A Game of Thrones Chapter Six

Catelyn Of all the rooms in Winterfell's Great Keep, Catelyn's bedchambers were the hottest. She seldom had to light a fire. The castle had been built over natural hot springs, and the scalding waters rushed through its walls and chambers like blood through a man's body, driving the chill from the stone halls, filling the glass gardens with a moist warmth, keeping the earth from freezing. Open pools smoked day and night in a dozen small courtyards. That was a little thing, in summer; in winter, it was the difference between life and death. Catelyn's bath was always hot and steaming, and her walls warm to the touch. The warmth reminded her of Riverrun, of days in the sun with Lysa and Edmure, but Ned could never abide the heat. The Starks were made for the cold, he would tell her, and she would laugh and tell him in that case they had certainly built their castle in the wrong place. So when they had finished, Ned rolled off and climbed from her bed, as he had a thousand times before. He crossed the room, pulled back the heavy tapestries, and threw open the high narrow windows one by one, letting the night air into the chamber. The wind swirled around him as he stood facing the dark, naked and empty-handed. Catelyn pulled the furs to her chin and watched him. He looked somehow smaller and more vulnerable, like the youth she had wed in the sept at Riverrun, fifteen long years gone. Her loins still ached from the urgency of his lovemaking. It was a good ache. She could feel his seed within her. She prayed that it might quicken there. It had been three years since Rickon. She was not too old. She could give him another son. â€Å"I will refuse him,† Ned said as he turned back to her. His eyes were haunted, his voice thick with doubt. Catelyn sat up in the bed. â€Å"You cannot. You must not.† â€Å"My duties are here in the north. I have no wish to be Robert's Hand.† â€Å"He will not understand that. He is a king now, and kings are not like other men. If you refuse to serve him, he will wonder why, and sooner or later he will begin to suspect that you oppose him. Can't you see the danger that would put us in?† Ned shook his head, refusing to believe. â€Å"Robert would never harm me or any of mine. We were closer than brothers. He loves me. If I refuse him, he will roar and curse and bluster, and in a week we will laugh about it together. I know the man!† â€Å"You knew the man,† she said. â€Å"The king is a stranger to you.† Catelyn remembered the direwolf dead in the snow, the broken antler lodged deep in her throat. She had to make him see. â€Å"Pride is everything to a king, my lord. Robert came all this way to see you, to bring you these great honors, you cannot throw them back in his face.† â€Å"Honors?† Ned laughed bitterly. â€Å"In his eyes, yes,† she said. â€Å"And in yours?† â€Å"And in mine,† she blazed, angry now. Why couldn't he see? â€Å"He offers his own son in marriage to our daughter, what else would you call that? Sansa might someday be queen. Her sons could rule from the Wall to the mountains of Dorne. What is so wrong with that?† â€Å"Gods, Catelyn, Sansa is only eleven,† Ned said. â€Å"And Joffrey . . . Joffrey is . . . â€Å" She finished for him. † . . . crown prince, and heir to the Iron Throne. And I was only twelve when my father promised me to your brother Brandon.† That brought a bitter twist to Ned's mouth. â€Å"Brandon. Yes. Brandon would know what to do. He always did. It was all meant for Brandon. You, Winterfell, everything. He was born to be a King's Hand and a father to queens. I never asked for this cup to pass to me.† â€Å"Perhaps not,† Catelyn said, â€Å"but Brandon is dead, and the cup has passed, and you must drink from it, like it or not.† Ned turned away from her, back to the night. He stood staring out in the darkness, watching the moon and the stars perhaps, or perhaps the sentries on the wall. Catelyn softened then, to see his pain. Eddard Stark had married her in Brandon's place, as custom decreed, but the shadow of his dead brother still lay between them, as did the other, the shadow of the woman he would not name, the woman who had borne him his bastard son. She was about to go to him when the knock came at the door, loud and unexpected. Ned turned, frowning. â€Å"What is it?† Desmond's voice came through the door. â€Å"My lord, Maester Luwin is without and begs urgent audience.† â€Å"You told him I had left orders not to be disturbed?† â€Å"Yes, my lord. He insists.† â€Å"Very well. Send him in.† Ned crossed to the wardrobe and slipped on a heavy robe. Catelyn realized suddenly how cold it had become. She sat up in bed and pulled the furs to her chin. â€Å"Perhaps we should close the windows,† she suggested. Ned nodded absently. Maester Luwin was shown in. The maester was a small grey man. His eyes were grey, and quick, and saw much. His hair was grey, what little the years had left him. His robe was grey wool, trimmed with white fur, the Stark colors. Its great floppy sleeves had pockets hidden inside. Luwin was always tucking things into those sleeves and producing other things from them: books, messages, strange artifacts, toys for the children. With all he kept hidden in his sleeves, Catelyn was surprised that Maester Luwin could lift his arms at all. The maester waited until the door had closed behind him before he spoke. â€Å"My lord,† he said to Ned, â€Å"pardon for disturbing your rest. I have been left a message.† Ned looked irritated. â€Å"Been left? By whom? Has there been a rider? I was not told.† â€Å"There was no rider, my lord. Only a carved wooden box, left on a table in my observatory while I napped. My servants saw no one, but it must have been brought by someone in the king's party. We have had no other visitors from the south.† â€Å"A wooden box, you say?† Catelyn said. â€Å"Inside was a fine new lens for the observatory, from Myr by the look of it. The lenscrafters of Myr are without equal.† Ned frowned. He had little patience for this sort of thing, Catelyn knew. â€Å"A lens,† he said. â€Å"What has that to do with me?† â€Å"I asked the same question,† Maester Luwin said. â€Å"Clearly there was more to this than the seeming.† Under the heavy weight of her furs, Catelyn shivered. â€Å"A lens is an instrument to help us see.† â€Å"Indeed it is.† He fingered the collar of his order; a heavy chain worn tight around the neck beneath his robe, each link forged from a different metal. Catelyn could feel dread stirring inside her once again. â€Å"What is it that they would have us see more clearly?† â€Å"The very thing I asked myself.† Maester Luwin drew a tightly rolled paper out of his sleeve. â€Å"I found the true message concealed within a false bottom when I dismantled the box the lens had come in, but it is not for my eyes.† Ned held out his hand. â€Å"Let me have it, then.† Luwin did not stir. â€Å"Pardons, my lord. The message is not for you either. It is marked for the eyes of the Lady Catelyn, and her alone. May I approach?† Catelyn nodded, not trusting to speak. The maester placed the paper on the table beside the bed. It was sealed with a small blob of blue wax. Luwin bowed and began to retreat. â€Å"Stay,† Ned commanded him. His voice was grave. He looked at Catelyn. â€Å"What is it? My lady, you're shaking.† â€Å"I'm afraid,† she admitted. She reached out and took the letter in trembling hands. The furs dropped away from her nakedness, forgotten. In the blue wax was the moon-and-falcon seal of House Arryn. â€Å"It's from Lysa.† Catelyn looked at her husband. â€Å"It will not make us glad,† she told him. â€Å"There is grief in this message, Ned. I can feel it.† Ned frowned, his face darkening. â€Å"Open it.† Catelyn broke the seal. Her eyes moved over the words. At first they made no sense to her. Then she remembered. â€Å"Lysa took no chances. When we were girls together, we had a private language, she and I.† â€Å"Can you read it?† â€Å"Yes,† Catelyn admitted. â€Å"Then tell us.† â€Å"Perhaps I should withdraw,† Maester Luwin said. â€Å"No,† Catelyn said. â€Å"We will need your counsel.† She threw back the furs and climbed from the bed. The night air was as cold as the grave on her bare skin as she padded across the room. Maester Luwin averted his eyes. Even Ned looked shocked. â€Å"What are you doing?† he asked. â€Å"Lighting a fire,† Catelyn told him. She found a dressing gown and shrugged into it, then knelt over the cold hearth. â€Å"Maester Luwin—† Ned began. â€Å"Maester Luwin has delivered all my children,† Catelyn said. â€Å"This is no time for false modesty.† She slid the paper in among the kindling and placed the heavier logs on top of it. Ned crossed the room, took her by the arm, and pulled her to her feet. He held her there, his face inches from her. â€Å"My lady, tell me! What was this message?† Catelyn stiffened in his grasp. â€Å"A warning,† she said softly. â€Å"If we have the wits to hear.† His eyes searched her face. â€Å"Go on.† â€Å"Lysa says Jon Arryn was murdered.† His fingers tightened on her arm. â€Å"By whom?† â€Å"The Lannisters,† she told him. â€Å"The queen.† Ned released his hold on her arm. There were deep red marks on her skin. â€Å"Gods,† he whispered. His voice was hoarse. â€Å"Your sister is sick with grief. She cannot know what she is saying.† â€Å"She knows,† Catelyn said. â€Å"Lysa is impulsive, yes, but this message was carefully planned, cleverly hidden. She knew it meant death if her letter fell into the wrong hands. To risk so much, she must have had more than mere suspicion.† Catelyn looked to her husband. â€Å"Now we truly have no choice. You must be Robert's Hand. You must go south with him and learn the truth.† She saw at once that Ned had reached a very different conclusion. â€Å"The only truths I know are here. The south is a nest of adders I would do better to avoid.† Luwin plucked at his chain collar where it had chafed the soft skin of his throat. â€Å"The Hand of the King has great power, my lord. Power to find the truth of Lord Arryn's death, to bring his killers to the king's justice. Power to protect Lady Arryn and her son, if the worst be true.† Ned glanced helplessly around the bedchamber. Catelyn's heart went out to him, but she knew she could not take him in her arms just then. First the victory must be won, for her children's sake. â€Å"You say you love Robert like a brother. Would you leave your brother surrounded by Lannisters?† â€Å"The Others take both of you,† Ned muttered darkly. He turned away from them and went to the window. She did not speak, nor did the maester. They waited, quiet, while Eddard Stark said a silent farewell to the home he loved. When he turned away from the window at last, his voice was tired and full of melancholy, and moisture glittered faintly in the corners of his eyes. â€Å"My father went south once, to answer the summons of a king. He never came home again.† â€Å"A different time,† Maester Luwin said. â€Å"A different king.† â€Å"Yes,† Ned said dully. He seated himself in a chair by the hearth. â€Å"Catelyn, you shall stay here in Winterfell.† His words were like an icy draft through her heart. â€Å"No,† she said, suddenly afraid. Was this to be her punishment? Never to see his face again, nor to feel his arms around her? â€Å"Yes,† Ned said, in words that would brook no argument. â€Å"You must govern the north in my stead, while I run Robert's errands. There must always be a Stark in Winterfell. Robb is fourteen. Soon enough, he will be a man grown. He must learn to rule, and I will not be here for him. Make him part of your councils. He must be ready when his time comes.† â€Å"Gods will, not for many years,† Maester Luwin murmured. â€Å"Maester Luwin, I trust you as I would my own blood. Give my wife your voice in all things great and small. Teach my son the things he needs to know. Winter is coming.† Maester Luwin nodded gravely. Then silence fell, until Catelyn found her courage and asked the question whose answer she most dreaded. â€Å"What of the other children?† Ned stood, and took her in his arms, and held her face close to his. â€Å"Rickon is very young,† he said gently. â€Å"He should stay here with you and Robb. The others I would take with me.† â€Å"I could not bear it,† Catelyn said, trembling. â€Å"You must,† he said. â€Å"Sansa must wed Joffrey, that is clear now, we must give them no grounds to suspect our devotion. And it is past time that Arya learned the ways of a southron court. In a few years she will be of an age to marry too.† Sansa would shine in the south, Catelyn thought to herself, and the gods knew that Arya needed refinement. Reluctantly, she let go of them in her heart. But not Bran. Never Bran. â€Å"Yes,† she said, â€Å"but please, Ned, for the love you bear me, let Bran remain here at Winterfell. He is only seven.† â€Å"I was eight when my father sent me to foster at the Eyrie,† Ned said. â€Å"Ser Rodrik tells me there is bad feeling between Robb and Prince Joffrey. That is not healthy. Bran can bridge that distance. He is a sweet boy, quick to laugh, easy to love. Let him grow up with the young princes, let him become their friend as Robert became mine. Our House will be the safer for it.† He was right; Catelyn knew it. It did not make the pain any easier to bear. She would lose all four of them, then: Ned, and both girls, and her sweet, loving Bran. Only Robb and little Rickon would be left to her. She felt lonely already. Winterfell was such a vast place. â€Å"Keep him off the walls, then,† she said bravely. â€Å"You know how Bran loves to climb.† Ned kissed the tears from her eyes before they could fall. â€Å"Thank you, my lady,† he whispered. â€Å"This is hard, I know.† â€Å"What of Jon Snow, my lord?† Maester Luwin asked. Catelyn tensed at the mention of the name. Ned felt the anger in her, and pulled away. Many men fathered bastards. Catelyn had grown up with that knowledge. It came as no surprise to her, in the first year of her marriage, to learn that Ned had fathered a child on some girl chance met on campaign. He had a man's needs, after all, and they had spent that year apart, Ned off at war in the south while she remained safe in her father's castle at Riverrun. Her thoughts were more of Robb, the infant at her breast, than of the husband she scarcely knew. He was welcome to whatever solace he might find between battles. And if his seed quickened, she expected he would see to the child's needs. He did more than that. The Starks were not like other men. Ned brought his bastard home with him, and called him â€Å"son† for all the north to see. When the wars were over at last, and Catelyn rode to Winterfell, Jon and his wet nurse had already taken up residence. That cut deep. Ned would not speak of the mother, not so much as a word, but a castle has no secrets, and Catelyn heard her maids repeating tales they heard from the lips of her husband's soldiers. They whispered of Ser Arthur Dayne, the Sword of the Morning, deadliest of the seven knights of Aerys's Kingsguard, and of how their young lord had slain him in single combat. And they told how afterward Ned had carried Ser Arthur's sword back to the beautiful young sister who awaited him in a castle called Starfall on the shores of the SummerSea. The Lady Ashara Dayne, tall and fair, with haunting violet eyes. It had taken her a fortnight to marshal her courage, but finally, in bed one night, Catelyn had asked her husband the truth of it, asked him to his face. That was the only time in all their years that Ned had ever frightened her. â€Å"Never ask me about Jon,† he said, cold as ice. â€Å"He is my blood, and that is all you need to know. And now I will learn where you heard that name, my lady.† She had pledged to obey; she told him; and from that day on, the whispering had stopped, and Ashara Dayne's name was never heard in Winterfell again. Whoever Jon's mother had been, Ned must have loved her fiercely, for nothing Catelyn said would persuade him to send the boy away. It was the one thing she could never forgive him. She had come to love her husband with all her heart, but she had never found it in her to love Jon. She might have overlooked a dozen bastards for Ned's sake, so long as they were out of sight. Jon was never out of sight, and as he grew, he looked more like Ned than any of the trueborn sons she bore him. Somehow that made it worse. â€Å"Jon must go,† she said now. â€Å"He and Robb are close,† Ned said. â€Å"I had hoped . . . â€Å" â€Å"He cannot stay here,† Catelyn said, cutting him off. â€Å"He is your son, not mine. I will not have him.† It was hard, she knew, but no less the truth. Ned would do the boy no kindness by leaving him here at Winterfell. The look Ned gave her was anguished. â€Å"You know I cannot take him south. There will be no place for him at court. A boy with a bastard's name . . . you know what they will say of him. He will be shunned.† Catelyn armored her heart against the mute appeal in her husband's eyes. â€Å"They say your friend Robert has fathered a dozen bastards himself.† â€Å"And none of them has ever been seen at court!† Ned blazed. â€Å"The Lannister woman has seen to that. How can you be so damnably cruel, Catelyn? He is only a boy. He—† His fury was on him. He might have said more, and worse, but Maester Luwin cut in. â€Å"Another solution presents itself,† he said, his voice quiet. â€Å"Your brother Benjen came to me about Jon a few days ago. It seems the boy aspires to take the black.† Ned looked shocked. â€Å"He asked to join the Night's Watch?† Catelyn said nothing. Let Ned work it out in his own mind; her voice would not be welcome now. Yet gladly would she have kissed the maester just then. His was the perfect solution. Benjen Stark was a Sworn Brother. Jon would be a son to him, the child he would never have. And in time the boy would take the oath as well. He would father no sons who might someday contest with Catelyn's own grandchildren for Winterfell. Maester Luwin said, â€Å"There is great honor in service on the Wall, my lord.† â€Å"And even a bastard may rise high in the Night's Watch,† Ned reflected. Still, his voice was troubled. â€Å"Jon is so young. If he asked this when he was a man grown, that would be one thing, but a boy of fourteen . . . â€Å" â€Å"A hard sacrifice,† Maester Luwin agreed. â€Å"Yet these are hard times, my lord. His road is no crueler than yours or your lady's.† Catelyn thought of the three children she must lose. It was not easy keeping silent then. Ned turned away from them to gaze out the window, his long face silent and thoughtful. Finally he sighed, and turned back. â€Å"Very well,† he said to Maester Luwin. â€Å"I suppose it is for the best. I will speak to Ben.† â€Å"When shall we tell Jon?† the maester asked. â€Å"When I must. Preparations must be made. It will be a fortnight before we are ready to depart. I would sooner let Jon enjoy these last few days. Summer will end soon enough, and childhood as well. When the time comes, I will tell him myself.†

