too – with commuters and houses and children (p. 186). He had been in the ward for about 20 years, and a lot had probably passed since he was younger. However, this glimpse into society makes them realize that they (as patients) aren’t as monotonous as this, and they can be more free than they are already. Within a week of the trip, Nurse Ratched is ready with her new plan. She tries to show McMurphy as a con man, stealing and wining money from all the patients. But she is shocked to discover that all the patients were happy to lose that money, as they enjoyed themselves, and weren’t using it for anything else anyway. After a few more instances of insurgence (McMurphy and Bromden’s fight with the staff {p. 215}; continuous interruptions to ward procedures {p. 229}), the final insurrection came: McMurphy’s party. McMurphy organizes for two of his â€Å"friends† to come to the ward for a party that would also serve as his breakout. After a great night, everyone falls asleep, and in the morning, the day-staff came before anyone can wake up in time. After searching for Billy Bibbit, and finding him unashamed of his actions the previous night, the Nurse gives him a guilt trip, threatening to tell his mother, and then locking him in the ward’s doctor’s room. Billy commits suicide, and the Nurse tries to blame it on McMurphy’s lack of respect for authority. Realising that any chances of surviving are ruined, and that his battle with authority is now at it’s final stage, McMurphy sacrifices himself (and consequently his mental-independence) by attacking Nurse Ratched, exposing her as a vulnerable woman, and destroying any sense of authority and control she had left over the patients. This is the final action between two desperate factions: the authority and the autonomy. The showdown ends with McMurphy being captured, but because the other patients see the nurse as a woman, and not as the dominant Nurse, she can never have the same control over them as she had previously had. McMurphy is lobotomized, but before the ward can see him in his vegetable-like state, Chief Bromden smothers him with a pillow, and then breaks down a wall to freedom. The patients never get to see McMurphy as a vegetable, so their last memory of him alive is his attack on the Nurse. McMurphy is remembered as a symbol of resistance, and as a hero against the authority that had cowed the patients for so long. I believe that McMurphy shows the reader that while the authority may be able to make you conform, you can still remain free inside, which is more important than anything else on earth. Because it is against national  regulations to take away freedom, and as long as you have your sanity and your mental independence, nothing can beat you.

Corporation information Essay

This section it’s dedicated to provide all the information related to the company that our clients need, and to offer a brief history of how the company was created as a responsible company and providing a service that exceeds our customer’s expectations. Our company recognizes that accomplishment and maintenance of security program is our personal responsibility, therefore, we will have to take initiative and be an example, this way we will maintain our system implemented by different techniques and tools like: Trainings on C-TPAT Security processes described * Security Controled and Registred. * Technology of innovation * Personnel recruited * Internal Audits * Selection of business partners Since we look for  implementation and development of the program of security C-TPAT we must fulfill some requirements to maintain a greater security in all the chain of supplies. Thus we have verifiable writings for selection of our businesses partners. We request for procedures of security and the processes to fulfill the minimum requirements of security established by the C-TPAT, participating in a questionnaire applied by our company. When completing this questionnaire, not only will help us to fulfill our obligations like member of the C-TPAT, but also some of our customers will look for fulfill requirements for importer and to become members of the C-TPAT. Guarantee security of our processes and our clients’ also. Questionnaire is designed to identify those areas where improvements are necessary to fulfill minimm security requirements. Correct identification of a security weakness will not affect our relation of businesses, but it will allow us to work with our clients to develop a plan of security improvement if necessary. All the people working on the company contribute to our success. An integration of our different talents and perspective, stimulate new and creative opportunities for our business. Collectively, it will generate a rewarding and more exciting work atmosphere where each individual feels like person in charge of performance of our company. We respect rights and dignity of all employees. We made an effort for being a company that independently attracts the best people, no matter origin, beliefs or life style. We are commited to create a work atmosphere with confidence and respect, inclusion and diversity, and employees are listened to improve team work. We assure all employees know our job enviroment, tasks, responsibilities and general activities to aim our organization. We develop their capacities through open and constructive conversations on their professional direction. Also we try to guarantee that all the employees are recognized and compensated by their yield. For our company the responsibility of each individual as employe is being conscious of policies and be responsible of his own behavior. Our integrity and reputation as company will not have to be committed. Any attitude that can seem questionable is not acceptable. (Customs Trade Partnership Against Terrorism), is a joint initiative of the government and businesses of create cooperation relations to fortify security of supply chains and borders. By this project, customs requests all companies to guarantee integrity of their security and to communicate this to commercial partners of supply chain. The company look for a certification as member of C-TPAT. Obtaining this certification, we will offer a better service to our customers with great security, reliance and rapidity exporting cargo, also our customers (importers) and our company will be benefitted with results obtained with implementation of C-TPAT. In order to articipate in C-TPAT, companies must elaborate and apply programs of integral security to improve security internal and external with partners and clients. Therefore, we have developed and maintained a complete and detailed security plan with directives of values of EE. UU. Customs. As C-TPAT includes all components of supply chain, such as importers, carriers, intermediaries, operators of warehouses and manufacturers, the company is determined to communicate security requirements for C-TPAT to suppliers and clie nts.

Productivity Essay Example | Topics and Well Written Essays - 2000 words

Productivity - Essay Example define productivity as a measure of performance as compared to the ratio of output produced in relation to the input inserted into any task or project. This definition, however, shouldn’t tie any other opinion down as various knowledge bases would come up with various definitions given their respective contexts. Many factors have been brought to the forefront in a bid to expound the basis that productivity is defined. Leonhard and Simaan consider productivity as a function derived from quality of work, time, and the initial budget. On the other hand, Young groups factors that affect productivity such as the human resource management, work environment, and the particular job in context (Young, 2010). This report will consider some of those factors that affect productivity, especially in construction-related projects, therefore, trying to see points in which productivity could be improved. The structure of the paper will have a literature review section, an analysis of the relevant aspects that surround productivity, and a conclusion summed up from the entire work (Leonhard and Simaan, 2010). This section will sample two case studies of construction projects where analyses were performed to measure the productivity levels at each scenario using various techniques, and the conclusion summed up from the analyses. The undertaken steps to rectify the factors that lowered productivity will be discussed. All these discussions will be aligned with the factors that affect productivity and the refinement will help us see some ways to improve productivity; these aspects will be expounded more in the next section of this report. Construction of the Commercial Bank Headquarters in Edinburgh was undertaken as a case study to see some of the factors that affected productivity. The managers in charge of this big project took the initiative to check up on their employee productivity. The main participants were the top-level project managers and the onsite workers who were used

Research business proposal Essay Example | Topics and Well Written Essays - 2500 words

Research business proposal - Essay Example In addition to integration into corporate structures and processes, CSR also frequently involves creating innovative and proactive solutions to societal and environmental challenges, as well as collaborating with both internal and external stakeholders to improve CSR performance (McDonald & Rundle-Thiele, 2008). The proposed research paper will address the issue of definition as well the nature of the challenges calling for public and private sector action on the CSR front. It also intends to outline components that can be used by businesses and other organizations to review and potentially enhance their performance in relation to CSR. It will further explore the best practices on the part of industry to attain positive and proactive outcomes on CSR. Additionally, the proposed research paper will also provide an outlook of Industry activities and initiatives that support the promotion of CSR and that define and provide pragmatic viewpoints on the linkages between CSR and innovation. It will also offer some recommendations for the further exploration of CSR. There are different concepts and factors that are considered of importance in the operation and management of different types and forms of organizations. One of the said factors is the corporate social responsibility or CSR. The terms can be considered synonymous to corporate responsibility, corporate citizenship or responsibility in business. ... 3.3. Data collection method . 15 3.4. Ethical issues.. 16 3.5. Data analysis & Nature and form of results... 17 3.6. Variables 17 4.0. References 18 5.0. Appendix. 19 1.0. Introduction 1.1. Background There are different concepts and factors that are considered of importance in the operation and management of different types and forms of organizations. One of the said factors is the corporate social responsibility or CSR. The terms can be considered synonymous to corporate responsibility, corporate citizenship or responsibility in business. The main principle for the said concept is the need of the company to take responsibility on its operation on the basis of the fact that the establishment of an enterprise can affect the community and the environment one way or another (Catalyst Consortium, 2002). The detrimental effects of the continuous industrialization and modernization of the corporate world had turned the trend of the organizations and companies from the objectives of financial prowess solely towards expansion of aims and priorities in terms of responsibilities thus including the welfare of the environments and surroundings including the adjacent communities and other issues related to ethics and behaviours of the employees and the members of the company or organization. The CSR then can be defined on the basis of giving attention to three objectives that includes the profitability in the financial aspect, the social responsibility and the environmental issues and concerns (Catalyst Consortium, 2002). 1.2. Problem Statement and objectives Corporate social responsibility can be said as idea whereby business organizations consider the interests of society by taking obligations for the

