Wednesday, July 31, 2019

Patient Risk Essay

This example of a reflective essay is presented in association with Price, B and Harrington, A (2013) Critical Thinking and Writing for Nursing Students, London, Learning Matters. Readers are introduced to the process of critical and reflective thinking and the translation of these into coursework that will help them to achieve better grades in nursing courses. Stewart, Raymet, Fatima and Gina are four students who share their learning journey throughout the chapters of the book. In this essay on the assessment of pain, Raymet demonstrates her reflective writing skills near the end of her course. Raymet had by this stage written several reflective practice essays and gained good marks. This time though she was encouraged to deepen her reflections, speculating selectively on how the account of pain experienced by a patient (Mrs Drew) might help her to work more creatively with patient perceptions and reported needs. N.B. Remember, copying essays such as this, submitting them as a whole or in part for assessment purposes, without attributing the source of the material, may leave you open to the charge of plagiarism. Significant sanctions may follow for nurses who do this, including referral to the Nursing and Midwifery Council. Assessing Mrs Drew’s Pain Mc Caffery and Pasero (1999) state that pain is what the patient says it is. If we accept that point, then nurses need to explore the patient’s perceptions of pain, as well as their report of experiences. The two are not quite the same. Patients may report their pain in a variety of ways, dependent on the nature and the intensity of pain and the context in which it is felt (e.g. whether they are ever distracted from the pain). Their perception of pain is a little more though and it includes the meaning that the pain has for them. It includes explanation of why the pain is there in the first place, what it indicates about their body and what it could  suggest might happen in the future (getting better, getting worse). The nurse assesses the account of pain shared by the patient, and this may be given in the form of a story. This is how it began, this is how it felt, this is what that meant to me and this is what I did about it (Mishler et al. 2006) In this essay I explore the assessment of pain as conducted with one 60 year old patient whom I will call Mrs Drew. Whilst the essay describes an assessment of pain with a single patient, I try to share too some ideas and questions that this provokes within me about pain assessment more generally. Mrs Drew made me think about other patients, future assessments and what I had to do as a nurse to help patients. To help structure this essay I use the framework described by Gibbs (1988). Whilst the episode concerned relates a stage in Mrs Drew’s illness when she challenged her treatment protocol, it also includes some of the memories and thoughts that this patient refers to regarding her earlier illness and past ways of coping with pain. In particular, it prompted me to question to what extent I as a nurse should recommend analgesia, drawing on what I had been taught about the effective control of pain. I had learned that it was better to control rather than to chase pain ( e.g. Mann and Carr, 2006; Forbes, 2007). Mrs Drew was diagnosed with lung cancer a year earlier and had initially had her illness treated by chemotherapy. This had helped her to achieve a remission that lasted for nearly ten months (Hunt et al, 2009 describe the prognosis of this disease). The cancer had returned though and spread to her spine and it was here that she experienced most of her pain.It was at this stage that the doctors explained that her care would now be directed towards her comfort rather than a cure—to which she had replied, ‘you mean palliative care’. Mrs Drew was supported at home by her husband Neil and visited on a regular basis by community based nurses to whom I was attached as part of my student nurse training. She was prescribed oral morphine and could decide within stated limits how many tablets she could take in any one 24 hour period. The situation I had visited Mrs Drew on several occasions over the period of a month when the community nurse and I were confronted by a tearful patient who announced that she did not wish to take the oral opiates quite as often as we were recommending. As she spoke she held her husband’s hand tightly, looking across to him as she described her experiences and feelings about the matter. Yes, there had been some bad nights when the pain had woken her and she had to sit up and watch television to try and distract herself. Yes, sometimes the pain made her feel nauseous, but she was alarmed at how frequently she was taking the ‘pain tablets’ and how this made her feel about herself. However well meant the medication was, it didn’t feel dignified to be so reliant on drugs, or quite so sleepy and unresponsive for such a high percentage of the day. Whilst the analgesia was working well when she took the tablets, the quality of life wasn’t what she wanted. The community nurse listened patiently to Mrs Drew and then explained that it was normal to have panic moments about such medication. Morphine had a reputation, one that people associated with misuse of drugs, rather than their therapeutic use. Used on a regular basis, the drug wouldn’t cause addiction and it would provide a great deal of reassurance to Mr Drew as well. The community nurse stated that she was quite sure that he respected his wife’s need to sleep when she wished and to build the rhythm of the day around her needs. At this point Mrs Drew shook her husband’s hand, and said, ‘tell her†¦tell her what we’ve talked about!’ Mr Drew then explained that his wife was used to dealing with pain, she had suffered recurrent pain in her neck and shoulder after a road traffic accident some years before. The pain had sometimes been severe, but he had massaged her shoulders and used heat packs that she found soothing. They had decided that they wished to use this technique now, keeping the morphine for absolute emergencies, when she was losing sleep and couldn’t eat as a result of the discomfort. The community nurse assured them that they were in charge of the analgesia and would be allowed to make their own decisions. She started to make notes though, and announced that she was making a referral to the cancer pain clinic, something that would help them to take stock of the situation. There was very good reason to suppose that this might be a problem associated with choosing the right dosage of the  morphine, rather than using supplemental pain relief measures. Mrs Drew responded sharply, ‘You’re not listening to me though Jane (the community nurse’s name—a pseudonym is used here), I want to use heat packs instead of morphine, at least during the day. I want to be more alive with my husband.’ The community nurse assured Mrs Drew that she had heard what she had said and respected her point of view. There would though be nothing lost by using the clinic to gain a further check on this matter. With that she excused us, explaining that we had a further appointment that morning and we left, having checked that Mrs Drew had a sufficient supply of her different medicines. As we walked to the car the community nurse empathised with Mrs Drew’s plight, saying that if she had lung cancer she would probably grasp at straws too. She would reach out for things that seemed more normal, and then observed, ‘but this isn’t normal is it, the pain she has isn’t normal. It’s not just a whip lash injury and old age.’ Feelings I remember that during this episode feeling a mixture of confusion, surprise, anger and impotence. Mrs Drew had surprised me by the way she had spoken, using what seemed to be a planned announcement. They had waited for and perhaps rehearsed this moment. Nothing in my experience to date had prepared me for such an encounter, at least in such circumstances, where we as nurses were so obviously working to support the patient. It was only later that I called the episode a confrontation. Mr and Mrs Drew had confronted the community nurse and I had been the largely silent witness to the event. As the discussion proceeded I remember making supportive noises, remarking how useful heat packs sometimes were and glancing across at Jane, who seemed to be signalling with her expression that I should leave this debate to her. I was trying to read her reactions to the Drew’s points and concluded that if I couldn’t support her arguments to the patient, then I should remain silent. The re were issues here that I perhaps hadn’t enough experience to deal with, at least, whilst ‘thinking on my feet’. My initial anger (with Mrs Drew for not acknowledging all that we were trying to do) quickly became displaced towards my colleague Jane. During the event I couldn’t explain why that was, but afterwards, when I made notes, I realised that it was because she seemed to have set the agenda in her own mind and to be requiring the patient to comply with concerns of her own. Put rather crudely, Jane seemed to be saying, listen I know about these things, this is a phase, an anxiety; you can work through all this. I believed at this point that she had missed the significance of the event, the way in which the Drew’s had arranged the conversation. For them, this was not a phase at all, but a considered and very important decision, one that they wanted the nurses to accept (Freshwater, 2002 and Edwards and Elwyn, 2009 emphasize the importance of negotiated care planning). My feelings of impotence were associated strongly with my lack of clinical experience. I have met this before. No matter how many placements I do, no matter how good the mentoring I receive, I keep meeting situations where I am unsure about how to respond next. I feel younger, less knowledgeable than I should be at this stage in my training. I want to reassure patients, to support colleagues and to give good advice, but there is not enough confidence to do that. If I felt unsettled and uncertain about Jane’s response to the Drew’s, right then I couldn’t easily explain that. I couldn’t offer a second opinion, couldn’t suggest an idea that might help support the patient. To my annoyance I couldn’t manage that either as we left the house. Jane had made some fair points, she  clearly seemed concerned about the patient’s needs, but perhaps she hadn’t spotted the right need—for Mrs Drew to determine in greater part how she de alt with her illness. Experience evaluated Afterwards, this short episode prompted doubts and debates about several important aspects of nursing for me. Setting aside the etiquette of learning in clinical practice, not challenging a qualified nurse in front of a  patient, there were problems here associated with supporting patient dignity, with my assumptions relating to analgesia and pain control strategies, and I realised, with my assumptions about types of pain and who had the expertise to define these. Dignity is more than simply using the appropriate terms of address, protecting the privacy of patients and attending to their expressed concerns (Price, 2004). It is about clarifying the ways in which they live and accommodate illness or treatment. It is about finding out what benchmarks they use to say that ‘yes, I am doing well here, this makes me feel good about myself’. Upon reflection, I sense that we on this occasion had not worked hard enough to discover how Mr and Mrs Drew define quality of life, or being in charge of their situation. We were more concerned with providing resources, sharing research or theory about medication and questioning the familiar misconceptions associated with morphine. To put it simply, we were ‘missing a trick’, reading the encounter as something that had happened many times before—the report of problems or anxieties, a request for help, rather than a decision that the patient and her carer had already come to. Reading situations well seemed, with the benefit of hindsight, to be the first basis for dignified care. ‘What is happening here, what will help the patient most?’ were questions that we perhaps assumed that we already knew the answer to. I realised that in my training I had already accepted the argument that patients would wish to remain pain free come what may and that the tackling of fears about prospective pain, was something that nurses engaged in. I assumed that because cancer pain represented such a major threat, because it was greater and more all encompassing, that there was little or no doubt that it should be removed. What was so unsettling, and took so much time to examine, was that Mrs Drew acknowledged the possible severity of metastatic cancer pain, but that she still preferred to respond to it using measures that had worked for her whiplash neck injury. Mrs Drew was willing to trade off a pain free state for something that gave her a greater sense of control and which perhaps enabled her husband to express his support for her in a very tangible way (preparing heat packs, massaging her back, rather than simply giving her the tablets). Mr and Mrs Drew questioned all my assumptions about best analgesia pr actice, and seemed to write