Collaborative Working Essay

There are many different ways to define ‘Collaborative Working’. According to The National Center for Biotechnology Information bookshelf (NCIB) Collaboration in health care is defined as health care professionals assuming complementary roles and co-operatively working together, sharing responsibility for problem-solving and making decisions to formulate and carry out plans for patient care. Collaboration between physicians, nurses, and other health care professionals increases a team member’s awareness of each other’s type of knowledge and skills, leading to continued improvement in decision-making. To work collaboratively it is also important for all team members to be willing to take part and trust other health professionals to accomplish a collective outcome, which is the health and wellbeing of the patient. Thomas et al (2005) mentions that willingness is one step of developing interpersonal collaboration and trust has been seen as a vital part to assist the development of effective team working. All professionals need to trust each other and learn new competencies and be able to take on new roles without resentment, as this requires a willing and trusting approach. Therefore, to give the patient the best possible care, it is imperative to  work in conjunction with other healthcare professionals to meet the needs of the patient. Each professional has to show mutual respect for one another in order to be able to work together or else there will be conflict in the team and the outcome of the patient will suffer. Thomas et al (2005) continues to say that confidence has been pointed out as an important feature in collaborative working as professionals who are confident in their own roles have the ability to work flexibly into other boundaries without feeling jealous or threatened. Confidence shows leadership and allows others to trust the work of that individual, therefore creating a trusting environment for them all to work together. The terms interprofessional, multiprofessional and interdisciplinary are all related to collaborative working, Thomas et al. (2005) defines the prefix ‘multi ‘ as the participation of staff from different professions, and the prefix ‘inter† means collaboration in the areas of decision making thus indicating that healthcare professionals, be it consultant, nurses, social workers or community staff work together to provide a high quality care and to achieve the best outcome for the patient. With skills and knowledge coming from these colleagues that major in different backgrounds, overall the team can provide an excellent service and duty to patients due to having specialists from different areas working together in the same team. Collaborative working involves interaction of various groups or professions to accomplish a general goal, which normally in the health care setting is the care of the patient. As a result of problem solving, an open and flexible approach to the roles and tasks of individual team members provide a more patient focused healthcare. Read more:  Sharing Responsibility Role of Local and State Bodies The aim of this essay is to establish what skills and knowledge are required to work collaboratively successfully. I will describe a care pathway, which will look at the care a patient received from different services in which I participated. In the health care service, working with people is a part of the working day. According to Goodman & Clemow (2010), working with other people is a fact of everyday life, whether you will be working the in community or in a  hospital environment you will be constantly interacting with people to assess, plan implement and evaluate care provided. Goodman and Clemow (2010) go on to say Nursing work is primarily people work, be it one-to-one patient care or team care. The principle of a care pathway is to recommend the most appropriate care required to meet the patient’s needs. According to Middleton & Roberts (2000) care pathways are evidence based care which is delivered to the patient by the correct individual at the specific time and the suitable environment. Middleton & Roberts (2000) continue to say that integrated care pathways are used to determine multidisciplinary practice based on guidelines for particular patients. According to the Royal College of nursing (RCN) 2014, care pathways are also known as integrated care pathways, anticipated recovery maps, critical pathways or care maps. Communication is very important in the healthcare service to ensure that the patient will receive the correct care plan to meet their needs. According to the Royal College of Nursing (RCN) 2014, communication is at the heart of everything we do in our society. It’s central to our learning, our work and our leisure interests. It is vital in health care, where patients/clients can feel vulnerable, isolated and anxious, therefore teams need to rely on good communication to help them deliver safe, coordinated and effective healthcare. Without communication between certain individuals in the team, it can cause conflict or friction between some colleagues therefore delaying the goal of impeccable patient care. Communication shared amongst teams can achieve a holistic goal that is clear and in which the outcomes are met amongst the team (RCN) 2014. Communication is not only verbal, it is also non-verbal and listening also plays a part. If health professionals are not working together then there is a failure of communication and errors will occur and the wellbeing of the patient will suffer. This may also happen when health professions used different terminologies within their profession, which others may not understand. This demonstrates the need for communication to be shared in a manner which all members can understand to avoid confusion and reduce the risk of mistakes  happening, i.e. language line, interpreters and other professionals who understands the language. Due to the importance of patient confidentiality I will be keeping the identity of my patient as anonymous and a pseudonym will be used for the purpose of the essay to protect the patient. This complies with the NHS Code of Practice on Confidentially (2003). Throughout this essay my patient will be referred to as Mr A. The Tuberculosis (TB) Services must be accessible to all health care professions in the community or hospital. An important part of the role of the TB service is to promote awareness of TB and ensuring that all suspected cases of TB are promptly referred for investigations, diagnosis, treatment, support to control the spread of TB. The most common pathway by which patients can access the TB service includes referrals from GP surgeries, accident and emergency, laboratory microbiology, hospital wards and other hospital specialties such as HIV (Gum clinic), rheumatology and paediatrics. TB services have one designated referral number, fax, email address and contact address. The care pathway for patients who show signs and symptoms of TB will require a number of investigations, which will include a Mantoux Skin test, when a small amount of Purified Protein Derivative (PPD) is injected into the arm and the results will be read 48/72 hours later, a chest x-ray, sputum samples or a bronchos copy. Once these investigations have been completed and if the results are positive for active TB, the patient will be commenced on TB treatment. This treatment will be for a minimum six months to two years depending on the type of TB diagnosed. My role as the Support worker for the TB team is to assist patients, to help them understand and come to terms with their diagnosis. In addition to this I will ensure that they receive the correct medication as distributed by the nurses, monitor any side effects and bring them to the attention of the specialist nurses who will give further advice or discuss with the senior consultant who will be able to decide on an appropriate care plan if needed. I also support patients with any welfare and social matters such as housing, immigration and social benefits. My role involves acting as the advocacy for patients and links them with the required services. In order  for this to work, I have to build a very good rapport with my patients, and I feel that this enables them to become open and honest with me, which results in us achieving our desired goal. Patient Scenario Mr A was admitted via accident and emergency complaining of chest pains, lethargy, loss of weight, cough and night sweats, the typical symptoms of TB. His chest x-ray showed left sided pleural effusion and sputum sample results were smear positive, indicating that he was infectious, His Mantoux result was 18mm and was diagnosed with smear positive pulmonary tuberculosis. Mr A was born in Romania and entered the UK originally in 2009. He was house sharing with other Romanians for three months until they were evicted by the police as they were possibly squatting and he became homeless. He was of no fixed abode with no clear connections in the UK. He has been living on the streets ever since being evicted. He has no means of contact, no money and has very limited understanding of English. Mr A was referred to the TB Service by the consultant on the respiratory ward. Due to his lack of English language, a Romanian interpreter needed to be booked to allow sufficient communication between staff and Mr A. I made a telephone call to the hospital interpreting service to book a Romanian interpreter to assist with the assessment. The TB assessment was carried out in the ward with the Romanian interpreter present. The TB assessment form was completed using Roper et al (2000) Activities of Daily Living. This assessment model looks at the patient’s needs as well as any possible problems connected with the patient i.e. social, physical, psychological and medical. According to Roper et al (2000) this model will give a holistic view of the individual instead of just the illness. This model recognises the impact of cultural, environment, and economic factors that affect both health and well-being (Barrett et al, 2012). Prior to our assessment on the ward I received a telephone call from the Infection control nurses to inform us of his sputum results. The results of his test were smear positive and this indicated that the patient was  infectious therefore he was placed in to a negative pressure side room. A negative pressure room is used to prevent the spread of TB. The National TB Centre describe a negative pressure room as a room where more air is drained than is supplied, so infectious particles are contained within the room by continuous air current being pulled into the room under the door. Therefore, when the negative pressure room is used airborne particles generated in the room cannot escape to the corridor. During this assessment it was brought to my attention that Mr A had no income and was homeless. My role as the Support Worker is to help patients with any welfare and housing issues. I was able to make a telephone call to the hospital social services for advice on Mr A and had a long conversation with the advisor. We agreed that I needed to contact Greenwich Social Services for further advice. I was informed by Greenwich Social services that Mr A was not entitled to any public funds because of his no recourse to public funds on entry to the UK. Due to Mr A’s situation, I spoke to my colleagues in Find and Treat who informed me that Mr A might be eligible for accommodation, and a referral form was faxed to me for completion with my patient. Find and Treat is a Department of Health Organisation within Public Health England that works alongside TB services to provide holistic, preventative and stabilising support to homeless people who are on TB treatment and have no recourse to public funds. The completed referral form was faxed back to Find and Treat. I received a telephone call from Find and Treat to inform me that the referral had been accepted at the homeless shelter and the next step was an interview with the shelter home manger and his allocated case worker to meet the patient to ensure that all his needs were met whilst in their care. The case worker and the manager met the patient in the ward in my presence with the interpreter to complete their full assessment for placement in view of the referral information and facts we presented. Once the meeting was complete, I had to liaison with the discharge coordinator on the ward to inform them that Mr A had been accepted at the shelter home. Prior to his discharge from the ward, the TB nurse checked  his TB medication and I booked transport for my patient to get to the organised accommodation and he was taken on the same day. The following day I made a telephone call to his case worker asking about his (Mr A) progress and how he was settling in. He was reported to be settling in well and had no concerns. Mr A had been visiting a homeless unit for food and shelter prior to this admission to the ward. Due to his smear positive sputum results; it is a requirement to refer all smear positive index cases to Public Health England (PHE) as TB is a notifiable disease. It is my duty to gather as much information as possible regarding the homeless unit. I completed an incident reporting form with all the information from the shelter unit and faxed it to PHE. I had a conversation with PHE by telephone to arrange an incident meeting between the shelter home, PHE and the TB nurses. Once a date was agreed with all parties we met at the shelter home to identify contacts and organise screening. It was agreed that all contacts who needed to be screened for TB were to be referred to the TB Service. Collaborative working sometimes may not always work smoothly as expected. Some team members may feel left out or not appreciated, Elizabeth Lark (2006) says to work collaboratively you need to be focused on a two way related dimension. The task that needs to be achieved, in this case the outcome of the patient, and the relationship with and between the people that need to be engaged in it. Therefore it is clear to say that all team members need to feel appreciated and valued in collaboration to make it work professionally. Another factor that may cause problems in collaboration is personality conflict, a lack of understanding in other professionals’ sphere and the influence of hierarchy in job roles within the multidisciplinary teams. Elizabeth Lark (2006) continues to say that these types of conflicts can be resolved by giving team members the chance to discuss their concerns in group meetings to identify clear working responsibilities before implementing the care of the pati ent. As a Support Worker collaborative working is very important to me to ensure that a service work as a team to give patients the required care they need to enable them to be able to return to their normal healthy lifestyle. When caring for patients we need to set standards and be professional regardless of the patient’s background and belief. The importance of my role as a Support Worker in advocacy and linking patients with other service has lead to the recovery of our patients, as many of our patients do not understand the diagnosis and the stigma related to the TB diagnosis. Having access to all these services has made it possible for me to help Mr A on the road to recovery and enable him to live a normal life again where he will be helped and assisted with some form of work and earn a living. Due to his lack of the English language it would have been very difficult for him to access these services by himself as I was the main link for Mr A to receive the correct care. Mr A was very happy with the care he received from all the different services, he said via the interpreter â€Å"I would not have known where to go to get help, I thank you all†. The care given to Mr A was delivered over a period of three months. He remained in hospital for 4 months, during this time I ensured that all of the hospital resources were coordinated to ensure that the highest level of service was delivered and that Mr A could return to living a normal healthy life style. My role as a Support worker in this collaborative working has helped other healthcare professionals such as ward staff, infection control nurses and hospital social services to gain better knowledge of TB and how working together to overcome obstacles to ensure that the patient can receive the correct care needed. We were able to identify the patient’s needs, which allowed the nurses and other services to coordinate and plan interventions to meet the patient’s requirements in regards to his recovery. It is evident that collaborative working does have the best outcome for patient. Working collectively has enabled me to expand my knowledge and skills required to work along side other health providers and social services. Communication is the key skill required in collaborative working to ensure and accomplish the best outcome for your patients. All services and organisations need to work well together and leave their differences, misunderstanding and challenges aside for the sake of the patient’s outcome.  Collaborative working takes away any additional stress and worry for patients who just want to overcome their illness and this was reflected in Mr A’s situation. References Barrett D, Wilson B & Woodlands A, (2012) Care Planning A Guide for Nurses, Second Edition, Essex, Pearson Education limited. Goodman B & Clemow R, (2010) Nursing and Collaborative Practice, Great Britain, MPG Books Group Lark E, (2006) Collaborative Advantages – How Organisation Win by Working Together, Hampshire, Palgrave Macmillan Middleton S & Roberts A (2000) – Integrated Care Pathways : a practical approach to implementation Oxford, Reed Education and Professional Publishing Ltd Roper N, Logan W & Thierney A J, (2000) The Roper Logan Tierney Model of Nursing Based on Activities of Living, Edinburgh, Churchill Livingstone. Thomas,J Pollard K C and Sellman D, (2005) Interporessioanl Working in Health and Social Care. New York, Palgrave Macmillian National Centre for Biotechnology Information Bookshelf http://www.ncbi.nlm.nih.gov/books/NBK2637/ Professional Communication and Team Collaboration – Patient Safety and Quality Access on 25/09/14 Royal College of Nursing http://rcnhca.org.uk/communication – First Steps for HCAs Accessed on 15/10/14 National TB Centre https://www.ndhealth.gov/Disease/TB/Documents/Infection%20Control.pdf Accessed on 30/10/14 NHS Code of Practice https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/200146/Confidentiality_-_NHS_Code_of_Practice.pdf Accessed on 08/11/14 Royal College of Nursing http://www.rcn.org.uk/development/practice/perioperative_fasting/good_practice/service_improvement_tools/care_pathways Accessed on 15/11/14