Comptronix Corporation-Case study on identifying Inherent and Control Assignment

Comptronix Corporation-Case study on identifying Inherent and Control Risk factors (Using the facts of the case and the relevant AUDITING standards, answer each of the questions) - Assignment Example Taking into account all the relevant factors, the auditor has to apply his professional knowledge and skills in taking appropriate decisions. â€Å"IR = Inherent risk (the risk that an assertion is susceptible to a material misstatement, assuming there are no related controls)† (Statements on Auditing Standards (SASs): Risk Assessment Standards par. 3). Examples of financial records that have low Internal Risk include fixed assets or traded securities as opposed to accounts with high Internal Risk. For instance, those for which estimates have to be used and computations have to be conducted. An audit comprising of a physical examination of Comptronixs equipment might have revealed that recognized assets do not exist. Considering the age of certain equipment, there is a need to take into account their depreciation. Thus, the actual value of the some equipment may not correspond to their book value. â€Å"Fictitious transactions frauds involve important accounts or just assets or revenues in general† (Ketz 407). Besides auditing in a way that would have exposed the absence of certain purchases of equipment, the assessor could have also carried out an examination of check accounts and bank records to see where and by whom the vouchers were cashed. This would have revealed that the checks were not cashed in by an outside party. Thus, the company would have been in a clear position to establish the involvement of someone within the organization in the said manipulation. In the same manner as in the case of fictitious accounts for equipment, the assessor could have checked the inventory to confirm the decrease in inventory of goods for sale with the actual sales to the consumers. â€Å"The auditor’s objective in examining accounts receivable is to form an opinion regarding management’s representation that an account receivable is presented fairly in conformity with

Introduction to Terrorism Essay Example | Topics and Well Written Essays - 500 words

Introduction to Terrorism - Essay Example Terrorists commit crime and spread fear because of many reasons. It can be because of their weakness to fight for justice with peace and show. Terrorists want to show power and its effects to the other concerned parties. This might be the reason for the leaders to get involved into the path of terrorism but small workers opt for it because they have no other ways to go. The simple workers do not have education, job or any other means to survive peacefully. Many of the persons also are compelled to choose the profession forcefully. According to Ahmad, terrorism is an act of anger of being lonely, helpless and neglected. It is also cause of betrayal from one’s own or supporting country. According to him, same happened when the United States betrayed Bin Laden. Ahmad recommended United States should not have double standards as he thought the United States to support the state terrors sponsored by Pakistan or Israel but is only opposed when it comes to Afghanistan as they are the victim then. Considering the features of the transnational terrorism of today, it can be well said that American Revolution was an also act of terrorism. In the eighteenth century, the Americans did many of the things that were similar to the acts of present day terrorists in order to get rid of the colonial powers. Still, one should remember the great cause behind the revolution. Just war can be referred as getting into war to win the battle without any consideration of human life and their rights. On the other hand, right to revolution is giving time to adapt the changing environment, understanding core of problem and providing solutions to bring revolutionary change in human so that they can understand the effect of violence and its result. Right to revolution bestows upon providing a chance to change. Hezbollah is a Lebanon based self - proclaimed Islamic revolutionary organization. It was formed to tackle the Israeli

SAM 344 UNIT 1 Essay Example | Topics and Well Written Essays - 250 words

SAM 344 UNIT 1 - Essay Example the past, top administrators of sports organizations used to dictate or make decisions in consideration to other factors, overlooking the characteristics of the target market segments. But they have realized that failure to take into consideration their needs, tastes and preferences, along with their attitudes and beliefs towards the products and services is counterproductive to the marketing gains made. Thus the sports organizations are today investing in efforts to acquire information regarding their target market segments (Chelladurai, 2006). Knowing the behaviors, attitudes, tastes and preferences of the target audiences is alone enough for firms to determine the sports marketing match. To do this, marketing research is needed. Marketing research helps an organization to have an idea of the hearts and thoughts of the sports fanatics. In the process, they acquire knowledge of who the fans are, whether they are excited or satisfied, what should be sponsored, and the various ways in which the sports sponsorship will influence customers (Chelladurai, 2006). The twenty-first century witnessed major changes in the demographic characteristics of the target audience. A case in point was women’s growing interests in sports. As fanatics in the sports industry transform, marketers ought to be continuously informed of their changing demographic characteristics as well as their interests. They must also assess the impacts that their sports sponsorship programs have on consumer behavior (Chelladurai, 2006). Finally, as marketers look into other factors dictating sports marketing, they need to understand that fan satisfaction, growth rate and loyalty are all significant considerations in marketing

A description of a person I had to work with Essay

A description of a person I had to work with - Essay Example He was a very kind person that had innate leadership abilities. He was also a part time professor at a local university. At that job I learn how to be a professional due to the influence George had one me. He would always dedicate some time at work just to talk to me about work related matters, current affairs, and personal advice. Whenever I had any doubts about a work task I always felt the freedom and confident to ask help from George. He was always willing to provide assistance. When one of our co-workers took a vacation George vouched for me to our boss and I receive a special assignment of replacing the co-worker while on vacation. My weekly shift increased from 20 hours to 40 hours for a one month period. My work duties changed during that period. During that time I demonstrated to the manager that I was a capable worker that was a quick learner. I was able to adapt very fast to my new work environment. My paycheck increased by twice the size thanks to George Lucas during that month. I considered George Lucas my mentor, friend, and the best co-worker I had the privilege to work with.

Consider the ways in which Radcliffe associates fear and power in The Essay

Consider the ways in which Radcliffe associates fear and power in The Italian - Essay Example The name of the girl is Ellena. Like most romantic relationships ever depicted in works of fiction such as Romeo and Juliet by Shakespeare, the love between these two young people is faced with lots of challenges. It is at this juncture where Radcliffe shows the direct connection between fear and power. After Vivaldi’s mother realises that her son is in love with the poor orphan, she immediately takes action to prevent the marriage. She uses Father Schedoni as the hit man to kill the relationship. She promises father Schedoni that she will help him get promoted if he manages to prevent the marriage. Father Schedoni then uses fear and intimidation to separate the two. At this juncture, Radcliffe uses another style of writing to deliver her thoughts on how fear and power is connected. In the story, father Schedoni is seen issuing threats and intimidating Vivaldi. Every time Vivaldi pays a visit to her lover, he meets with a Monk who tells him in an intimidating way that he shoul d leave the girl alone. However, Father Schedoni does not do this in person but rather uses an apparition to appear to Vivaldi. Radcliffe uses this style of writing as a way to not only entertain her audience but also as a way to drive home her point. The story being a renaissance story, it becomes necessary to understand how the inclusion of the spirit world would affect the story. To understand the importance of introducing this side of the story and using this style, one would have to understand how people in the earlier days would react to images of the spirit world. Radcliffe (453-476) discusses the use of ghosts and tries to indicate how this affects Radcliffe’s credibility. There could be a number of reasons why Radcliffe uses this style of writing to deliver her message (Clery, 158). To begin with, the appearance of the father as an apparition and in the form of a monk is an indication of the connection to the mysterious world of spirits, which can make things to be m ore fearsome. Secondly, although father Schedoni could appear as anything else such as a farmer to Vivaldi, he appears as a monk. A monk is a symbol of power and authority and in this case indicates that power and authority comes by fear, what Radcliffe is trying to tell her audience is the fact that to be powerful one has to be feared. Yet, to be feared, one has to frighten other people, to place their lives at risk in order that they will fear and respect him. This kind of attitude to power can be seen even in the modern Italian mafia. Radcliffe also connects fear and power in other ways. For instance, when Vivaldi’s mother uses Father Schedoni to circumvent the marriage, it is an indication of the fact that she is very powerful and that father Schedoni is also scared of her. This is however not exactly revealed until near the end of the novel where father Schedoni realises that Elena is his daughter. Father Schedoni is on a mission to assassinate Elena when he realizes tha t Elena was her blood daughter. After the realisation, he has to protect her and to do so, he has to hide her from Vivaldi’s mother, an indication that he was also scared of her. Fear is also propagated when Signora Bianchi, Elena’s aunt, suddenly and mysteriously dies after allowing Vivaldi to marry Elena and made Vivaldi the guardian of Elena. In this case, Radcliffe is trying to show how the powerful can use not only power, but also actual brutality in trying to keep the balances of power in check. Although it is not entirely clear who killed