a large  question mark on the textbooks I had read about chasing rather than controlling pain in palliative care situations (Mann and Carr, 2006). Reflections (learning opportunities) The episode with Mrs Drew left me uncomfortable because my past approach to pain management was theoretical. I (and I believe Jane too) regularly made use of science to decide what could be done as regards pain relief and to assume that patients would wish to achieve all of those benefits. This wasn’t about local applications of heat versus morphine, Mrs Drew could use both, it was about choice and how patients made choices—why they reached the decisions that they did. It was for me, about accepting very personally, that providing that patients are given all the relevant facts, alerted to the options, that they really are able to make choices that work for them. The very fact that Mrs Drew’s illness was now incurable, that she and her husband usually tackled pain together, meant that her solution to the challenge was different to those that many other patients arrived at. Having dealt with this pain for some time, knowing that it could and probably would get wors e, meant that she was better equipped than other less experienced patients to make a decision here. This took nothing away from the benefits of sharing further discussion with pain clinic experts. I thought, Mrs Drew will stand her ground, she will insist on doing things her way if her husband is strong too. What it did highlight though was the importance of listening to patients, hearing how they perceive pain, how they narrate not only the pain but what they did about it. In this instance the narration was all about dignity, and coping, and finding ways to help one another and how this enables us to feel in the face of such a terrible illness. So, in telling us about her pain, what she did about it, using morphine when it was ‘absolutely required’, Mrs Drew was not reporting her ignorance of what could be achieved if the medication was used differently, but what she preferred to do as it enabled her to achieve different goals. Mrs Drew’s goals were about liveliness, alertness and stoicism, showing that she could bear at least a measure of pain. I wondered why I hadn’t listened carefully enough to such a story? Was it because of time pressure, or perhaps complacency, that Jane and I felt that we already knew what account would be  shared? Did we think that the patient would ask for help, more help, as the pain continued? If so, then our guesses had prompted us to behave as experts, and problem solvers, on the patient’s behalf. Perhaps hearing a patient narrative is about discovering what sort of role they would like you to fulfil. If so, then it might be a difficult role. I thought hard about how hard this was for Jane. She was going to be asked to witness Mrs Drew’s future pain, one that was now less perfectly controlled. She was going to be asked to reassure, to suggest measures that might help, without reminding the patient that she ‘already knew that you couldn’t manage pain that way!’ When I think about it now, that is very stressful for a nurse. It is about caring and allowing patient’s to make choices that we personally might not make. Conclusions I have drawn then three conclusions from the above reflection. First, that being patient centred is never easy and requires real listening and interpretation skills. My criticism of what Jane chose to do, to try and dissuade Mrs Drew from a course of action, recommending further appraisal of the situation, is an easy one to make. Nurses confront situations such as this relatively unprepared and react as considerately as possible. It is easy in hindsight to recommend other responses, a further exploration of what motivated Mrs Drew’s pain management preferences. Second, that experience can be a valuable teacher, the equal of textbooks. If nurses are interested in care, then we should be concerned with the sense that patients make of their own illness, the treatment or support that they receive. We need to understand what patients have to teach us and have to acknowledge that this means that we won’t always seem in control ourselves, expert and knowledgeable. Our expertise might be elsewhere, helping patients to reach their own decisions. Third, that one way to understand patient perspectives on illness or treatment, on pain management in this example, is to hear how they talk  about the situation. How do they describe the pain, how do they refer to what they did about it? The way in which the story is shared, how we coped, how this made us feel, is as important as the facts related. Sometimes a patient needs to feel stalwart, even heroic in the face of illness. Future care It would be foolish and unprofessional to recommend to other patients that they might not wish to remove pain, or that overcoming pain doesn’t always mean we don’t continue to experience it. For every Mrs Drew there may be many other patients who would welcome the complete removal of pain, so that they can die calmly, quietly, with their own version of dignity. But it does seem to me, that it will be worth thinking about the diversity of patients and how they prefer to cope when I assess pain and help manage this problem in the future. I won’t be able to walk away from the responsibility of debating whether I have explained all that I could, detailed the strengths and limitations of different ways of coping. I will need to find reflection time to ponder what patients have said and if necessary to go back and say, ‘I’ve been thinking some more about your words last week..’ knowing that this doesn’t make me any the less professional. References Edwards, A and Elwyn, G (2009) Shared decision-making in health care: achieving evidencebased patient choice, 2nd ed. Oxford, Oxford University Press Forbes, K (2007) Opiods in cancer pain, Oxford, Oxford University Press Freshwater, D (2002) Therapeutic nursing: improving patient care through self awareness, London, Sage. Gibbs G (1988) Learning by doing: a guide to teaching and learning methods, Oxford, Oxford Polytechnic Further Education unit Hunt, I., Muers, M and Treasure, T (2009) ABC of lung cancer, Oxford, Wiley-Blackwell/BMJ Books Mann, E and Carr, E (2006) Pain management, Oxford, Blackwell McCaffery, M and Pasero, C (1999) Pain: Clinical manual, Mosby, Philadelphia Mishler, E., Rapport, F and Wainwright, P (2006) The self in health and illness: patients, professionals and narrative identity, Oxford, Radcliffe Publishing Ltd Price, B (2004) Demonstrating respect for patient dignity, Nursing Standard, 19(12), 45-51