Barc Sample Paper

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Article Summaries Essay Example | Topics and Well Written Essays - 250 words

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Reviewing the literature Essay Example | Topics and Well Written Essays - 1750 words

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Review the molecular mechanisms used by adult schistosoma worms to Essay

Review the molecular mechanisms used by adult schistosoma worms to survive in the bloodstream - Essay Example The remaining eggs often go into circulation and get filtered in the periportal tracts within the liver, and this causes periportal fibrosis. According to Ashton and Wilson (2001), the major schistosome species that affect individuals are: Schistosoma haematobium, Schistosoma mansoni and Schistosoma japonicum. These parasites experience remarkable physiological and morphological changes throughout their life as a means of survival and adaptation to their varying living conditions in different hosts. These parasites are unique because they exhibit unique adaptations both to free-living, as well as parasitic living. The adaptations exhibited by these parasites allow movement between intermediary hosts and the ultimate host. Schistosomes survive within the host by adopting mechanisms that counter the effect of the hosts’ defense mechanisms. These adaptations occur both at the molecular and structural levels. Schistosomes have various adaptations at the molecular level and these i nclude anti-oxidant production and glycoproteins secretion among others. Structural adaptations also help facilitate survival, and these include tails or cilia for swimming, secretory glands for penetration into the host, a glycocalyx for host immuno-modulation or protection of the parasite, a gynaecophoric canal for continued coupling between sexes, and a well-organized reproductive system for proper egg fertilization, as well as muscular suckers for feeding and attachment. This paper reviews these adaptation strategies, and how they are employed in survival. Additionally, possible interventions are proposed to counter the effect of these adaptations so as to make the parasites vulnerable to the host’s immune system and possible elimination. Adaptations for survival among schistosomes entail evasive strategies that enable the parasites to survive within the host without being affected by the hosts’ immunity. The evasion

Critical Reflection and Self-Evaluation in the Context of Systems Essay

Critical Reflection and Self-Evaluation in the Context of Systems Thinking - Essay Example It is due to the rapid changes to organizations that organizations have to readjust to the inevitable changes to cope in a highly chining environment such as the one involved in event management. Event planning changes affect the IS project outcomes in the in such a project and it is not until shortcomings are indentified in event planning that portrays a need to reassess and reevaluate the IS are taken appropriately. This brought about the concept of soft system thinking and hard thinking in the â€Å"Bear-Wear† event coaching group. Hard systems regard to situations that human behaviors perceived to play minimal roles though there are many people involved in the system ( Waring, 1996). Hard systems in this case referred to tools, machines and to other equipment that were used in the project, which were quantifiable, predictable, and those that were relatively undisputable. Hard systems as Checkland & Holwell (1997) explain included the natural systems. Natural systems are th ose that are not manmade, which include the biological systems, weather, volcanoes and other natural phenomena. Logistics and ticketing are susceptible to interruptions as a result of the hard systems such as weather and disruptions of the equipment. This was taken care of in risk awareness. On the other hand, soft systems refer to those systems that involved the team members’ behaviors and beliefs. Human beings are unpredictable in most cases in the physical aspect and the way they think. Soft systems refer to the beliefs, attitudes, behavior values, opinions that describe each of the team members. Checkland & Scholes (1999) explain that soft system methodology is intended for use in situation that exhibit crisis, uncertainty, conflict or unease in relationship among the human actors. In the event hosting and management, different opinions and personality will surface in the team or from the clients. Advocating for creative thinking and providing coaching and counseling serv ices to Grad Com and anyone involved will enable the team work to work harmoniously. Gesellschaft & Gemeinsschaft, which relates to sociality maintained by instrumental goals of participating individuals vs. the inherent connectedness of participating individuals (Kitayama & Cohen, 2010) were two major views that would guide in implementing operations in the event planning, management and counselling services. Soft approach related to information in attribution of meanings and sense making and would utilize interpretative actions as the modes of managing environment around project members (Auyang, 1998). Since organisations and the IS are mutually dependent on one another, they both affect each other proportionately to make an organisation environment. Soft System thinking application Systems thinking concept was first applied to real world problems as early as 1970s and 80s. The design of system thinking was as a result of indentifying that problems were mainly caused as a result o f the analyst’s inability to indentify describe objectives amongst the other, in an environment with numerous conflicting and ambitious alternatives (Auyang, 1998). System analysts therefore led leaders and other analysts to design and construct models that could be used by analysts as devices that would help in structuring questioning procedures to address

Responsible Gambling Assignment Example | Topics and Well Written Essays - 2000 words

Responsible Gambling - Assignment Example It is done in order to save the customers from the negative impacts of gambling or gaming. Apart from this, maximum extent of the industries or organizations operating in this industry try to implement land-based and online gambling services so as to enhance the reliability of the customers (Wenderoth, 2009, p. 21). Other than this, with the help of responsible gaming or gambling process, the customers get protection from vulnerable practices, protection against fraud and non-ethical behaviours of other consumers, maintenance of varied information’s utterly private, ensuring prompt payments, delivering a fair and ethical gaming experience, high-level of commitment is also observed to enhance customer satisfaction and demands to retain them. Such types of behaviours are extremely essential for the consumers of the industry of gaming or gambling as their age-bar differs from one another. The prime target audiences seen in the industry of gaming or gambling are mainly youths within an age limit of 18 to 28. In order to fulfil their excitement and fun, maximum extent of these youths of the wealthy families of China, Thai and Korea enter into this sector. The individuals getting attracted to gambling, desire to attain relief from varied types of mental distress and tension, so it is extremely essential to present humble behaviour with them. Otherwise, due to certain fraudulent conducts, he or she might get disturbed resulting in breakdown of their physical and mental health. Due to which, the reputation and image of the organization might get ruined resulting in switch-over of numerous other customers as well. Moreover, adults and parents, suffering from varied types of economic and social hardship, desire to engage themselves in gambling to get rid from such problems. Thus any type of worse behaviour might create an

Jhon Barleycorn by Jack London Essay Example | Topics and Well Written Essays - 1250 words