Professional Learning Experience Essay Example | Topics and Well Written Essays - 750 words

Professional Learning Experience - Essay Example 70). Realizing the challenges I have to face in socialization and conflict resolution, I decided to focus Professional Learning Experience (PLE) at addressing the dilemmas of profession and its humane aspects. Awareness is the first step towards overcoming professional inadequacies and shortfalls. In many professional settings and situation, I found myself in tight spots, where it was hard to draw a line between my responsibilities as a nursing professional and the demands of social decorum. Overcoming such issues in professional career is of significant importance, in a society, hyper sensitive on the display of professional approach and social values in perfect mix. The professional socialization goal identified in this connection includes, conflict resolution, overcoming dilemmas, and role identification for nurse based on the rationale of ethics, values and social expectations. Kozier et al. (2008) presents the broad description of these goals of professional socialization and st ates, â€Å"The education of professional involves a complete socialization process, more far reaching in its social and attitudinal aspects and its technical features than is usually required in other kinds of occupation† (p. 17). ... The occurrence was reported a little late in time and when we rushed to the spot, things have already gone worse than affordable in isolation ward. Patients were gathered around a patient, speaking laud and violent. The patient was not ready to hear any argument and was insisting on his claim of being mishandled and mistreated. There were also signs of personal grudge towards the nursing staff that has been handling the case. Susan immediately grabbed his hand and patted it lovingly while asking him to cool down and drove him to a corner where she can hear his stance in private. She assured him of getting possible assistance, in getting his point over to physician and administration for reconciliation. Soon, she managed patient’s agreement over a peaceful and graceful dialogue. The patient was a retired army officer and looked genuinely hurt over the issue. Susan managed to convince him on a detailed description of his reservations. This patient told her the backdrop of the si tuation from his perspective and complaint against the behavioral shortcomings and inadequacies of the nursing staff, while Susan provided very mild and easygoing explanations to some of the professional intricacies and limitations under the circumstances. Susan was successful in pursuing the patient for a shift in isolation ward while assuring him on redress of grievances. She also manages to get his agreement over filing a written complaint of the incident. The incident had a great deal of learning for me and I closely watched various actions, behaviors and gestures which Susan has applied to overcome the conflict. Specially, her skills in convincing the patient on peaceful negociations were

The Impact of Internet on ways in which Citizens Participate on Political and Social Systems Essay Example for Free

The Impact of Internet on ways in which Citizens Participate on Political and Social Systems Essay In every single day, the internet expands by the social, political, and economic activities of people all over the world; consequently its impact on the participation of citizens grows exponentially. Internet has disregarded geographical distances and separations in this new world, as borders no longer have great impact on limiting people’s activities. People are encouraged to participate and contribute on different aspects which have drawn different experiences and pooled resources together. Actions and reactions have become instantaneous in cyberspace and this has made internet to be more gratifying and attractive. The resultant effect is that internet has impacted our society in almost all areas of human endeavour. The problem is that the impact has been both positive and negative and as such, caution has been advocated as a means in which citizens should approach the internet. An internet safety plan is thus required in which shall protect children and security in e-businesses has to be more guaranteed (Kedem 1999). Impact of internet on the political systems We will analyse this impact by first posing a query whether internet has any effect, whether positive or negative on the amount of political participation and the extent it contributes to the generation of a more participative society. Authors had initially suggested that a reduction in levels of political participation could be expected as a result of the use of the internet. They reasoned out that internet brings with it atomisation and a weakening of social cohesion, which can also take up a large part of people’s free time (Davis 1999). According to Meinardus (2003) the new technology back in 1990s created an internet-euphoria. It was assumed that the digital technology would lead mankind to a better world creating more chances for mass participation in the political and economic market place. These euphoric assessments have given way to more cautious appraisals, as more and more people become conscious of the potential dangers of the technological advancement. Internet has been used by politicians in order to win some scores on different activities and events. In South Korea, students of digital politics admire what one reporter termed as the most advanced online democracy on the planet. They called it â€Å"webocracy† which became apparent to a wider international audience during a presidential election. The election was won by a politician who no longer relied primarily on the traditional mass rallies, but exploited the possibilities of the internet and other modern communication devices, systematically. The politician succeeded in mobilizing millions of mainly young supporters, who logged onto his website to donate money and receive political updates. He received messages that contained policy recommendations which the candidate promised to consider seriously in his decision making (Meinardus 2003). Cyberspace campaigning has become very prevalent. It is with no doubt that new technology has opened the door to new forms of grass-roots participation. There is every indication that on-line politics are changing the traditional power structures. Internet has therefore made political process more transparent, more communicative, more participatory and hence more democratic. Internet use has increased democracy level, e-mails with political content have been sent in order to try to influence government decisions through comments posted on websites (Tab Working Report 2005). The ability to face the costs of political participation is a determining factor in the decision whether or not to participate. The impact of internet on political system depends on the availability of resources. The members of a nation with little time, money or other resources might not participate in the use of the internet in sharing their views and comments as the cost of participation is very high for them. The low cost of accessing internet has on the other hand fuelled the impact of the internet on political systems. Internet allows almost unlimited, fast, and cheap access to political information which can not be easily obtained by other means. People thus have resulted top use of the internet to obtain information which has enabled them participate even the more in political debates, and policies which are about to be implemented (Milner 2002). In deed a Tab Working Report (2005) argues that internet is currently being widely used for communication between political and the public, and routines have developed at various points. There has been an increase in activities for e-participation and online discussion at the international level. There is also a programmatic consensus that the internet can play an important role in strengthening representative democracy Limitations Internet enables access to political information that make people participate more in political systems. The access of information does not mean that one obtains the capacity to process and interpret that information which is required to make the information knowledge that can be beneficial to the individual and in which one can make rational decisions. Internet might contain a sea of information but that does not guarantee the quality of such information which might be interpreted wrongly. This may lead to consequences that would have negative impact on the individual if not on the whole society (Polat 2005). The use of internet has created international havoc as countries around the world struggle to develop laws that will permit geographical regulation of a borderless medium. The internet is thought to offer unlimited free speech which can be detrimental and in most cases when the free speech is abused by politicians, the effects are adverse. Censorship is nevertheless increasing as countries develop tools for limiting content that is available to its citizens Another limitation on the impact created by the internet on the citizen in participating to the political system is the struggle needed to obtain the information from the internet. It requires an initiative by the user to access it. Most information from the internet will mean that the user has to subscribe for it. There are other attractive websites which are social sites that would easily distract the user from obtaining the required political information (Davis 1999). Impact of internet on social system It is a matter of fact that easy access to the internet, which includes the availability of personal computers with rather cheap prices, introduction of rather reliable internet services and establishment of internet cafes has changed the nature of people’s connection to each other in their social field. Physical proximity is no longer an essential in communicating to one another face to face. This has made it easy for rapid connections across long distances and people are now in a position to write electronic mails that are transmitted virtually immediately throughout the globe (Eskicumali 2010). Eskicumali (2010, p. 1) argues that many aspects of the lives of people, especially the young people have been changed by the internet. The basic nature of their relationships with one another has been greatly influenced by the internet. This is due to the reason that there has been a global diffusion of information and communication technologies that has expanded the domain of â€Å"absent presence† which in turn has resulted to an erosion of face to face community centred relationships. The internet has created new type of social relations and virtual communities that has not been formed ever since. Theses virtual communities are social network of individuals who interact through specific media, and potentially crossing geographical and political boundaries, so as to pursue mutual goals and interests. The internet has also impacted the social system in form of communication. There is diversity in the internet-mediated communication which is displayed in different sectors such as politics, art, family, and mass media among others. It has become the bearer of different kinds of communication. This is due to several features of internet’s technical and textual structure which has promised to have a crucial impact on communication. According to Fushs (2008, p. 2) internet is here to stay, it has changed the life of many of us and transformed the lives of our society. It is ubiquitous in everyday life, and it is here that we search for information, plan trips, read newspapers and articles, communicate with each other by chatting, using emails, video conferencing, listen to music and radio, watch videos and other activities. It is in the internet that we have learnt to know other people, develop intimate relationships; maintain contact with one another, access government sites, share ideas and create knowledge together with others. Disadvantages of Internet Use on the Social System It is evident that from the roles that internet play, computerized network technologies change all areas of society. It poses challenges and opportunities in a networked globalizing world. One of the great disadvantage that internet has on the social is that no one can claim ownership of the internet. As such any body can post anything which has made it the home of political propaganda, racism, pornography and other controversial and illegal material. Internet has brought with it internet crime. These crimes include the interception of the details of customers’ credit cards and online transactions, hacking into personal, private files with criminal intent, fraudulent web sites taking credit card details from the customers, and the spreading of viruses through the internet. This has made it necessary for steps to be undertaken so as to reassure the general public that the internet is safe. The methods might reduce majority of the cyber crimes, but they do little to net down the risk, that people find themselves in when using internet (Fushs 2008). Conclusion With scores of people all over the world resulting to the use of internet to carry out various roles and responsibilities, the impact on the political and social system has been amplified. The social network service providers have increased their subscribers, which have provided information that has impacted the social system. Internet has thus enabled people to participate more, on global and national politics since they have been empowered by the easy availability of information. Networking has improved and this has initiated an embrace of diversity in race, religion, and culture.