Tuesday, July 30, 2019

The Return: Midnight Chapter 1

â€Å"Dear Diary, I'm so frightened I can hardly hold this pen. I'm printing rather than writing in cursive, because that way I have more control. What am I terrified of, you ask? And when I say â€Å"of Damon†you don't believe the answer, not if you'd seen the two of us a few days ago. But to understand, you have to know a few facts. Have you ever heard the phrase â€Å"Al bets are off†? It means that anything, anything, can happen. So that even somebody who figures out odds and takes bets from people gives them back their money. Because a wild card has entered the situation. You can't even figure the odds to take a bet. That's where I am. That's why my heart is pounding in my throat and head and ears and fingertips in fear. Al bets are off. You can see how shaky even my printing is. Suppose my hands shake like this when I go in to see him? I might drop the tray. I might annoy Damon. And then anything might happen. I'm not explaining this right. What I should be saying is that we're back: Damon and Meredith and Bonnie and me. We went to the Dark Dimension and now we're home again, with a star ball – and Stefan. Stefan was tricked into going there by Shinichi and Misao, the brother and sister kitsune, or evil fox-spirits, who told him that if he went to the Dark Dimension he could get the curse of being a vampire removed and become human again. They lied. All they did was leave him in a stinking prison, with no food, no light, no warmth†¦until he was at the point of death. But Damon – who was so different back then – agreed to lead us to try to find him. And, oh, I can't even begin to describe the Dark Dimension itself. But the important thing is that we finally found Stefan, and that by then we'd found the Twin Fox key we needed to release him. But – he was a skeleton, poor boy. We carried him out of the prison on his pallet, which later Matt burned; it was so infested with creepy-crawlies. But that night we gave him a bath and put him to bed†¦and then we fed him. Yes, with our blood. All the humans did it except Mrs. Flowers, who was busy making poultices for where his poor bones were almost sticking out of his skin. They had starved him to that point! I could kill Them with my own hands – or my Wings Powers – if only I could use them properly. But I can't. I know there is a spell for Wings of Destruction, but I have no idea how to summon it. At least I got to see how Stefan blossomed when being fed with human blood. (I admit that I gave him a few extra feedings that weren't on his chart, and I'd have to be an idiot not to know that my blood is different from other people's – it's much richer and it did Stefan amazing amounts of good.) And so Stefan recovered enough that the next morning he was able to walk downstairs to thank Mrs. Flowers for her potions! The rest of us, though – all the humans – were totally exhausted. We didn't even think about what had happened to the bouquet, because we didn't know it had anything special in it. We'd gotten it just as we were leaving the Dark Dimension, from a kind white kitsune who'd been in the cell across from Stefan's before we arranged a jailbreak. He was so beautiful! I never knew a kitsune could be kind. But he had given Stefan these flowers. Anyway, that morning Damon was up. Of course, he couldn't contribute any of his own blood, but I honestly think he would have, if he could. That was the way he was back then. And that's why I don't understand how I can feel the fear I feel now. How can you be terrified of someone who's kissed you and kissed you†¦and called you his darling and his sweetheart and his princess? And who has laughed with you with his eyes dancing with mischief? And who's held you when you were frightened, and told you there was nothing to be afraid of, not while he was there? Someone you only had to glance at to know what he was thinking? Someone who has protected you, no matter what the cost to himself, for days on end? I know Damon. I know his faults, but I also know what he's like inside. And he's not what he wants people to think he is. He's not cold, or arrogant, or cruel. Those are fa?ades he puts on to cover himself, like clothes. The problem is that I'm not sure he knows he isn't any of these things. And right now he's all mixed-up. He might change and become all of them – because he's so confused. What I'm trying to say is, that morning only Damon was really awake. He was the only one who saw the bouquet. And one of the things Damon definitely is, is curious. So he unwrapped all the magical wards from it and it had a single pitch-black rose in the center. Damon has been trying to find a black rose for years, just to admire it, I think. But when he saw this one he smelled it†¦and boom! The rose disappeared! And suddenly he was sick and dizzy and he couldn't smell anything and all his other senses were dulled as well. That was when Sage – oh, I haven't even mentioned Sage, but he's a tall bronze gorgeous hunk of a vampire who's been such a good friend to all of us – told him to suck in air and to hold it, to push it down into his lungs. Humans have to breathe that way, you see. I don't know how long it took Damon to realize that he really was a human, no joke, nothing anyone could do about it. The black rose had been for Stefan; and it would have given him his dream of being human again. But when Damon realized it had worked its magic on him†¦ That's when I saw him look at me and lump me in with the rest of my species – a species he's come to hate and scorn. Since then I haven't dared look him in the eye again. I know he loved me just days ago. I didn't know that love could turn to – well, to all the things he feels now about himself. You'd think it would be easy for Damon to become a vampire again. But he wants to be as powerful a vampire as he used to be – and there isn't anyone like that to exchange blood with him. Even Sage disappeared before Damon could ask him. So Damon is stuck like this until he finds some strong, powerful, and prestigious vampire to go through the whole process of changing him. And every time I look into Stefan's eyes, those jewel-green eyes that are warm with trust and gratitude – I feel terror, too. Terror that somehow he'll be snatched away again – right out of my arms. And†¦terror that he'll find out how I've come to feel about Damon. I hadn't even realized myself how much Damon has come to mean to me. And I can't†¦ stop†¦my feeling†¦for him, even if he hates me now. And, yes, damn it, I'm crying! In a minute, I have to go take him his dinner. He must be starving, but when Matt tried to take him something earlier today, Damon threw the whole tray at him. Oh, please, God, please don't let him hate me! I'm being selfish, I know, in just talking about what's going on with Damon and me. I mean, things in Fell's Church are worse than ever. Every day more children become possessed and terrify their parents. Every day, parents get angrier with their possessed children. I don't even want to think about what's going on. If something doesn't change, the whole place will be destroyed like the last town Shinichi and Misao visited. Shinichi†¦he made a lot of predictions about our group, about things we've kept secret from the others. But the truth is, I don't know if I want to hear any of his riddles solved. We're lucky in one way. We have the Saitou family to help us. You remember Isobel Saitou, who pierced herself so horribly while she was possessed? Since she's gotten better, she's become a good friend, and her mother, Mrs. Saitou, and her grandmother, Obaasan, too. They give us amulets – spells to keep evil away, written on Post-it Notes or little cards. We're so grateful for that kind of help. Someday maybe we can repay them all. Elena Gilbert put down the pen reluctantly. Shutting her diary meant having to face the things she had been writing about. Somehow, though, she managed to make herself walk downstairs to the kitchen and take the dinner tray from Mrs. Flowers, who smiled encouragingly at her. As she set out for the boardinghouse's storage room, she noticed that her hands were trembling so that the entire tray of food she was carrying jingled. Since there was no access to the storage room from inside, anyone who wanted to see Damon had to go out the front door and around to the addition tacked on near the kitchen garden. Damon's lair, people were cal ing it now. As she passed the garden Elena glanced sideways at the hole in the middle of the angelica patch that was the powered-down Gateway where they'd come back from the Dark Dimension. She hesitated at the storage room door. She was stil trembling, and she knew that was not the right way to face Damon. Just relax, she told herself. Think of Stefan. Stefan had had a grim setback when he'd found that there was nothing left of the rose, but he had soon recovered his usual humility and grace, touching Elena's cheek and saying that he was thankful just to be there with her. That this closeness was al he asked of life. Clean clothes, decent food – freedom – al these were worth fighting for, but Elena was the most important. And Elena had cried. On the other hand, she knew that Damon had no intention of remaining as he now was. He might do anything, risk anything†¦to change himself back. It had actual y been Matt who had suggested the star bal as a solution for Damon's condition. Matt hadn't understood either the rose or the star bal until it was explained that this star bal , which was probably Misao's, contained within it most or al of her Power, and that it had become more bril iant as it absorbed the lives that she took. The black rose had probably been created with a liquid from a similar star bal – but no one knew how much or whether it was combined with unknown ingredients. Matt had frowned and asked, if the rose could change a vampire to a human, could a star bal change a human to a vampire? Elena hadn't been the only one to see the slow rising of Damon's bent head, and the glimmer in his eyes as they traveled the length of the room to the star bal fil ed with Power. Elena could practical y hear his logic. Matt might be total y off track†¦but there was one place a human could be sure to find powerful vampires. In the Dark Dimension – to which there was a Gateway in the boardinghouse's garden. The Gateway was closed right now†¦for lack of Power. Unlike Stefan, Damon would have absolutely no qualms about what would happen if he had to use al the star bal ‘s liquid, which would result in the death of Misao. After al , she was one of the two foxes who had abandoned Stefan to be tortured. So all bets were off. Okay, you're scared; now deal with it, Elena told herself fiercely. Damon's been in that room for almost fifty hours now and who knows what he's been plotting to do to get hold of the star bal . Stil , somebody's got to get him to eat – and when you say â€Å"somebody,†face it, it's you. Elena had been standing at the door so long that her knees were starting to lock. She took a deep breath and knocked. There was no answer, and no light went on inside. Damon was human. It was quite dark outside now. â€Å"Damon?†It was meant to be a cal . It came out a whisper. No answer. No light. Elena swal owed. He had to be in there. Elena knocked harder. Nothing. Final y, she tried the knob. To her horror it was unlocked, and it swung open to reveal an interior as dark as the night around Elena, like the maw of a pit. The fine hairs at the back of Elena's neck were standing up. â€Å"Damon, I'm coming in,†she managed in a bare whisper, as if to convince herself by her quietness that there was nobody there. â€Å"I'l be silhouetted against the very edge of the porch light. I can't see anything, so you have al the advantages. I'm carrying a tray with very hot coffee, cookies, and steak tartar, no seasonings. You should be able to smel the coffee.† It was odd, though. Elena's senses told her that there was no one standing directly in front of her, waiting for her to literal y run into him. Al right, she thought. Start with baby steps. Step one. Step two. Step three – I must be wel into the room now, but it's stil too dim to see anything. Step four†¦ A strong arm came out of the darkness and locked in an iron grip around her waist, and a knife pressed against her throat. Elena saw blackness shot with a sudden gray network, after which the dark closed in overwhelmingly.