Jhon Barleycorn by Jack London - Essay Example a dimension which is free from any rules or obligations. Probably the one who is under the influence, sees things clearly, well at least from a different angle. This angle is far from the norm or what people are used to. The way first chapter of the book begins, it speaks volumes about the mental state of the man. He is going to vote for something very important and he’s drunk. Probably logic doesn’t do justice when it comes to voting. He votes for women suffrage amendment. The popular vote is probably a fabrication, a concoction, and people who craft the ballet box and the election system, design it in such way so that it gets picked up by the majority. It is equivalent to giving a person a set of choices and when he’s done choosing his favorite, he feels liberated as he used his freedom of choice to get what he liked but little does he know that all choices were acceptable by the person who gave him the choice. The interesting thing about the state of mind (of the protagonist) is when he’s under the influence, he gets more indignant while explaining or talking about something. He explains why he voted for the woman suffrage amendment. Although he claims that he was not under the influence but probably he was. He gives his reason that he ride his way back from the polling station on the back of the wildest horse. No one can ride it drunk, that’s why he couldn’t be drunk. Nice explanation but it doesn’t prove he wasn’t under the influence. People consider Jack’s book his autobiography. There is no doubt that he was an alcoholic himself. And this book probably is a preaching book towards alcoholism. What a man feels when he’s drunk is something a man can’t understand unless he’s drunk. Some strange wisdom, which is â€Å"beyond life’s wisdom† starts flowing as the rum goes in the body. The question is what kind of explanation is that? On the surface it might seem

QUANTITATIVE RESEARCH METHODS-SEEN EXAM Coursework

QUANTITATIVE RESEARCH METHODS-SEEN EXAM - Coursework Example 2. By using or combining several time series of cross section observations, panel data provide â€Å"more informative data, more variability, less collinearity among variables, more degrees of freedom and efficiency† as per Baltagi’s discussion (1995, p. 3-6). 3. Panel data are able to study better the dynamics of change because the panel data technique is able to cover repeated cross section of observation across time. Thus, panel data is believed to more appropriate than either of the two methods (cross section and time series analysis) in the study of situations like successive waves of minimum wage increases across localities and local minimum wages and over time 4. Panel data can detect and measure effects better than what purely time series and cross-section data can do. 5. Panel data are able to study complicated behavioural models like economies of scale and technical change---better than what pure time series and pure cross-section analysis can do. For example, panel data can study the interaction of the variables involved over time, which cannot be done by pure time series data. 6. By covering more units over time, panel data can minimize the biases that may result as data are aggregated. In 1995, Baltagi pointed out that time series and cross-section studies were not controlling for heterogeneity and run the risk of obtaining biased results (p. 3). For example, Baltagi (1995, p. 3) cited for example that consumption of cigarettes is often modelled as a function of lagged consumption, price, and income but the specification of the same function can vary across countries, state, and time. Baltagi 1995, p. 4) added that panel data are able to control for location specific and time invariant variables while a time-series study or a cross-section study cannot at that time. As panel data can cover heterogeneity, Baltagi (1995, p. 4), not accounting for country heterogeneity can cause serious specification error. In addition, Baltagi (1995, p. 4) said that panel data are able to study the dynamics of adjustment. Meanwhile, Verbeek (2008, p. 655) said that the main advantage of panel data over either time series or cross-section analysis is that through panel data, economists are able to specify more complicated and realistic models than a single time series or cross-section data can do. (b) Explain the intuition behind the fixed effect model (FEM) and describe the least square dummy variable (LSDV) and the time demeaned approaches to estimating a FEM. [30 Marks] Verbeek (2008, p. 359) defined the fixed effects model as simply a regression model in which the intercept terms vary over the individual units. Gujarati (2004, p. 642) pointed out that the main intuition behind the fixed effect model or FEM is that although the intercept may differ across individual elements, each specific intercept does not change over time or is time invariant. The methods for estimating the fixed effects model (FEM) are the least square dummy variable (LSDV) and the time demeaned approaches towards estimating the FEM. In the LSDV method, the main instruments for capturing the fixed effects are dummy variables. The time demeaned variable approach to FEM modelling, reconstruct the basic model yit = ? + ?xit + uit as departures of a variable from its mean over time or yit - i ?(xit - i ) + ( uit - )i) where the values with bars denote the time mean of the said variable (Brooks

Cannon Fodder and The Armistice Essay Example for Free

Cannon Fodder and The Armistice Essay The two poems are both written during the time of the First World War, and reflect the emotions felt towards the war. Both poets have different experiences of the war, yet share a common grief. They reflect their grief and other emotions through their use of language. In the poem cannon Fodder, Wilfred Owen tries to convey to the reader the terror that he felt when discovering the corpse of the soldier seven days after his death. Owen uses very powerful imagery to show the reader the horror of the corpse: Feeling the damp, chill circlet of flesh Loosen its hold On muscles and sinews and bones This represents the decay and decomposition of the corpse, and he shows us the horror of seeing the extent of the decay by using a metaphor. The flesh isnt really holding on to the dead soldiers body, but it is there to inform us that it is falling apart. Owen also tries to convey to the reader the feeling of futility towards the war. He shows the pointlessness of it all by using rhetorical questions: Is death really a sleep? The soldier who has discovered the corpse is asking the corpse this question, but of course, the soldier will get no answer because he is talking to a dead man. This task in itself is pointless, and reminds us just how pointless all of the war seems to Owen. Owen also uses a lot of Prefixes on words instead of using a different word. This can change the mood of a sentence: Uncared for in the unowned place The use of the suffixes makes the place sound so desolate, that it is not worth dying for. The place is called no mans land, and this is why it is referred to as unknown. Uncared makes us feel that there is no recognition of the bravery of the soldier, or for the respect to bring his body in from no mans land. In Owens poem, we also feel for the soldier who found the corpse. He thinks back to what the dead soldiers life at home was probably like. This makes us feel as though the soldier wishes he was at home, feeling all of the comforts presented in the soldiers thoughts: But at home by the fire The word but instantly indicates that the mood of the poem is about to change, and that the reader is about to see a contrast between what they have just read, and what they are about to read. Owen also uses his line structure to add power to the words and the meaning he is trying to convey: Your bright-limbed lover is lying out there Dead The last line of the quote is very emphatic and powerful, because death is such a strong word and it is being used alone, almost being used as a false stop to the idyllic life being lived by the dead soldiers lover. During stanzas two, three and four, Wilfred Owen uses the soldier to try and tell the story for the people back home by using the context that they will understand: O mother, sewing by candlelight, Put away that stuff. This quote was used to show the reader that the war would affect them back at home almost as badly as the soldiers are feeling it over in France. In stanzas two, three and four, one can detect a large amount of bitterness, and possibly anger, yet the anger is conveyed more subtly than in poems like dulcet et decorum et where the stanzas are set out almost like tirades. We detect this bitterness by the rudeness to the people back at home. In stanzas three and four, he even tells the mother and the lover what to do. In the poem, The Armistice by May Wedderburn Cannan, the reader feels some entirely different emotions than the ones conveyed in Cannon Fodder. The first different emotion that the reader detects from the poem is relief. The whole office feels this, as it descends in chaos: One said, its over, over, its the end: The War is over: ended The reader can feel the hustle and bustle of the people in the office, as their excitement and relief boil over. This is shown by the repetition in the workers speech. They repeat the words end and over. This is to stress the key fact that the killing will come to an end, and that their families and loved ones will get them back. In the second stanza, the workers also being to recollect: I cant remember life without the war This shows that to the people, war had become a way of life, and that people had forgotten their old lives. The fact that the people are reflecting about the war is good, because it shows their concern and respect for the men on the front line, and this is probably Wedderburn Cannans subtle way of saying thank you to the men who were frontline. The reader can also detect feelings of isolation from the two women left behind after the others leave the room: Big empty room This suggests that the women do not feel left behind by the other staff, but left behind by their men who went and fought, and died in the army. The big empty room is a metaphor for the womens empty hearts now that the loves of their lives have left them for good. The reader is also given a view of the idyllic thoughts that one of the women is thinking about the front line: It will be quiet tonight Up at the front: first time in all these years, And no one will be killed there anymore This is an idyllic view of the frontline, however it is also ironic, because it is a well-documented fact that lives were lost even after the armistice because it took a while for news to spread of the end of the war. It is also a little upsetting, because these mens lives are being lost in vain. Wedderburn Cannan also makes us feel empathy towards the two female characters at the end of the poem: Its over for me toomy man was killed, Woundedand died The pauses in the dialogue make the reader feel that the woman is struggling to force back tears. It also makes us feel that maybe she is contemplating what the future holds, and reflecting on her dead husband. The poem comes to an extremely sombre ending, and this is very similar to the ending of the war: Peace could not give back her dead. This makes us feel that the whole war was worthless. Even in the times of peace, people like the woman in the poem are still feeling the grief that devastation of the war had caused. The two poems are from different times, wartime and post-war but the anti-war message is still the same and is still being utilised effectively by the strong language used in both poems. In Cannon Fodder, Wilfred Owen displays to us the full of horror of the war in gory detail, whilst in The Armistice, the horror of the war is the loneliness of the people left behind. Whereas Owen uses shock tactics to put his message across, Wedderburn Cannan tries to draw the readers empathy instead.