Evaluation of Hospital Audit Report

Evaluation of Hospital Audit Report Josefina B. dela Cuesta   Executive Summary This paper will critically evaluate the audit report of CHT St Johns Hospital which was conducted last September 2015 which is the Certificate of Audit under the Health and Disability Auditing New Zealand in accordance of the standard of the Health and Disability of the Health and Disability Services (Safety) Act 2001 for the compliance of the Ministry of Health. On this study it will tackle the key findings of the audit report of the CHT St John Hospital. The key findings will focus on six areas which are the consumer rights, organizational management, continuum of service delivery, safe and appropriate environment, restraint minimization and safe practice lastly the infection and prevention and control. As a result of the audit done in CHT St John Hospital they have fully attained the six areas that adhere to Health and Disability Services (Safety) Act 2001. In addition, this paper study also discusses the four auditing principles, the consumer focus, outcome focus, system and process focus and transparency and openness. Furthermore, this paper report includes recommendation and conclusion for the organization. Introduction Health is very important to every individual thus it is very vital to evaluate every program implemented to different organization, facilities, or a health program to view the effectiveness   and make necessary interventions for specific program. Health care audit is defined as the review of an existing practice against standards in any part of Health care and it includes clinical and non- clinical Audit. Furthermore the key purpose of a health care audit is to monitor to what degree of standards for any given health care activity are achieved or met (Daly, 2008). In New Zealand, heath care sector are basing from the Health and Disability Standard Service standard which is the Safety Act of 2001 which required auditing the different health programs in New Zealand. The major purpose of this Act are, first to promote the safe delivery of health and disability services to all New Zealanders, second establish a consistent and reasonable standard in giving health and disability services to the public safely, thirdly, reassure providers of health and disability service to take accounts for providing those services, lastly reassure providers of health and disability services to endlessly improved the quality of services (Ministry of Health, 2017) Health and Disability Auditing New Zealand Limited conducted the auditing for Aged rest home, hospital and other residential facilities designated by the Health and Disability of the Health and Disability Services (Safety) Act 2001, for the compliance to the Ministry Of Health. The CHT St John and Hospital where I worked   as a part time care giver is the audit report to be used and it is located at Epsom Auckland which has 70 residents during the auditing last September 14-15 , 2015. This paper report will discuss the audit report of CHT St John Hospital and to critically evaluate to its significance, methodology, contribution to topic and quality. Moreover, it will also tackle the four audit and evaluation processes and approaches. Background of the Organization Christian Health Trust (CHT) St Johns Hospital is an independent healthcare trust which caters residential care to aged people. The company is located at Epsom Auckland and it was established in the year 1962. Furthermore, CHT St John offers a calm and peaceful sense of home for residents. The facility is redeveloped in 1999 and second floor is added in the year 2003 which has 8 and 10 bed suites (Eldernet, 2017) CHT St John concentrates all energy and resources into caring for residents and their respective families and communities. In addition, CHT St John have been serving over the fifty (50) years and leading provider of residential care in Auckland New Zealand. Furthermore, they have different amenities provided to their residents like Gardens, outdoor seating spaces, BBQ area, shared lounge spaces, Shared dining room, activities programme , organized outings. Moreover, the organization had opened their dementia unit in early 2016. Auditing and Critical Evaluation of CHT St John Hospital The Audit report of CHT St. John Hospital has conducted by the Health and Disability Auditing New Zealand which is the Certificate of audit surveillance that was done last September 2015 this is under the section of the Health and Disability Services (Safety) Act of 2001 ( Ministry of Health,2014). The auditing report comprises of review of their policies and procedures, interview and observation with the residents and staff. Furthermore the certificate of audit also reviews the sustainability of the ten (10) suites that provide aged and hospital care to residents. Moreover, as result of their auditing report CHT St John Hospital the auditing in charge did not find any areas of improvement and they exceeded with the standard set by the Health and Disability Auditing New Zealand (Ministry of Health, 2014) Continually, in conducting the audit of an organization or a health program it requires the different principles like with fair performance, ethical conduct, professional care and support, independence and an evidenced approach as required by the Ministry of Health. The different principles are consumer focus, outcome focus, system and process focus, openness and transparency (Ministry of Health, 2016). The first principle is consumer focus, which concentrate on the care for patients, support services with updated standard of practice and being consistent with the consumer. The auditing committee will make use of technical and clinical skill to gather audit evidence straightly form the consumers, families , providers which includes the review of the care and support received both on the individual components of care and care of   patients ( Ministry of Health, 2016). In CHT St John Hospital auditing on consumer focus was done through face to face interview with the residents, families and the staff and the providers and this area was fully attained by the organization. The second principle is the outcome focus that describes that outcome can be accomplished by several inputs, practices, and outputs in rendering service to the clients. Moreover, the audit evidence should comply with requirements of the Health and Disability Services Standards in providing care and services to the consumers. The CHT St John Hospital when it comes to outcome focus they have updated standard of care and risk management committee comprises of philosophy, goals and planners to continually serve their clients with outmost respect, dignity and best quality care. Third principle system and process focus concentrates on how an organization is effective in terms of service delivered. In addition, on this principle the auditors consider the evidence of audit based on the standard of service and care and services do not rely on one person but on the system implemented and process (Ministry of Health, 2016).The CHT St John Hospital had competent staff and clinical manager who manage the system and they attained it well specially on the different policies and procedures. Lastly, the openness and transparency principle describes as the gathered information is communicated effectively throughout the audit process and ensures the stakeholders are involved in the auditing process. Furthermore, organization should adhere to Health and Disability standard the quality of care and CHT St John Hospital has achieved this area of principle (Ministry of Health, 2016). Method of Evaluation The CHT St John used Certification of Audit as method of evaluation; this audit has been conducted by the Health and Disability Auditing New Zealand that is chosen under section thirty two (32) of the Health and Disability Services (Safety) Act 2001 for submission to the Ministry of Health. Certificate of Audit is   done every 1-4 years, after the audit, rest homes are certified for   a given set of time but it depends how the rest home performed during the   certification of audit and once expired the facility should again renewed and evaluated ( Ministry Of Health, 2014). The audit happened last September 2015 and there were 65 residents and the service is overseen by the unit manager and supported by the clinical coordinator and the area manager. The clients and the resident physician shared their positive outlooks about the service. Furthermore the audit process comprises of examination of policies and procedures, to the residents and employees files, observation and interviews with the residents, staff and management. Moreover, as a result of this audit, the auditing team did not recognize any areas that require an improvement; their service was exceeded with the necessary standard (Ministry of health, 2014). Key findings 1. Consumer Rights The outcome audit of CHT St John as to consumer right contains thirteen (13) standards that support the outcome where clients obtain safe   services of an right standard that comply with consumer rights. The services offered in CHT St John are provided in way that is respectful of the clients rights, facilities, informed choice, lessens harm and recognizes the cultural and individual values and principles. Moreover as to their audit report, staff of CHT St John do their best to ensure that their care is being provided that focuses on the individuals, values, maintaining the privacy