Monday, July 29, 2019

“The interrogation” by Edwin Muir

The poem â€Å"The interrogation† by Edwin Muir is about the different ways that people deal with and react in different situations. I think this poem is about a few emigrants who are illegally crossing the border to enter a country they are not lawfully permitted to. The interrogation that the poem talks about is the questioning that these people are put through by the law enforcement troops that these emigrants encounter at the border. We know that the poem is about this illegal emigration because at the beginning of the poem states, â€Å"and then came the patrol;† This confirms that there is a governmental group of people involved. I think the central opposition of the poem is about courage and fear. The way these people choose to handle the ‘interrogation' determines whether or not they will be able to cross the border. If they answer with courage and confidence then they will be much more likely to be allowed through as opposed to if they answer with fear. We know that they reacted unwisely in this scenario because the poem says they â€Å"hesitated† in their approach to crossing the border. This is what led them to be interrogated by the â€Å"patrol†. This has a direct relation to real life; you are more likely to succeed in things that you handle with courage then those that you handle with fear, as fear leads to suspicion. These people are doing an illegal act and we know that they handle the situation with the wrong approach. We are further confirmed that what these people are doing is illegal when the poem says â€Å"Must come out now, who, what we are,† It conveys a sense of deception to the readers. I also think that according to the poem some people, that were confident and came as families were let through to cross the border with ease. This is supported because the poem says, â€Å"The careless lovers in pairs go by,† Near the end of the poem, the poet talks about the response and state of mind of these emigrants. The poem tells us that these people are getting more nervous as they are being questioned more and more. This is a build-up in the poem and it demonstrates how the people are increasingly getting more nervous as this interrogation progresses. We know so from the following lines, â€Å"And the thoughtless field is near. We are on the very edge, Endurance almost done, And still the interrogation is going on.† There is a contrast between the different groups of people shown in this poem because the people that are going in â€Å"pairs† tend not to â€Å"hesitate† when they cross the border, whereas these other people do. This is a contrast between the different ways that people handle situations. We can assume, from the evidence that I have given that it is an interrogation that questions the actions of these emigrants and why they are trying to cross the border. These would be regular routine questions. The fact that the poem is written using â€Å"we† shows that there is more than one and perhaps it's a gang or group of people. However, the impression that is given to the readers is that these emigrants are innocent people just looking for a new home, rather than a group of criminals. The poem is written in clear language and has a lasting effect on the readers. It demonstrates how actions can determine where different people will end up in the long run. It gives the readers a chance to think of how and why some of the people were held back and interrogated while others weren't and crossed this road without difficulty. The effect of the courage and fear aspects is significant and seems like it was the main intention of the reader to highlight those features in the poem. They happen to be very effective techniques in catching the reader's attention. However, the poem is not so predictable and changes its style in which the points are pointed out to the reader often.

