Management of pressure ulcers in a high risk patient: a case study

1. Introduction Clinically, pressure ulcers are defined as the lesions that are the result of localized tissue damage or cell death (generally necrosis), developed because of pressure over a bony prominence.More commonly, they are also known as pressure sores or bedsores as they are mainly developed by patients that are bed-bound (Wake, 2010). Approximately, 3 million adults are affected by pressure ulcers and are most common in hospitalized patients (Lyder and Ayello, 2008). However, effective management and care plans against pressure ulcers are still lacking. The role of nursing care is a fundamental aspect to pressure ulcer management, including its prevention and treatment (Wake, 2010). In this case study report, I visited a diabetic patient as a district nurse for insulin administration and provide support by assessing the patient’s risk of developing pressure ulcers due to associated pathological and other risk factors.1.1. Purpose of the studyIn all health care settings, pressure ulce rs remain one of the major issues. More so, pressure sores or pressure ulcers are associated with significant cause for morbidity in the medical community. The main purpose of this patient visit was to provide healthcare support for patients who were at risk of developing pressure ulcer. The healthcare support included the risk minimisation by doing risk assessment, therapeutic interventions, suggestions for lifestyle changes including exercise and dietary habit. All these were targeted with the views of providing timely assessment of pressure ulcers in high risk patients, and suggest therapeutic interventions for timely treatment of the condition.1.2.Patient historyThe patient was 75 years old male, diabetic and paralysed due to recent stroke attack. He was completely bed bound and was on wheelchair. Furthermore, the patient was suffering from cancer of the oesophagus. Since the patient could not mobilize, his family members and carers used to transfer him from the bed to his whe elchair and wheelchair to his bed.1.3. Risk assessments of needs, vulnerabilities and strengths of the patientThe patient was chronically ill and had several complications associated with his conditions. Stroke attack had caused him paralysis and was unable to move. This had put him in significant risk of developing pressure ulcers. The patient was also diabetic. Diabetes causes slow healing of wounds that may lead to ulcer (Guo, et.al. 2010). In this patient, the combination of factors including diabetes and immobility had increased his risk of developing pressure ulcers. Other factors such as old age of the patient, cancer and dietary factors would trigger the development of these pressure sores. Cancer is a chronic disease that may cause severe debilitation and prolonged confinement to bed. Therefore, it is expected that patients with cancer are at significant risk of developing pressure ulcers (Walker, 2001). Diet may have a supporting role in the development of pressure ulcers . Although the role of nutrition in preventing the development of pressure ulcers is still debatable, it is obvious that patients who are malnourished are at risk of developing those (Doley, 2010). Thus, nutrition therapy could be central in minimising the risk of developing pressure ulcers. It was seen that the patient was clearly underweight due to his chronic health conditions. Overall, the following risk factors of the patient were considered while making his assessment. Based on these risk factors, care plans and suggestions were made to minimise the risk in the patient. Sensory factor: This factor was assessed in order to identify how well the patient can process sensory input from the skin, as well as how effectively he can communicate level of sensation. Since the assessment of skin is an important way to identify patient’s risk of developing pressure ulcers, it would ensure the degree of risk of pressure ulcer in this patient and hence, take measures to prevent them before complications arise. Moisture: Moisture is another hallmark of pressure ulcers. Excess skin moisture puts patients at greater risk of developing pressure ulcers. It is common that patients who are confined to bed produce more sweat. Thus, it is required to evaluate what degree the skin is exposed to moisture. Activity Lack of activity is one of major risk factors of developing pressure ulcers in bedbound patients. Continuous friction between the skin and bed mattress may result the development of pressure sores. Measuring the activity is another important parameter to predict the patients’ risk of pressure, irrespective of their degree of mobility. Patients who are unable to move need to be physically turned by healthcare staffs or family members at regular intervals Nutrition As mentioned earlier, although nutrition may not have direct effects on the patient’s risk of developing pressure ulcers, it may be