of the patients and their own choices. Furthermore, their service functions conform to Health and Disability Commissioners (Ministry of Health, 2016) (Ministry of Health, 2015) (Ministry of Health, 2014) Code of Consumer Rights, their cultural needs of the patients is achieved. Continually, policies were implemented well to upkeep the residents rights. In addition, care plans includes their families and complaints and concerns had been accomplished and their complaints were maintained (Ministry of Heath, 2015) 2. Organizational Management The CHT St John comprises of nine (9) standards that support the outcome where patients, receives services in accordance with the legislation and are achieved in a harmless, effective and well-organized manner. Moreover, they have fully attained their standards with exceeded some of their standards. Furthermore, CHT St John has a unit manager and a registered nurse, clinical coordinator, and health care staff support. Their quality and risk management comprises of service philosophy, goals and quality planner. In addition, quality activities were piloted and this produces improvements on their practice and service delivery (Ministry of Health 2014). The CHT St John conducting meetings to tackle quality and risk management process and residents meetings with their own families are conducted every year. Furthermore, health and safety policies, system and process are implemented to cope with risk. The incidents and accidents were conveyed and followed -up. There are also complete education and training program and it has been implemented well. Continually, precise employment processes are observed to and all employees have yearly appraisal and their rooster of staff were sufficient to meet the quality of service (Ministry of Health, 2014). 3. Continuum of Service Delivery The CHT St John comprises of thirteen (13) standards that support the outcome of clients and receive appropriate assessment followed by their services that are well planned, organized and   conveyed in a timely and correct method with compliance to the current legislation and all standards suited on this service were fully attained with some standards exceeded ( Ministry of Health, 2014) In CHT St John the clinical coordinator manages the services offered with assistance from the registered nurses. Moreover, first hand-in assessment were accomplishes by the nurse which includes the InteRAI assessment and complete the care plan evaluations within the mandatory time. In addition, care plans are centered on InteRAI findings and each of their patients or residents are being interviewed and involved in the care planning and review process (Ministry of Health, 2014). Furthermore, medicines are kept and managed properly in accordance to legislation and guidelines. The resident physicians review the patients every three months and more frequently if needed. Continually, their meals were prepared on the site by a contracted agency under the direction of a dietitian, and menu are wide-ranging and appropriate, and patients were interviewed and they were satisfy about the food service offered by CHT St John (Ministry of Health, 2014). 4. Safe and Appropriate Environment As to safe and appropriate environment CHT St John have achieved their service are fully attained which includes eight (8) standards that supports the outcome where their services are offered in a clean and safe environment that is applicable to the age or need of the residents, make certain physical privacy and it is well maintained. Sufficient space and amenities to conduct independence is appropriate to meet the needs of people with disabilities (Ministry of Health, 2014). Moreover, the building of CHT St John has a up-to-date warrant fitness and emergency evacuation plan and ongoing maintenance problem are solve and being addressed. The facility has eight (8) suites that comprises of eight to ten patients and bedrooms are single occupant and they their own suite. Furthermore, there is enough space to permits residents to move around freely and the facility utilized mobility aids for the residents. In addition there is an open lounge and dining area in each suite, outdoors section is safe and certainly  Ã‚   accessible. The maintenance departments are able to provide the appropriate services and the employees of St John have planned and strategies in case of emergency and emergency system are in place in the event of a fire or exterior disaster (Ministry of Health, 2014). 5. Restraint Minimization and Safe Practice The CHT St John comprises of three (3) standards that support outcomes where the clients received and experienced services in the least and safe way through restraint minimization and this standard of practice in the facility was fully attained. The CHT St Johns Hospital has a restraint minimization and safe practice policies and procedures wherein the employees received trainings on restraint for patients who have challenging behavior. During the audit last September 2015 there were six patients with restraint and three with an enabler. The restraint management procedures were applied (Ministry of Health, 2014). 6. Infection and Prevention and Control The CHT St John has six (6) standards that minimize the risk of infection to their clients, service providers and visitor. The Infection Control Policy and procedures is practical, safe and appropriate for the type of service rendered that adheres to the legislative and accepted good practice. In addition, the facility offers significant education on infection control to all the service providers and clients and surveillance of the infection control is done as well. The standard of infection control of CHT St John service is fully attained (Ministry of Health, 2014). Moreover, the documentation evidence that is related to infection control education is provided to the service providers as a part of the orientation and as a part of an ongoing in service education program. Furthermore, the type of surveillance carry out is suited for the organization as to its size and complexity and standardized definitions were utilized for the identification and classification of infection events. The results of the surveillance were acted upon, assessed and reported to the relevant person in a well-timed manner (Ministry of health, 2014). Recommendation In CHT St. John Hospital certificate of audit is done last September 2015 which they have fully attained the different areas conducted by the Health and Disability Auditing New Zealand. This shows that the organization had achieved a success in providing quality of care to their consumers. Nevertheless, it is recommended that CHT St John Hospital should expand more their services like putting up additional building so that it could cater more patients to care. Moreover, the organization should add more services like for emergency procedures and minor operations that will help the residents instead of referring to other facility. Conclusion In conclusion, CHT St John Hospital certificate of audit was done as a result they have attained or achieved the different standard set by the Health and Disability Services (Safety) Act of 2001. Furthermore, it is very fundamental in every organization to conduct an audit because it measures the effectiveness and accuracy of the services rendered and to measure the competency of the staff as well as the providers and stakeholders. Moreover, auditing plays an important role especially in the delivery of care to the clients because this would determine the success of the organization through the feedback of the clients and family involved. Having a positive feedback of the organization can raised the confidence of the staff as well as the organization thus success of the organization will be visible. References Daly, M. (2008). Healthcare Audit Criteria and Guidance. Retrieved March 2017, from http://hse.ie/eng/about/Who/qualityandpatientsafety/resourcesintelligence/Quality_and_Patient_Safety_Documents/guid.pdf Ministry of Health. (2013). Rest home Certification and Audits. Retrieved March 2017, from Ministry of Health: https://www.health.govt.nz/your-health/services-and-support/health-care-services/services-older-people/rest-home-certification-and-audits Ministry of Health. (2014, April). Health and Disability Service Standards. Retrieved March 2017, from Ministry of Health: https://www.health.govt.nz/our-work/regulation-health-and-disability-system/certification-health-care-services/services-standards Ministry of Health. (2015, September). Christian Health Trust St John. Retrieved March 2017, from Ministry of Health: https://www.health.govt.nz/sites/default/files/prms/audit_summaries/AuditSummary_PRMS_CommunicatePublish_000001594001.pdf Ministry of Health. (2016, December). Designated auditing agencies. Retrieved March 2017, from Ministry of Health: https://www.health.govt.nz/our-work/regulation-health-and-disability-system/certification-health-care-services/information-providers-health-care-services/designated-auditing-agencies Ministry of Health. (2016, July). Designated Auditing Agency Handbook. Retrieved March 2017, from Ministry of Health: http://www.health.govt.nz/publication/designated-auditing-agency-handbook Ministry of Health. (2017, February 14). Health and Disability Services (Safety) Act. Retrieved March 2017, from Ministry of Health: https://www.health.govt.nz/our-work/regulation-health-and-disability-system/certification-health-care-services/health-and-disability-services-safety-act