Mrs. Compton on the Five-Forty-Eight Essay Example for Free

Mrs. Compton on the Five-Forty-Eight Essay When Mr. Blake’s eyes met mine on the five-forty-eight, I smiled and could tell it did not affect his mood a bit. Of course it was my usual smile—sweet and slightly welcoming—but I knew Mr. Blake was a harder shell to crack than I encountered on a daily basis, and it did not bother me the least that he neither returned nor politely acknowledged my own outward kindness. It did not surprise me, either, since his wife and I had what I would consider a mutual relationship in regards to womanly confessions and the general outrage we keep inside until the right person (usually myself) ends up—coincidentally or not—in the other person’s life. I do have a keen eye for the â€Å"suffering,† and while anyone with a husband such as Mr. Blake had to be in all sorts of pain, Louise Blake just radiated the emotional pain I was familiar with hearing and, in effect, relieving by that very same act of just listening. So was I surprised to hear that Mr. Blake had given Louise another one of his childish â€Å"I’m not talking to you† fits? Hardly. Neither was I shocked to learn from his feigned indifference that he disapproved of my relationship with his wife, as most men did. Now I do not particularly enjoy being a â€Å"busybody† as some might put it, but when the woman asked Mr. Blake if she could sit beside him, I was slightly intrigued. Not so much in the woman posing that question in an only half-full car, but in Mr. Blake’s once more feigned, but convincing, approval. He tried to hide his shock, or maybe it was nervousness, but I could Mr. Blake’s comfort level had certainly been violated. I am an optimist, but certainly know when a man is disturbed by a woman. There was nothing platonic about this â€Å"meeting.† I unfortunately could not hear, being several cars ahead, but kept myself facing forwards so he could not gauge how closely focused I was. Louise is my friend, and I felt it was my duty as such a friend to keep her out of harm’s (emotional and physical) way. So I had no issue with trying to grasp the situation. Mr. Watkins, who is Mr. Blake’s neighbor and a man he dislikes far more than me, did not show any sign of acknowledging the pair, though he could have been hiding it as well as I do. It was not long before I took a quick peak back and realized Mr. Blake’s face, which had a habit of glowing bright red as a furnace when he was angry—and so, a good portion of the time was burning—had suddenly turned as white as a heavy snow. Not just thick, either, but blanketing. Something Mr. Blake wanted to keep hidden was stowed away beneath that layer of pale, perhaps even cold, skin. Even the gloom and shadow of the rain and graying clouds outside could not veil it, and instead probably intensified it, because snow is always stronger in a dark environment. Over the next while I managed to sneak glances at the two, and it was obvious whatever conversation they were having was neither a happy one nor entirely forgiving upon Mr. Blake’s complexion. I could just imagine the conversation though, and Mr. Blake’s frustration building up until he realized the woman was planning on blabbing to the wife about their after-work adventures. Then she slipped him a letter, and as he glanced up at me I pretended as if I had seen nothing, not the look of fear in his eyes or the flash of devils in hers. This is how it went for the next while: folks boarded and I snuck more glances back to see how the two were acting. She was whispering something into his ear. Must be trying to blackmail him now. Or force him to divorce Louise. Poor Louise! â€Å"Shady Hill, next, Shady Hill.† The conductor’s voice brought me back to the image of the car and the rest of the world. Again, I try not to be a â€Å"busybody† but this was an exception. Louise’s husband had not only cheated on her, but was now plotting to leave her for the woman! Maybe I am getting ahead of myself, though. It really could be nothing. But the look on his face, and the fire in her eyes†¦ The train stopped and I forgot all the parcels I had with me, and quickly gathered them with my mind still drawn to the awkward couple behind me. As I stepped off the train, I questioned what I should do. Tail them and see where they go? Confront him, perhaps? I kept my eyes straight so as not to give myself away. The rain stung my eyes and face with its cold little bodies. Should I call Louise as soon as I arrived home? Tell her what I saw? And could I be the one to break her poor little heart? I suppose I could; it would be better from me than him. With all the pain he has put her through, she was likely to kill him.