Special Populations Health Care Essay Example | Topics and Well Written Essays - 2000 words

Special Populations Health Care - Essay Example utilizing the resources of Department of Health and Department of Education, involving primary and secondary school administrations, engaging the misinformed parents, and signing up well known and relatable role models. According to the latest statistics from US Census Bureau, the amount of population between 10 to 24 years old is approximately 1,726,672, which shows that there are more than a million individuals above the age of 10, and below the legal drinking age of 21 years old (US Census Bureau, 2010). Furthermore, according to the research conducted by the Department of Human Services of New Jersey, an alarming fact discovered is that the local youth have professed â€Å"experimenting with alcohol at a rate above that reported nationally.† Also, it is found that the average age, among the youth, of consuming alcohol for the very first time is 11 years, whereas, around 407,000 individuals are committing underage drinking every year (Division of Addiction Services, 2008). Additionally, other surveys of New Jersey high school students have indicated that around 72.1 percent have consumed a kind of alcoholic beverage at some instance in their lives, and also, female students reported to an increased underage drinking as compared to male students. At the same time, the white and Latino students professed to a greater alcohol use as compared to African American and other ethnic students (Division of Addiction Services 2009, p. 15). In an another study conducted within the high schools, by the New Jersey Department of Education, it was found that the alcohol related incidents, such as violence and vandalism, have increased 14 percent between the years 2007 and 2009 (Hendricks 2010, p. 8). In addition to the large number of the youth involved in alcohol abuse, the massive cost associated with this societal dilemma is definitely an eye opener. According to the latest research conducted by the Pacific Institute for Research and Evaluation, in collaboration with

Sunday, July 28, 2019

Exemplar approach Essay Example | Topics and Well Written Essays - 2750 words

Exemplar approach - Essay Example The results of the approach depend on the categorization which is done based on the concept categorization. When compared to the other approaches, exemplar approach can be applied to any sort of psychological illusions and problems. The category is classified based on the psychological approaches and this is done to ensure that they are classified in a proper manner. Concepts and categories form the major part of the exemplar approach. The cognitive and psychological functions require concepts and categories. This is one of the striking differences between exemplar approach and other psychological approaches. These are essential to determine the psychological functions and activities of a person. Concepts are considered as the representations and activities based on the mental representations. The use of these concepts is more in exemplar approach due to the varied psychological aspects used in it. Concepts indicate the ideas and ideologies pertaining to a particular idea. These repr esentations include understanding; thinking and even the memory power are included in the classification of concept. Since these are the direct interpretation from one’s mind, they are given more importance. Concepts are classified into three major types namely classification, prototype and exemplar approach. ... (Shan, 2005). These categories are classified and described using several approaches like prototype approach, definitional approach and exemplar approach. In terms of exemplar approach, category is described as the principle that helps to point out the knowledge that has been classified using the concepts. (Braisby, 2005). Category is a collection of properties or items that are similar in nature or by their property. The similar objects possess things that have common properties. The words and properties that are used to define an object are also considered as concepts since they directly deal with the ideas of the people. Exemplar- A Unique Approach Exemplar approach stands out due to its unique approach and easy methodology that is used in dealing with psychological problems. There are certain differences that make exemplar the most sought after method. The major problems with classical approach and prototype approach are eradicated in this approach. Classical approach generally h as problem with defining attributes for a particular category, where as exemplar approach easily generates the required attributes. Classical approach uses fuzzy concept, but exemplar approach uses well defined objects to determine the mental representations. Prototype approach also lacks in certain aspects but exemplar approach scores over them in almost all the aspects. Prototype approach implements abstract concept and this act as a disadvantage while deriving categories. In case of exemplar approach, concrete concept is used since it deals with physical presence. A definite and predefined structure is not followed either in prototype or classical approach. Exemplar approach makes use of predefined steps

Saturday, July 27, 2019

The american Scene no country for old men Essay

The american Scene no country for old men - Essay Example The beginning of the movie is witnessed with Sherriff and Tom Bell conversing with another character. The two characters are talking about the past of the Sheriff’s in Texas in different areas. From the camera one is able to see the vistas that are gorgeous from western Texas. The images are crisp and beautiful and the transitions look seamless. As an example, there is the depiction that there are no individuals (witnesses) when Moss spots a dog that is hobbling when he is hunting antelopes and it is at a distance. The only things that can be viewed at a distance are five to four pickup trucks with open doors. There are no witnesses or individuals to account on what has actually taken place for the trucks to look abandoned. The bareness of the land is made clear when he begins to head towards the trucks and all that can viewed are dead bodies in the tall grass with no individuals to explain the real causes of their death. The absence of witnesses is even stressed when there ar e battles in the streets with the hit men and gangs of Mexican all in the pursuit of the money in Moss possession. At the end of the movie, most of the characters that could have provided the real account of what actually took place are dead. These include the individuals Moss found dead from the drug deal, Moss himself, Clara Jean who was the wife to Moss, and store and hotel clerks that Chigurh killed (Coen & Coen). Most of the area in the movie is expansive and desolate with no homes. This, in the movie, is evidenced by an expansive desert. In addition, when moss as hunting, the land was mainly occupied by tall grass. Some of the homes that are shown in the movie are the trailer home belonging to Llewelyn Moss the Vietnam-veteran where he lived with his wife Clara Jean. From the footage there are fewer houses around their home hence the evidence that there was lack of homes. The other one is that belonging to Carla