Study on the use of reflection in nursing

Study on the use of reflection in nursing In recent years, reflection has undoubtedly become an important concept in nursing, stimulating debate and influencing nursing practice and education around the world. Much has been written about the theory of reflection, the majority of which has been applied to the educational setting (Price 2004). However, the process of reflecting has been described as a transferable skill which may be incorporated into clinical practice, enabling practitioners to better understand themselves and others, and solve problems (Mantzoukas Jasper 2004). Indeed, the capability to reflect consciously upon ones professional practice is generally considered important for the development of education and, hence, for clinical expertise (Mamede Schmidt 2004). Reid (1993) defines reflection as a process of reviewing an experience of practice in order to describe, analyse, evaluate and so inform learning about practice (Reid 1993, p. 305). The nursing profession seems to advocate the need for nurses to be educated and practice in ways that develop their critical thinking, autonomy and sensitivity to others (Reed Ground 1997). Bulman (2004) contends that reflective practice may provide a means of achieving this. Within an intensive care setting, some evidence exists to suggest a strong relationship between lived experience and learning, with most critical care practitioners learning from previous experience (Hendricks et al 1996). More recently, reflection has been closely associated with the concepts of critical thinking and deconstruction. It is argued that a combination of these principles create a retrospective and prospective dimension, giving the practitioner the ability to deconstruct events, to reason the origins of situations, and to consider what has gone before and what may happen yet (Rolfe 2005). In order to be effective in practice there is a requirement to be purposeful and goal directed. It is suggested therefore that reflection cannot just be concerned with understanding, but must also focus on locating practice within its social structures, and on changing practice (Bolton 2001). This suggests that a structured approach to reflection is of benefit to the practitioner. Indeed the use of a model or framework of reflection is advocated as a tool which can aid and facilitate the practitioner in reflection, promoting a process of continuous development (Bulman 2004). Reflection is seen as a dynamic process and not a static one (Duke 2004), and thus the use of a framework which adopts a cyclic approach to reflective practice seems appropriate. One such framework is Gibbs (1988) Reflective Cycle, which is adapted form a framework of experiential learning, and uses a series of questions to guide, and provide structure for the practitioner when reflecting on an experience. Gibbs (1988) highlights 6 important areas of consideration when reflecting on a specific situation, encouraging the practitioner to consider what happened, why it happened and what could be done differently in the future. The 6 components of the Reflective Cycle are outlined below: Description What happened? Feelings What were you thinking and feeling? Evaluation What was good and bad about the situation? Analysis What sense can you make of the situation? Conclusion What else could you have done? Action Plan If the situation arose again, what would you do? It is clear that the idea of reflective practice has come to have a considerable impact on the nursing profession. This paper will focus on 2 clinical scenarios occurring within an intensive care setting. The issues raised will be discussed within the context of Gibbs (1988) Reflective Cycle. The aim in doing so is to highlight the benefits of a structured reflective process, and to identify ways in which clinical practice may be improved in the future. Scenario 1 Description The first scenario concerns the care of an elderly, critically ill patient, who was being treated in a surgical intensive care unit. At the time of this scenario the patient had been in intensive care for almost 3 weeks, having been admitted with respiratory failure requiring intubation, and displaying clinical symptoms consistent with sepsis. The patient had many other underlying medical problems, was morbidly obese, and despite antibiotic therapy was requiring high levels of inotropic and ventilatory support. Despite the patients symptoms, no definite source of sepsis had been identified. The above patient was being cared for by the author on a 12 hour day shift and at the morning ward round it was noted that the patients condition had deteriorated significantly over the previous 2 days, with increased inotrope dependence and worsening renal function. With few treatment options left to try, the consultant anaesthetist decided that the patient should have a CT scan to identify or rule out an abdominal problem as a source of the sepsis. The patient was reviewed by a consultant surgeon who felt that in view of the patients co-morbidity, surgery of any kind would not be appropriate, despite potential positive findings on CT. Knowing that a CT scan had been carried out 1 week previously with no significant findings, the author raised concerns about the benefit of such a procedure, and suggested that at the very least the patients family should be informed or consulted about the planned investigation. The patients son had been spoken to the previous day and informed that the prognosis was very poor. Withdrawal of treatment had been mentioned as a possibility in the event of no improvement in the patients condition. The son however was not informed about the scan which went ahead the same day. Transferring the patient to the radiology department for scan proved difficult. The patient was sedated for transfer resulting in a need for increased inotropes due to further hypotension caused by the sedation. The patients large size also created a problem in finding an appropriate transfer trolley to take the patients weight. Again the author voiced concerns, stating that perhaps transfer was inadvisable in view of the patients unstable cardiovascular status. The anaesthetist decided that we should proceed with the scan. The patient remained unstable throughout the transfer, requiring a further increase in inotropes on arrival at scan. Whilst on the CT table, the patient became dangerously hypotensive and bradycardic, and it seemed that cardiac arrest was imminent. Adrenaline boluses were administered, and large fluid boluses of gelofusine were also given. In view of this, the CT scan was abandoned midway, and the patient was quickly transferred back to ICU. Further adrenaline boluses were needed during transfer. On arrival back to ICU, the author was met by the patients son, who was not aware that the patient was being scanned. He was made aware of the patients poor condition. Back in ICU it was decided that further resuscitation was not appropriate. The son was present when the patient died a few minutes later. Feelings On the day these events took place, the predominant thoughts and feelings of the author were ones of guilt and inadequacy. Having considered the multiple health problems faced by the patient at this time, the author felt that the process of transferring the patient to CT scan and carrying out the scan itself may cause the patient stress, discomfort and potential danger, and ultimately be of little or no benefit. During the transfer and scanning process, the author became increasingly anxious about the immediate safety of the patient, and the potential for deterioration in the patients condition. When the patient became dangerously bradycardic and hypotensive, the authors thoughts were concentrated on trying to prevent cardiac arrest. On returning to ICU and meeting the patients son, it seemed that neither the dignity of the patient or the concerns of the family had been respected. The author felt an inadequacy and felt that the interests of the patient had not been properly advocated. The patient passed away in a distressing and undignified manner, and the son did not have the opportunity to spend personal time with the patient prior to this happening. The author felt guilty, as it seemed that the CT scan should not have happened and that the undignified circumstances surrounding the patients death need not have occurred. Evaluation Looking back on the events of scenario 1, it seems that there were both positive and negative aspects to the experience. During transfer to CT scan and the emergency situation which followed, the author felt that there was good teamwork between the different professionals involved in the care of the patient. Because of this, prompt action was taken, preventing cardiac arrest. However, it seems that this situation may have been avoided, which in turn raises many questions relating to the care of the patient. Ethically, one must question how appropriate it was to scan a severely septic, unstable patient, especially when corrective treatments would have been inappropriate in the event of an abnormality being discovered. Should the author have advocated the interests of the patient and family more forcefully? Was there a lack of communication and consensus between the critical care team? The events of this incident culminated in a clinical emergency situation which led to the patients death. Thus, the author feels that the patients clinical condition and the ethical issues and dilemmas surrounding the patients care must be examined and discussed, in the hope that lessons can be learned through the reflective process. Analysis Sepsis Most illness and death in patients in intensive care is caused by the consequences of sepsis and systemic inflammation. Indeed, sepsis affects 18 million people worldwide each year (Slade et al 2003), with severe sepsis remaining the highest cause of death in patients admitted to non-coronary intensive care units (Edbrooke et al 1999). Sepsis is a complex condition that results from an infectious process, and is the bodys response to infection. It involves systemic inflammatory and cellular events that result in altered circulation and coagulation, endothelial dysfunction, and impaired tissue perfusion (Kleinpell 2004). Dellinger et al (2004) define sepsis as the systemic response to infection manifested by 2 or more of the following: High or low temperature (>38 °C or Heart rate > 90 beats per minute Respiratory rate > 20 breaths per minute or PaCO2 