The Well Meadows Hospital Management System

The Well Meadows Hospital Management System This document describes an online management system for a small hospital named as wellmeadows. This system creates online data storage for all the information related to the proceedings of the hospital and hence making the information available as well as more reliable to the users. The information becomes easily accessible as well as more secure with the system being secured by user credentials. The hospitals current functionality is based on a register based system that involves the maintaining of every transaction, records of patients, doctors, nurses in huge files that are stored in hospitals store room. It is not only difficult to search for certain information but also very difficult to maintain historical data. The old files are prone to get damaged and it is very difficult to manage this huge collection of documents and keep it organized. The new system is based on a database management system that allows secure, easy and reliable storage of data and retrieval is also very easy. In the old system, a user needed to know in which register particular information is stored but in the new system a user has a graphical interface, where he can simply search for the information by doing some clicks and selecting the correct options (Liang 2010). The ease in accessing information not only improves the information management but also impacts the day to day activities of the hospital. It reduces the delay in information retrieval and the delay in providing necessary treatment to the patients as per their historic records is also reduced that will improve the efficiency and effectiveness of the treatment (Prokosch Dudeck 1995). Intended Audience and Reading Suggestions This document is meant for the users of the system i.e. the administrators and staff of the wellmeadows hospital. This document explains the system design and its usage and not meant for external users. This document not only guides the user how to operate the system but also tells how to use the system efficiently to match with requirements of the user and let him take the profit out of it. This document will also help the developers in the situation where modifications are required in the system. Project Scope The project currently is limited to the internal use of the hospital and is simply meant to store and provide useful information. The system doesnt generate any information or predictions of its own. The system will be helpful in better management of the hospital and will provide all the information in an organized manner. This project is not meant for users outside the hospital and will not allow any person outside the hospital to see the internal and personal information of the people connected to the system. The system will keep the information secure and will keep it limited to people with proper access only. Overall Description Product Perspective This product is a change of methodology for the hospitals and firstly, it will be implemented in the Wellmeadows hospital. There are several similar systems in other big hospitals but this system is designed to meet the cost and utility requirements of the small hospital. This product is an evolutionary product that will be improved in the future and more functionality will be added to it. Product Features The product is useful to the hospital in a number of ways as it provides following features to the hospital:- Easy, storage and retrieval of all patients information that not only helps to maintain track record but also helps the doctors as they can know the treatment history of the patients. Store the entire information about doctors that allow the hospital to decide, which patient will be treated by which doctor. This product not only helps in providing better treatment to the patients but also helps in building trust with patients. It also helps to know about the doctors, who are preferred by patients (Sumathi Esakkirajan 2007). Storage of staffs information that helps in smooth running of the hospital. Storage of all drugs used in the hospital and all drugs being prescribed to the patients that allows more control over the quality of drugs used. It also ensures uniformity among various doctors and to maintain the stock of drugs as per their requirements (Sumathi Esakkirajan 2007). User Classes and Characteristics The system will be used by internal users only and will be accessible to outside users in a limited form. Following are the users of the system: Hospital receptionists: The hospital receptionist will act as system administrators and will make all the entries in the system. They will have access to all the information in system and will take control of the normal proceedings of the hospital. Receptionists will register the patients, allocate staff to various wards, give appointments to patients and will maintain the central stock of medicines and drugs. Charge Nurses: The charge nurses will manipulate the information related to their specific ward and will be able to see all patients information in their ward and provide medication accordingly. They will also be able to see which staff is on duty in their ward and also will be able to see the stock of medicines in their ward. Consultants: The consultants will able to see the patients information and the list of appointments that have been allocated to them. The will be also able to see the wards in which they are assigned duties and will also be able to prescribe medicines to their patients. Patients: Patients will be able to see the appointments they have in the hospital and will be able to see the medicines that have been prescribed to them from the system. Operating Environment The system will be a web based system and can be accessed within and outside the hospital through a link over hospitals website. The users will login the system using a username and password that will be provided to them by the system administrator and the system will be independent of the operating system. Assumptions and Dependencies The system assumes that the information being added to the system is correct and authenticated. It is also assumed that the username and password will be kept secret and will not be shared with anyone. The users will be themselves responsible for losing passwords. This system doesnt include a mailing feature and hence the user should not lose their passwords in any case. The passwords will have to be reset by the database administrator only. System Flow A data flow diagram as its name suggests represents the flow of data in any system. There is a huge flow of data and information in any information system. This flow is analyzed with the help of data flow diagrams. Data flow diagrams can be used for visualization of data processing. On a DFD, data items flow from an external data source or an internal data store to an internal data store or an external data sink via an internal process (Calmet Pfalzgraf 1996). A data flow diagram is composed of several components: Entities: Entities are the sources of information in any system. These entities are the external sources of information in any system. It is very important to mention all the entities in a system. This ensures the proper flow of information in a system. These also act as external sinks for the system (Dennis, Wixom Roth 2006). Database or data store: A database stores the information in any system. These act as internal data sources for a system. It stores the information from one process and provides information to other processes. It also acts as internal sinks in the system. Processes: A process is a function performed by the system. Each process helps to access the information from database or an entity and provide the information back to the entity or database (Dennis, Wixom Roth 2006). The DFDs are represented in several levels. With increase in each level the details in the diagram also increased. Level-0 would contain minimum details, while level 1 would contain more details than level 0 and so on. This section explains flow of the system, how the system operates and its functionalities with the help of data flow diagrams. The level of details increases with each diagram. The system at the highest level is nothing but a hospital management system; the inner details are not specified in the data flow diagram level-0 (Johns 2002). Here is the zero level data flow diagram (DFD level: 0) The above diagram shows the four entities that will be involved in the system- patients, doctors, hospital staff and nurses. These are the four main sources of information in the system. As the system is broken down into several modules, these entities match up their desired roles (Johns 2002). This breakdown gives us the exact information about the operations performed by the system and the entities involved in each operation. (DFD level:1) In the DFD level -1, the system is divided into three major domains namely patient management system, stock management system and staff management system. Patient management system is related to patients that includes two types of patients- inpatients and outpatients. Inpatients are those, which get admitted in the hospital and stay there while the outpatients take appointments and visit the hospital at given date and time (Johns 2002). The second major section of the system is stock management system. In this, the requirements of the hospital are analyzed and accomplished such as clinical and non clinical requirements like drugs, bandages and other requirements. This part also maintains the division of these items among various wards and among various departments of the hospital. The third section of the system is about the staff allocation system that ensures that all staff is being assigned proper duties and each wards getting proper number of employees and nurses for its daily operations and also for emergency situations. It also ensures that the consultants are visiting the wards on time and each patient is getting proper attention. External Interface Requirements User Interfaces The user interface is simply a web interface, which is presented to the user through a web browser. This allows user to enter data and select from various drop down menus. These drop down menus show the content read from the database. By simply clicking to submit buttons, user can save data into database. The user interfaces will also implement checks for null values being entered into database (Galitz 2009). It displays the format for date values to be entered, but doesnt validate them. If there is any error in entering any values to the database, the system generates the error message and asks the user to retry. This helps the user to be ensured that the values have been entered and hence a consistency in the system is maintained (Galitz 2009). Hardware Interfaces As the system is a web based system, the website will be hosted on a central server machine with other machines getting access to it through the network. The other machines could be simple computers or especially dedicated machines that provide access only to the content. For our current implementation, we will rely on general desktop systems. Communications Interfaces The system uses HTTP (hypertext transfer protocol) for sending and receiving data over the internet (Groth, Skandier, Lammle Tedder 2005). When the system is used within the hospital, it is presented on same network hence its generally faster as the server is also located within the hospital, but outside the hospital the system is accessible via internet and hence a domain is needed to be registered with the DNS servers hosted at the ISP. Data Model This section explains the data model used for the system. The section begins with recognizing all the entities to be used in the system and their relationships and then converting those entities and relations to tables. These tables will be normalized to 3NF form. This section captures the cardinality and referential integrity rules needed to ensure that the data is of good quality for the users. The main aim of data models is to support the development of information systems by providing the definition and format of data. Entity-relationship model The E-R (entity-relationship) data model views the real world as a set of basic objects (entities) and relationships among these objects (Bai 2010). It is intended primarily for the DB design process by allowing the specification of an enterprise scheme. If the information system, being designed, is based on a database then the conceptual data model will later be mapped on to a logical data model, which in turn will be mapped on to a physical model during the physical design process (Bai 2010). The E-R diagram shows all objects involved in the system as entities and the function among them as relationships. Here is a description of entities used in our system:- Entity: An entity is nothing but an object that exists and is distinguishable from other objects. Entities could be concrete such as a person or it could be an abstract entity that is nothing but a concept (Stallings 2008). An entity could also be considered as a source of information for the system. There are following entities in well meadows:- Doctor or consultant (concrete) Change nurse (concrete) Patients (concrete) Wards (abstract) Drugs (concrete) Administrator (concrete) Staff (concrete) Qualification (abstract) Inpatient (concrete) Outpatient (concrete) Attributes: Attributes are unique qualities that can be possessed by both relationships and entities. Attributes are represented by ovals that are connected to the entity sets that possess them by a line. With the exception of weak entities, all entities have to a minimum amount of attributes. These make up the primary key of the entity (Stallings 2008). Following are the attributes of the various entities described above:- Doctor: id, name, address, telephone, duty shift, date of birth Change nurse: id, name, address, telephone, date of birth, ward allocated. Patients: id, name, address, telephone, date of birth Ward : ward_num, ward_name, location, in charge nurse, number of beds Drugs: id, name, type, dosage, methodology, price, stock Administrator:- username, password, name, address, telephone, date of birth Staff: id, name, address, telephone, date of birth, ward allocated. Qualification:- institution name, qualification name Inpatient:- id, name, address, telephone, date of birth, date of admit, expected stay, expected date of leaving, actual date of leaving Outpatient: id, name, address, telephone, date of birth, date of appointment, consultant name, location, time of appointment. Here is an entity relationship diagram for the given system:- (Entity Relationship Digram) The patients are categorized into inpatients and outpatients as explained above while the staff has two categories doctors and nurses. The remaining staff is covered under staff itself. Wards are there in the hospital that is controlled by the nurses while drugs are referred by the doctors and they are taken by the patients. Both the inpatients and outpatients are treated by the doctors, while inpatients have a separate relationship with wards that they are admitted to it. Database design and normalization Normalization can be defined as the process in which data is taken from problem and reduced to a set of relations through data integrity and elimination of data redundancy (Gunderloy Jorden 2008). Data integrity: The data in the database is consistent and satisfies the all integrity constraints. Data redundancy Data redundancy incurs if it is found in two different locations (direct redundancy). At the same time the calculation of data from other items (indirect redundancy) also creates redundancy (Oppel 2004). First normalized form: The multi valued attributes are removed that facilitate a single value at the intersection of each row and column in a table. Second Normal form: In second normal form, all the non key attributes must be dependent on complete primary key and not on a single part of primary key. Third normal form: In a third normal form, all the non keys are determined only by the primary keys (Oppel 2004). Boyce-Codd normal form: The anomalies have been removed that resulted from the functional dependancies (Gunderloy Jorden 2008). The normalized schemas of the tables used in our database are given below:- Drug drug_ID drug_name description dosage method Stock Reorder cost Patient patient_id First Name Last name Address telephone Date of birth Sex Marital status Date of registration Staff Staff_id First Name Last name Address telephone position Inpatient id Patient_id Ward number Bed number Date placed Expected Stay Expected Date of leaving Actual date of leaving Ward Ward number Name location extension Charge nurse id(staff.staff id) Outpatient id patient id Consultant id Date Time location Qualification id Staff_id Type Institution Completion date Weekly allocation Ward number Staff id shift date Prescription Patient_id drug_id Start Date Units per day End date Database implementation The database defined above needs to be implemented over a database system. We use a relational database management system as our designs are based on relational model. Considering the requirements of hospital that are not very large, we can use an open source, free of cost database management system named as MySQL. MySQL is a relational database management system (RDBMS) that runs as a server providing multi-user access to a number of databases. It works on most of the available operating systems and is generally the most popular choice for implementing small database applications. It also has a plug-in named as phpmyadmin that provides a GUI access to the database (Lambrix 2010). Here are the implementations of SQLs for the database:- phpMyAdmin SQL Dump version 3.2.4 http://www.phpmyadmin.net Host: localhost Generation Time: Dec 12, 2010 at 08:58 AM Server version: 5.1.41 PHP Version: 5.3.1 SET SQL_MODE=NO_AUTO_VALUE_ON_ZERO; /*!40101 SET @[emailprotected]@CHARACTER_SET_CLIENT */; /*!40101 SET @[emailprotected]@CHARACTER_SET_RESULTS */; /*!40101 SET @[emailprotected]@COLLATION_CONNECTION */; /*!40101 SET NAMES utf8 */; Database: `hospital` Table structure for table `drug` CREATE TABLE IF NOT EXISTS `drug` ( `drug_num` int(11) NOT NULL AUTO_INCREMENT, `name` varchar(100) NOT NULL, `description` varchar(100) NOT NULL, `dosage` varchar(100) NOT NULL, `method` varchar(100) NOT NULL, `stock` int(11) NOT NULL, `reorder` int(11) DEFAULT NULL, `cost` decimal(10,0) NOT NULL, PRIMARY KEY (`drug_num`) ) ENGINE=MyISAM DEFAULT CHARSET=latin1 AUTO_INCREMENT=1 ; Dumping data for table `drug` Table structure for table `inpatient` CREATE TABLE IF NOT EXISTS `inpatient` ( `inpatient_id` int(11) NOT NULL AUTO_INCREMENT, `patient_id` int(11) NOT NULL, `expected_stay` int(11) NOT NULL, `date_placed` date NOT NULL, `date_leave` date DEFAULT NULL, `actual_leave` date DEFAULT NULL, `ward_num` int(11) NOT NULL, `bed_num` int(11) NOT NULL, `spouse_id` int(11) DEFAULT NULL, PRIMARY KEY (`inpatient_id`) ) ENGINE=MyISAM DEFAULT CHARSET=latin1 AUTO_INCREMENT=2 ; Dumping data for table `inpatient` INSERT INTO `inpatient` (`inpatient_id`, `patient_id`, `expected_stay`, `date_placed`, `date_leave`, `actual_leave`, `ward_num`, `bed_num`, `spouse_id`) VALUES (1, 1, 5, 2010-08-12, 0000-00-00, 0000-00-00, 1, 45, 0); Table structure for table `outpatient` CREATE TABLE IF NOT EXISTS `outpatient` ( `appointment_num` int(11) NOT NULL AUTO_INCREMENT, `consultant_id` int(11) NOT NULL, `patient_id` int(11) NOT NULL, `date` date NOT NULL, `time` time NOT NULL, `location` varchar(100) NOT NULL, PRIMARY KEY (`appointment_num`) ) ENGINE=MyISAM DEFAULT CHARSET=latin1 AUTO_INCREMENT=1 ; Dumping data for table `outpatient` Table structure for table `patient` CREATE TABLE IF NOT EXISTS `patient` ( `patient_id` int(11) NOT NULL AUTO_INCREMENT, `firstname` varchar(50) NOT NULL, `lastname` varchar(50) NOT NULL, `address` varchar(500) NOT NULL, `tel` varchar(20) NOT NULL, `dob` date NOT NULL, `sex` varchar(10) NOT NULL, `mar_status` varchar(20) NOT NULL, `reg_date` timestamp NOT NULL DEFAULT CURRENT_TIMESTAMP, PRIMARY KEY (`patient_id`) ) ENGINE=MyISAM DEFAULT CHARSET=latin1 AUTO_INCREMENT=3 ; Dumping data for table `patient` INSERT INTO `patient` (`patient_id`, `firstname`, `lastname`, `address`, `tel`, `dob`, `sex`, `mar_status`, `reg_date`) VALUES (1, yash, yash, yash, 7799, 0000-00-00, Male, UnMarried, 2010-12-08 00:03:10); Table structure for table `prescription` CREATE TABLE IF NOT EXISTS `prescription` ( `prescription_id` int(11) NOT NULL AUTO_INCREMENT, `patent_id` int(11) NOT NULL, `drug_num` int(11) NOT NULL, `units per day` int(11) NOT NULL, `startdate` date NOT NULL, `enddate` date NOT NULL, PRIMARY KEY (`prescription_id`) ) ENGINE=MyISAM DEFAULT CHARSET=latin1 AUTO_INCREMENT=1 ; Dumping data for table `prescription` Table structure for table `qualification` CREATE TABLE IF NOT EXISTS `qualification` ( `q_id` int(11) NOT NULL AUTO_INCREMENT, `staff_id` int(11) NOT NULL, `type` varchar(100) NOT NULL, `institution` varchar(100) NOT NULL, `date` date NOT NULL, PRIMARY KEY (`q_id`) ) ENGINE=MyISAM DEFAULT CHARSET=latin1 AUTO_INCREMENT=1 ; Dumping data for table `qualification` Table structure for table `requets` CREATE TABLE IF NOT EXISTS `requets` ( `request_id` int(11) NOT NULL AUTO_INCREMENT, `ward_num` int(11) NOT NULL, `drug_num` int(11) NOT NULL, `quantity` int(11) NOT NULL, `date` date NOT NULL, `processed` int(11) NOT NULL DEFAULT 0, `process_date` date DEFAULT NULL, PRIMARY KEY (`request_id`) ) ENGINE=MyISAM DEFAULT CHARSET=latin1 AUTO_INCREMENT=1 ; Dumping data for table `requets` Table structure for table `staff` CREATE TABLE IF NOT EXISTS `staff` ( `staff_id` int(11) NOT NULL AUTO_INCREMENT, `firstname` varchar(50) NOT NULL, `lastname` varchar(50) NOT NULL, `address` varchar(500) NOT NULL, `sex` varchar(10) NOT NULL, `dob` date NOT NULL, `tel` varchar(20) NOT NULL, `position` varchar(50) NOT NULL, PRIMARY KEY (`staff_id`) ) ENGINE=MyISAM DEFAULT CHARSET=latin1 AUTO_INCREMENT=4 ; Dumping data for table `staff` INSERT INTO `staff` (`staff_id`, `firstname`, `lastname`, `address`, `sex`, `dob`, `tel`, `position`) VALUES (1, abcd, pqrs, asasd, Male, 0000-00-00, 123123, Charge Nurse); Table structure for table `staffhier` CREATE TABLE IF NOT EXISTS `staffhier` ( `id` int(11) NOT NULL, `description` varchar(100) NOT NULL ) ENGINE=MyISAM DEFAULT CHARSET=latin1; Dumping data for table `staffhier` INSERT INTO `staffhier` (`id`, `description`) VALUES (1, consultant), (2, Charge Nurse), (3, physiotherapist), (4, nurse); Table structure for table `tblusers` CREATE TABLE IF NOT EXISTS `tblusers` ( `username` varchar(50) NOT NULL, `password` varchar(50) NOT NULL, `name` varchar(50) NOT NULL, `wrong_count` int(11) NOT NULL DEFAULT 0, PRIMARY KEY (`username`) ) ENGINE=MyISAM DEFAULT CHARSET=latin1; Dumping data for table `tblusers` INSERT INTO `tblusers` (`username`, `password`, `name`, `wrong_count`) VALUES (admin, 123456, administrator, 1); Table structure for table `ward` CREATE TABLE IF NOT EXISTS `ward` ( `ward_num` int(11) NOT NULL AUTO_INCREMENT, `ward_name` varchar(50) NOT NULL, `location` varchar(100) NOT NULL, `ext` int(11) NOT NULL, `num_beds` int(11) NOT NULL, `nurse_id` int(11) NOT NULL, PRIMARY KEY (`ward_num`) ) ENGINE=MyISAM DEFAULT CHARSET=latin1 AUTO_INCREMENT=2 ; Dumping data for table `ward` INSERT INTO `ward` (`ward_num`, `ward_name`, `location`, `ext`, `num_beds`, `nurse_id`) VALUES (1, ank, asasd, 6666, 3, 1); Table structure for table `weeklyallocation` CREATE TABLE IF NOT EXISTS `weeklyallocation` ( `allocation_id` int(11) NOT NULL AUTO_INCREMENT, `staff_id` int(11) NOT NULL, `ward_num` int(11) NOT NULL, `shift` varchar(50) NOT NULL, `startdate` timestamp NOT NULL DEFAULT CURRENT_TIMESTAMP, PRIMARY KEY (`allocation_id`) ) ENGINE=MyISAM DEFAULT CHARSET=latin1 AUTO_INCREMENT=4 ; Dumping data for table `weeklyallocation` INSERT INTO `weeklyallocation` (`allocation_id`, `staff_id`, `ward_num`, `shift`, `startdate`) VALUES (1, 1, 1, EARLY, 2010-12-07 18:52:40), (2, 1, 1, NIGHT, 2010-12-07 23:33:40), (3, 0, 1, , 2010-12-08 00:05:25); /*!40101 SET [emailprotected]_CHARACTER_SET_CLIENT */; /*!40101 SET [emailprotected]_CHARACTER_SET_RESULTS */; /*!40101 SET [emailprotected]_COLLATION_CONNECTION */; This script will create the database and will make few entries in the tables as well. The username and passwords are stored in a table named as tblUsers. The admin password is also stored in the same table. This is the dump of the database exported by using phpmyadmin. Same script can be executed using the tool or also can be imported using the import option in phpmyadmin (Lambrix 2010). This will setup the database and the application can now be configured. System implementation The software package we choose for this system is XAMPP. Xampp is a software package that is used for hosting websites and the combination of four software packages namely php, apache, mysql and phpmyadmin. Xampp is a simple program that can be run on any machine; it does not require any specific hardware. Xampp is free software and it is available for various operating systems such as Linux, Windows, Mac OS, and Solaris etc. The programs sets up a mysql server on the system as well as an apache web server on the machine. The package also configures php for the machine and also provides phpmyadmin for managing the mysql database (Newman Thomas 2008). Xampp provides a root directory named as htdocs that works for the web server. Xampp is the easiest way to host a website. Xampp is very easy to install and uninstall as compared to the separate installation and configuration of the services it provides. Xampp also includes support for filezilla, mercury etc. Developers Xampp is open source software developed by www.apachefriends.com. Apache friends were founded in 2002 by Oswald and Kay. Oswald is their webmaster, while Kay is the maintainer of apache for windows. Apache friends have Xampp as their only project (Newman Thomas 2008). There are no new projects till date. The software package is available through Sourceforge that hosted the download files on their website www.sourceforge.net and made this whole project possible. Benefits Xampp has several benefits that make web hosting easy. These are as below: It is available in many languages such as English, Dutch, Italian, French, Portuguese and Chinese etc. It makes database management very easy with support of phpmydmin. The sup