possible that lack of required nutrients may increase its complications. It is thus important to evaluate what constitutes the usual pattern and amount of caloric intake in the patients. After evaluating the above risk factors in the patient, it was concluded that the patient was likely to develop pressure ulcers if timely interventions were not introduced. These would have direct effect in patient’s health. These ulcers influence the risk of bacterial and viral infections, which can become life threatening in chronically ill patients. In addition, there is a high rate of mortality associated with pressure ulcers. Mortality rate is high as 60% is reported in older patients with pressure ulcers within 1 year of hospital discharges (Lyder and Ayello, 2008). The patient in this case study could have weakened immune system due to his old age and illnesses such as cancer and diabetes. In immune-compromised patients, the risk of infections spreading into their blood and other organs of the body are considerably high. This may result blood poisoning and septicaemia. Both these conditions are very fatal and categorised as medical emergencies (Redelings, et.al. 2005). However, despite of several associated risk factors, the patient was provided with proper care and support by his carers and family members. He was regularly taken off from his bed with the support of wheelchair. More so, the patient was on medications to control his blood sugar. He was also supplemented with vitamin to strengthen his immunity. To conclude, patient although was receiving appropriate healthcare service, these were mainly therapeutics which included medications against the chronic illnesses which he had. Patient and family members were lacking suggestions and expert advice in regards to minimising the risk of pressure ulcers. It was also observed that the patient was provided with a normal bed and mattress that would further trigger the risk of developing sores. 2. Interventions and referrals After evaluating the patient’s condition, as a district nurse, I provided the evidence based interventions and referrals to the patient and his family members and carers as preventive approaches of pressure ulcers. Firstly, the patient was provided with a hospital bed with pressure relieving mattresses. This would help minimise the friction between patient’s body and the bed and hence, reduce the risk of pressure ulcers. Moreover, this would provide support surfaces and help in pressure redistribution (Stannard, 2012). Several recommendations for skin care including the use of cold water instead of hot water, use of mild cleansing agents to minimise irritation and dryness of the skin and excessive moisture was suggested. The patient was also advised to avoid low humidity as it may promote scaling and dryness (Lyder and Ayello, 2008). Further suggestion such as avoiding mechanical loading was given. This is considered as one of the most effective preventive measures of p ressure ulcers in hospitalized patients (Lyder and Ayello, 2008). Thus, family members were advised to frequently turn and reposit the patient while in bed. It is essential that patient intake adequate levels of both macro and micronutrients to prevent complications of pressure ulcers. This patient was already supplemented with vitamins and minerals, so no action was taken. However, the patient was suggested to eat diet high in proteins, which are essential for wound-healing and overcome malnutrition. Management of pain is another key aspect in patients with pressure ulcers (Cooper, 2013). Pressure ulcers can be very painful and may require interventions with analgesics (Wake, 2010). However, this patient did not require analgesic treatment as the pain due to pressure ulcers was not very severe. Instead, focus was given on the preventative approaches in minimising the complications associated with pressure ulcers. Finally, the focus was given on the patient/carer education in the management of pressure ulcers. Both patient and carers/family members were made aware about the risk factors of pressure ulcers. Also, they were educated and made aware on the most vulnerable sites of the body that are at risk of developing pressure ulcers. General training was also given on how to take care of skins and methods for pressure reduction. They were told about the severity of the condition and requested to seek medical advice if symptoms of pressure ulcers persist. 