High or low white blood cell count (> 12,000 or In severe sepsis impaired tissue perfusion along with micro vascular coagulation can lead to multiple organ system dysfunction, which is a major cause of sepsis-related mortality (Robson Newell 2005). While all organs are prone to failure in sepsis, pulmonary, cardiovascular, and renal dysfunction occur most commonly (Hotchkiss Karl 2003). When multiple organ system dysfunction occurs, Dolan (2003) promotes evidence-based sepsis treatment whereby patients should receive targeted organ support. This includes mechanical ventilation, renal replacement therapy, fluids, vasopressor or inotropic administration, and blood product administration, to maximize perfusion and oxygenation. In recent years new therapies have emerged which have been shown, in some cases, to increase the chance of survival from severe sepsis. Recombinant human activated protein C has been shown to have anti-inflammatory, anti-thrombotic and pro-fibrinolytic properties (Dolan 2003). In a randomised controlled trial, Bernard et al (2001) found a significant reduction in the mortality of septic patients who had been treated with activated protein C. The National Institute for clinical excellence (2004) now recommends this treatment for adult patients who have severe sepsis resulting in multiple organ failure, and who are being provided with optimal ICU support. Steroids, the use of which in ICU has long been debated, have also been shown, in low doses, to reduce the risk of death in some patients in septic shock (Annane 2000). Despite the development of specific treatments to interrupt or control the inflammatory and procoagulant process associated with sepsis, its management remains a major challenge in healthcare (Kleinpell 2004). The patient in scenario 1 was clearly in a state of severe sepsis, with respiratory, cardiac and renal failure, and receiving some of the supportive treatments mentioned above. Indeed it seems that the severity of this condition should not have been underestimated. In view of this, the ethical issues surrounding the decision to take this patient to CT scan must now be considered. Ethical Dilemmas and Consensus Ethical issues have emerged in recent years as a major component of health care for critically ill patients (Friedman 2001). Thus, caring for these patients in an intensive care setting necessitates that difficult ethical problems must be faced and resolved (Fisher 2004). Traditionally, much of the literature in biomedical ethics comes from theoretical perspectives that include principled ethics, caring ethics and virtue ethics (Bunch 2002). Although these perspectives provide an ethical awareness, which can be helpful, they do not of necessity give much direction for clinical practice. Melia (2001) supports this notion, suggesting that many discussions of ethical issues in health care are presented from a moral philosophical viewpoint, which as a consequence leaves out the clinical and social context in which decisions are taken and carried through. Beauchamp Childress (1994) identify 5 principles pertinent to decision making in intensive care. These are: salvageability, life preservation, non-maleficence, beneficence, and justice. Ethical dilemmas occur when two or more of the above principles come into conflict. The principles of beneficence (doing good), non-maleficence (doing no harm) and justice (fair treatment) are well established within the field of bioethics. Within a critical care context however, the dilemma between salvageability and life preservation becomes an important focus for health care professionals. Indeed, Prien Van Aken (1999) raise the question of whether all medical means to preserve life have to be employed under all circumstances, or are there situations in which we should not do everything that it is possible to do. This question becomes particularly relevant when a patients condition does not improve but rather deteriorates progressively. Curtin (2005) suggests that at some point in the course of t reatment, the line between treating a curable disease and protracting an unpreventable death can be crossed. In such incidences Prien Van Aken (1999) identify a transitional zone between the attempt to treat the patient, and the prolongation of dying, in which a conflict between the principles of life preservation and non-maleficence develops. These concepts seem particularly relevant to scenario 1 where the interests of the patient may have been neglected in favour of further attempts to treat the patients condition. This, in turn created a conflict between the principles of salvageability and life preservation. The decision to perform a CT scan on a patient with such cardiovascular instability and a very poor prognosis, meant that the patient was subjected to dangers and harms when there were few, if any benefits to justify this. Hence, the conflict between the ethical principles was not resolved, and the professional duty of non-maleficence toward the patient was not respected. Such conflicts and dilemmas in intensive care can be made all the harder by the availability of advanced technologies. Callahan (2003) writes that one of the most seductive powers of medical technology is to confuse the use of technology with a respect for the sanctity of life. In addition, Fisher (2004) contends that it has become all too easy to think that if one respects the value of life, and technology has the power to extend life, then a failure to use it is a failure to respect that value. This is particularly true of diagnostic technologies (such as CT scanning) which must be used with caution, especially in cases where the diagnostic information will make little or no difference to the treatment of the patient, but can create or heighten anxiety and discomfort for the patient (Callahan 2003). Medical technology is a two-edged sword, capable of saving and improving life but also of ending and harming life (Curtin 2005). Good critical care medicine carries the responsibility o f preserving life, on the one hand, and making possible a peaceful death, on the other. Callahan (2003) concludes by warning that any automatic bias in favour of using technology will threaten that latter possibility. Consensus between members of the intensive care team is also highlighted as an important issue in ethical decision making. Effective communication and collaboration among medical and nursing staff are essential for high quality health care (Woodrow 2000). Collaboration can be seen as working together, sharing responsibility for solving problems, and making decisions to formulate and execute plans for patient care (Gedney 2000 p.41). In intensive care units where ethical problems are faced frequently, care has to be a team effort (Fisher 2004). In a qualitative study, Melia (2001) found that there was a strong desire within the intensive care team that ethical and moral consensus should be achieved in the interests of good patient care, even though it was recognised that there is no legal requirement for nurses to agree with ICU decisions. Cobaoglu Algier (2004) however, found that the same ethical dilemma was perceived differently by medics and nurses with the differences being related to the hospitals hierarchical structure and the traditional distinctions between the two professions. Similarly, it has been observed that differences between doctors and nurses in ethical dilemmas were a function of the professional role played by each, rather than differences in ethical reasoning or moral motivation (Oberle Hughes 2001). It seems therefore that while the medical and nursing professions share the same aims for patient outcomes, the ideas surrounding how these outcomes should be achieved may differ (Fisher 2004). These differences have contributed to the development of the concept of the nurse as patient advocate, which sees advocacy as a fundamental and integral role in the caring relationship, and not simply as a single component of care (Snowball 1996). The role of the nurse advocate should be that of mediator and facilitator, negotiating between the different health and illness perspectives of patient, doctor, and other health care professionals on the patients behalf (Mallik 1998). Empirical evidence is sparse and philosophical arguments seem to predominate in the field of patient advocacy. There is some evidence to suggest that nurse advocacy has had beneficial outcomes for the patient and family in critical care areas (Washington 2001). Hewitt (2002) however found that humanistic arguments that promote advocacy as a moral imperative are compelling. Benner (1984) writes of advocacy within the context of being with a patient in such a way that acknowledges your shared humanity, which is the base of nursing as a caring practice (Benner 1984, p. 28). It has been argued that advocacy, at least in a philosophical sense, is the foundation of nursing itself and as such should be regarded as an issue of great importance by all practitioners (Snowball 1996). Conclusion It can be concluded that sepsis in a critical care environment is a complex condition with a high mortality rate, requiring highly specialised treatments. As such, the ethical issues and dilemmas faced by health care staff caring for a septic patient can be both complex and far reaching. It must be noted, that there can be no general solutions for such ethical conflicts; each clinical case must be evaluated individually with all its associated circumstances. A study of ethical principles would suggest that it is important that the benefits of a specific treatment or procedure are established prior to implementation, and that these benefits outweigh any potential harms or risks to the patient. The ultimate decision maker in the scenario under discussion was the consultant anaesthetist, who should have provided a clearer rationale for performing a CT scan on such an unstable patient. As the nurse caring for the patient, the author recognises that the final decision regarding treatment rested with the anaesthetist. However, the author could have challenged the anaesthetists decision further, advocating the patients interests, with the aim of reaching a moral consensus within the team. Perhaps then the outcome would have been more favourable for all concerned. Action Plan By reflecting on this scenario, the author has gained an understanding of sepsis and the potential ethical problems which may be encountered when caring for a septic or critically ill patient. As a