Cabaret :: essays research papers

Brian says 'you're about as fatale as an after dinner mint!' Is Sally really harmless? Brian's exasperated accusation that Sally is 'as fatale as an after dinner mint' is expressed at the end of a weekend away with Max. The outburst reveals Brian's opinion that Sally is not the seductress she fancies herself to be, but is simply 'deluding' herself. However, one must stop to consider the meaning of harmless when applied to Sally Bowles. She is essentially self-absorbed and theatrical, a confused and childlike character, used in the film to demonstrate to the viewer the dangers of complacency and self-indulgence in a dangerous political environment. Sally is, in fact, unintentionally harmful, for her actions can corrupt and she is politically ignorant. Throughout the film Sally boasts her personal corruption, and perpetuates an acceptance that 'divine decadence' and debauchery are desirable lifestyles. A representative of the seedy and superficial cabaret world, Sally flaunts her promiscuity and chooses to live a life where external problems do not undermine her opinion that 'life is a cabaret'. Her world is an illusion; nothing will obstruct her view that Berlin's decadent society is a wonderfully exciting setting for her rise to stardom. Her self-absorption is obvious when she tells Brian she wants to know 'absolutely everything' about him, and then proceeds to talk over him. Similarly, her inability to assist Natalia in her romantic dilemma with Fritz suggests that she has immersed herself so completely in the amorality of the cabaret world that she cannot comprehend Natalia's emotions, or even face reality enough to contextualise her problem. This lack of empathy for those in tune with the real world rather than Sally's constru cted fantasy has the potential to damage her relationships. Sally is ardently ambitious, and her shameless espousal of hedonism is exemplary of her preparedness to do corrupt things to achieve her dreams. Sally is highly atuned to the potential of power and money to advance her career. To attain these things, she uses her sexuality as a commodity, simply another means for the advancement of her aspirations. Her liberal sexuality may ultimately harm both herself and Brian, as it makes him feel used, and her potential for any kind of real relationship is continuously pushed into the background until it becomes almost an impossibility. Sally's initial approach to all strangers is to attempt to seduce them, as seen with both Brian and Max.