Friday, July 26, 2019

Long day's journey into night Research Paper Example | Topics and Well Written Essays - 1500 words

Long day's journey into night - Research Paper Example O’Neill brings out the role of men and women in the society at that time and the difference between the father and his sons. The issue of gender and especially feminism is focused in the play through the life of Mary, who also happens to be the structural center of the play. A deeper analysis reveals that Eugene portrays Mary in a manner that she has many troubles and has many weaknesses evidenced by the use of morphine. She is being seen as irresponsible mother who cannot quite the addition. In addition, it is evident at times when James and Jamie talk alone and on the arrival of Mary, they shut up. The evidence concerning the fact that they are to be the only persons is from the fact that she is the one who can handle issues since they believe as seen in the statement, â€Å"Ive always believed Jamie did it on purpose. He was jealous of the baby. He hated him.† (2.2.103) (Eugen and Neill 103). James showed man character when he told Mary to forget the past. This is demonstrated by how strong he is and could forget the past. In addition, James Tyrone characters confirm feminism through his appearance and personality. It is evident that the story evolves around him as the head of the family but later we see the role of the woman becomes necessary when it comes to reliance and love. On the other hand, O’Neill uses Mary to show the â€Å"struggles that women go through in their daily lives† (Porter 80). Mary is described as a beautiful woman who takes up her role as a mother despite the addiction and other challenges that she has to overcome. For that reason, Mary started using morphine and got addicted to it after she had difficulty and was not treated well at the birth of her youngest son Edmond. Mary is also depicted as a tragic woman who is different from what she used to be in the past. She was innocent, beautiful and used to have dreams of becoming a Catholic nun a pianist. She also had strong religious faith in God.

Thursday, July 25, 2019

Leadership paper(what's the culture and leadership difference between Research Paper

Leadership (what's the culture and leadership difference between Asia and U.S.A) - Research Paper Example In his opinion, variables like language, environmental and technological considerations, contexting, authority conception, nonverbal communication behavior, time conception etc can affect the communication and leadership styles of a person (Victor, 2009). English is the major language of the Americans whereas Mandarin, Hindi, Arabic etc are some of the languages in Asia. English is an international language and hence the Americans always keep a dominating mentality in their leadership styles. Even Chinese and Indians forced to use the American language English as the medium in their communication with the Americans. Asia and America have different environmental characteristics. Asia is a heavily populated region with different political and legal systems. Communists control the administration in China whereas democracy is prevailing in countries like India, Japan etc. In some other Asian countries Islamic administration is implemented. But in most of the American countries democracy is prevailing. These political differences in Asia and America often reflect in the leadership styles also. Most of the American leaders try to lead their people in a democratic manner whereas in Asia, except in democratic countries, totalitarian approaches are prominent. For example, in China and Saudi Arabia like countries, leaders have the supreme authorities and the followers should blindly accept the instructions of the leaders. But in America, leaders try to hear the opinions of the followers before asking the followers to do something. If the level of knowledge (Contexting) possessed by the leader and the follower are different, it can affect the leadership styles. If the follower has more knowledge than the leader, it is difficult for the leader to instruct the follower. The leader should always possess better knowledge than the follower in order to lead the followers successfully.

Wednesday, July 24, 2019

Marketing Management Assignment Example | Topics and Well Written Essays - 4500 words

Marketing Management - Assignment Example It not only has non-stop aircrafts to other Middle-East countries but also has huge number of connecting flights to other countries across the globe. The network of connection by the company stretches from Europe to Asia with its presence in 29 countries and connecting more than 45 cities with a total of 34 fleets of aircrafts. Along with country’s vision of â€Å"Vision 2030†, Gulf Air also has its vision lined on the same line. The company’s strategy is to build a commercially sustainable, efficient airline which effectively serves to the people of Bahrain and also helps in the growth of the economy of the country representing its good image in the global world. Based on its strong strategy of growing at a fast pace the company has its main focus on three core areas which are providing a superior and more consistent product to the customer, a well-targeted and good expansion in the international network and third to become a modern and more efficient aviation c ompany that will provide good value for money to the customers and also will look to optimize value. Having a constant growth in the business operation the company has moved forward in a big way and in 2012 the company was been awarded with Silver Effie for building an effective and innovative brand in Bahrain. Though being in the global market from so many years the goal of the company has remained unchanged and its commitment towards bringing the latest technology in aviation industry is very well known, and its brand image has also increased by its hallmark Aviation hospitality. The company’s strong strategies to provide the best service have become the flagship for the company and the company is well known in the global market because of its high level of service and hospitality. In this report it can be seen how the company has utilised all its resources and capabilities in the best possible way to grow at such a fast rate and also the marketing strategies that are been used by the company