result, the author feels more confident to challenge those decisions made relating to treatment, which do not seem to be in the best interest of the patient, or which have the potential to cause more harm than good. The author now has a greater understanding of the professional responsibility to advocate on a patients behalf, with the aim of safeguarding against possible dangers. It is hoped that this will result in improved outcomes for patients in the authors care. Scenario 2 Description This incident occurred in a surgical intensive care unit while the author was looking after a ventilated patient who had undergone a laparotomy and right sided hemi-colectomy 2 days previously. Around 10.30am the patient was reviewed by medical staff and was found to be awake and alert with good arterial blood gases, and requiring minimal ventilatory support. In view of this, it was decided that the patients support should be reduced further, and providing this reduction was tolerated, that the patient should be extubated later in the morning. In the intensive care unit in which the author works an intensive insulin infusion protocol is used (see Appendix A). This is a research based protocol which aims to normalize blood glucose levels and thus improve clinical outcomes for critically ill patients. All patients on this protocol require either to be absorbing enteral feed at à ¢Ã¢â‚¬ °Ã‚ ¥30ml/hr, on TPN or on 5% dextrose at 100ml/hr (Appendix A, note 2). The patient involved in this incident was receiving enteral feed via a naso-gastric tube, and was on an insulin infusion which was running at 4 U/hr. When it was decided that the patient was to be extubated, the author stopped the enteral feed as a precaution, to prevent possible aspiration during or after extubation. The author however did not stop the insulin infusion which breached the protocol guidelines. About 12 noon the patients blood gases showed that the reduction in support had been tolerated, and so the patient was extubated. Shortly after this the author was asked to go for lunch break and so passed on to a colleague that the patient had recently been extubated but was managing well on face mask oxygen. Returning from lunch 45 minutes later, the author found the patient to be disorientated and slightly confused. With good oxygen saturations, the author doubted that the confusion had resulted from hypoxia or worsening blood gases. The author then realised that the insulin infusion had not been stopped with the enteral feed earlier. A check of the patients blood glucose level showed that it was 1.2mmol/L. The author immediately stopped the insulin infusion, administered 20mls of 50% dextrose intravenously, as per protocol, and recommenced the enteral feed. Twenty minutes later, the patients blood glucose level had risen to 3.7mmol/L. The patient continued on the insulin protocol maintaining blood glucose levels within an adequate range. There were no lasting adverse effects resulting from the hypoglycaemic episode. Feelings When it was realised that the insulin infusion had not been stopped, the author felt a sense of panic, anticipating correctly that the patients blood glucose level would be dangerously low. Thoughts then became concentrated on raising the blood glucose level, to ensure that no further harm would come to the patient as a result of the authors mistake. Following the incident, when the patients glucose levels had risen, feelings of guilt were prominent. At this point the author realised how much worse the outcome could have been for the patient. The author felt incompetent, knowing that the patient could have been much more severely affected, or could even have died as the result of such a simple mistake. Evaluation The events of scenario 2 highlight the fact that clinical errors, while easily made, can have potentially disastrous consequences. This is especially true of those errors which involve the administration of drugs intravenously. In the interest of patient safety, it is important that all such errors are avoided. The clinical error outlined above could easily have been avoided. It seems that there was not sufficient awareness, on the authors part, of the insulin infusion protocol and the guidelines concerning the administration of insulin. As a result, the insulin protocol was not adhered to. The following analysis therefore will focus on the importance of insulin therapy in critical care areas, and will consider the safety issues surrounding intravenous drug administration. Analysis Blood Glucose Control in Intensive Care It is well documented that critically ill patients who require prolonged intensive care treatment are at high risk of multiple organ failure and death (Diringer 2005). Extensive research over the last decade has focused on strategies to prevent or reverse multiple organ failure, only a few of which have revealed positive results. One of these strategies is tight blood glucose control with insulin (Khoury et al 2004). It is well known that any type of acute illness or injury results in insulin resistance, glucose intolerance and hyperglycaemia, a constellation which has been termed the diabetes of stress (McCowen et al 2001). In critically ill patients, the severity of this condition has been shown to reflect the risk of death (Laird et al 2004). Much has been learned recently about the negative prognostic effects of hyperglycemia in critically ill patients. Hyperglycaemia adversely affects fluid balance, predisposition to infection, morbidity following acute cardiovascular events, and can increase the risk of renal failure, neuropathy and mortality in ICU patients (DiNardo et al 2004). Research suggests that there are distinct benefits of insulin therapy in improving clinical outcomes. Such benefits have been seen in patients following acute myocardial infarction, and in the healing of sternal wounds in patients who have had cardiac surgery (Malmberg 1997; Furnary et al 1999). More recently Van den Berghe et al (2001) conducted a large, randomized, controlled study involving adults admitted to a surgical intensive care unit who were receiving mechanical ventilation. The study demonstrated that normalisation of blood glucose levels using an intensive insulin infusion protocol improved clinical outcomes in critically ill patients. In particular, intensive insulin therapy was shown to reduce ICU mortality by 42%, and significantly reduce the incidences of septicaemia, acute renal failure, prolonged ventilatory support, and critical illness polyneuropathy. The length of stay in intensive care was also significantly shorter for patients on the protocol. It is unclear as to why improved glycaemic control has been associated with improved outcomes in several clinical settings. Coursin and Murray (2003) have summarized several leading hypotheses including maintenance of macrophage and neutrophil function, enhancement of erythropoiesis, and the direct anabolic effect of insulin on respiratory muscles. The potential anti-inflammatory effects of insulin have also been evaluated (Das 2001). There is also uncertainty over whether it is the actual insulin dose received per se, or the degree of normoglycaemia achieved that is responsible for the beneficial effects of intensive glycaemic management. Van den Berghe (2003) analysed the data derived from their 2001 study and have concluded that the degree of glycaemic control, rather the quantity of insulin administered was associated with the decrease in mortality and organ system dysfunction. In a follow up to Van den Berghe et als 2001 study, Langouche et al (2005) found that a significant part of the improved patient outcomes were explained by the effects of intensive insulin on vascular endothelium. The vascular endothelium controls vasomotor tone and micro-vascular flow, and regulates trafficking of nutrients and several biologically active molecules (Aird 2003). Langouche et al (2005) conclude that maintaining normoglycaemia with intensive insulin therapy during critical illness protects the vascular endothelium and thereby contributes to the prevention of organ failure and death. Whatever the reasons for improved patient outcomes, the study by Van den Burghe et al (2001) has prompted much research in this field, all of which has yielded similar results. In a similar study, Krinsley (2004) found that the use of an insulin protocol resulted in significantly improved glycaemic control and was associated with decreased mortality, organ dysfunction, and length of stay in the ICU in a heterogeneous population of critically ill adult patients. Thus it seems that with the strength of the emerging data in support of a more intensive approach to glycaemic management, insulin infusions are being utilised with increasing frequency, and are considered by many to be the standard of care for critically ill patients (DiNardo et al 2004). It is important to note that a well recognised risk of intensive glucose management is hypoglycaemia. Indeed Goldberg et al (2004) emphasise that in the ICU setting where patients often cannot report or respond to symptoms, the potential for hypoglycaemia is of particular concern. The events of scenario 2 highlight the authors error in the administration of insulin resulting in hypoglycaemia. For this reason some issues surrounding intravenous drug therapy will now be discussed. Intravenous Drug Therapy There is an increasing recognition that medication errors are causing a substantial global public health problem. Many of these errors result in harm to patients and increased costs to health providers (Wheeler Wheeler 2005). In the intensive care unit, patients commonly receive multiple drug therapies that are prescribed either for prophylactic indications or for treatment of established disease (Dougherty 2002). Practitioners caring for these patients find themselves in the challenging position of having to monitor these therapies, with the goal of maximizing a beneficial therapeutic response, as well as minimizing the occurrence of any adverse drug-related outcome (Cuddy 2000). The Nursing and Midwifery Council (NMC) (2004) identifies the preparation and administration of medicines as an important aspect of professional practice, stressing that it is not merely a mechanistic task performed in strict compliance with a written prescription, but rather a task that requires thought and professional judgement. Heatlie (2003) found that the introduction of new insulin protocols and regimes could give rise to problems, espe