3.Critical evaluation and evidence-based examination of outcomes of interventions and referrals The interventions and referrals made for the patient in this case study were evidence based. Risk assessment was made considering the standard pressure ulcer prediction tool, Braden Scale, by observing the six vital signs of pressure ulcers as explained earlier. This tool has allowed for the early prediction of pressure ulcers and thus introduction of early interventions before the complications are developed (Sving, 2014). Classification of pressure ulcers is one of the best ways to predict its outcome. Pressure ulcers are classified into various stages (Lyder and Ayello, 2008). Stage I is determined by the presence of redness in the skin. In case if the redness in the skin is observed, nurses are required to make thorough skin inspection and advice patients about the preventive measures. Stage II is characterized by the loss of skin with the presence of blisters. In stage III loss of skin is quite thick; however, not exposed to muscle or bone tissue. In this stage, there is a high risk of infections, so care should be given in personal hygiene (Sving, 2014). Also, patient should be suggested to include vitamins and minerals in the diet to prevent the possible risk of infection. In stage IV there may be an exposure to bone, tendon and muscle. This condition is considered as potentially dangerous, due to associated risk of life threatening bacterial infections. In many cases, this may also require hospi tal admission to reduce further complications (Lyder and Ayello, 2008; Sving, 2014). To conclude, nurses are required to assess various stages of pressure ulcers and provide treatments and suggestions based on these stages. This is because; different stages of pressure ulcers may require different treatment plans. Some could be minor and may be improved through general suggestions such as encouraging patients to move and involve in physical activities and maintaining healthy diet; whereas some may require therapeutic interventions including the use of antibiotics to treat bacterial infections, dressing and cleaning of the wound and hospital admissions if complications are severe. (Wake, 2010). Ample evidence is now available on the understanding of effective pressure ulcer treatments. Treatment strategies such as use of hospital bed, avoiding mechanical loading, and physical activity are now considered as the standard form of treatments in pressure ulcers. These approaches not only reduce the risk of pressure ulcers, but are also beneficial in lowering its complications. Furthermore, the association of pressure ulcers with other chronic diseases such as cancer, diabetes and stroke are well understood. Thus, much attention is to be given while giving care to the patients who have these conditions. Educating patient and family members on the risk factors and management is another approach to pressure ulcer management as suggested by NICE guidelines (Wake, 2010) However, the available knowledge on the evaluation of risk assessment of pressure seems insufficient. The evidence lacks support and requires further epidemiological research to understand risk factors of pressure ulcers in greater depth. Some of the interventions and their effectiveness including re-positioning and nutrition are still questionable. Further studies on the influence of different turning intervals on the development of pressure ulcers need to be carried out. Similarly, what specific diet is suitable for pressure ulcer patients needs further clarification. Appendix1: Care plan of the patient Risk assessmentCare goalsInterventions and evaluations Patient’s needs and vulnerabilities : old age, bed-bound, chronic diseases including cancer and diabetes, paralysed due to strokeTo identify the patient’s risk of developing pressure ulcersThe patient was provided with hospital bed, cushion for his wheelchair and family members were suggested to move the patient time to time Patient’s strength: on proper medications, carers and family members providing the support, supplemented with vitamins and minerals to boost the immune functionTo build on the patient’s strengths and to meet his needsPatient was provided with full support from the family members. High protein diet was suggested as this may improve would-healing. Signs of complications, such as pain, bacterial and viral infections.To avoid complications associated with infections including blood poisoning and septicaemiaImmune booster such as vitamins and disinfectant creams to avoid infections. References Cooper, K.L. 2013, â€Å"Evidence-based prevention of pressure ulcers in the intensive care unit†, Critical Care Nurse, vol. 33, no. 6, pp. 57-66. Doley, J. 2010, â€Å"Nutrition management of pressure ulcers†, Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition, vol. 25, no. 1, pp. 50-60. Guo, S and DiPietro, L.A, 2010. Journal of dental research. Factors Affecting Wound Healing, vol. 89, no. 3, 219-229. Lyder, C.H and Ayello, E.A, 2008. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Pressure Ulcers: A Patient Safety Issue. Lyder, C.H, 2003. Clinician’s corner. Pressure Ulcer Prevention and Management, vol. 289, no. 2, pp. 223-226. Lyder, C.H. 2006, â€Å"Assessing risk and preventing pressure ulcers in patients with cancer†, Seminars in oncology nursing, vol. 22, no. 3, pp. 178-184. McInnes, E., Jammali-Blasi, A., Bell-Syer, S., Dumville, J. & Cullum, N. 2012, â€Å"Preventing pressure ulcers–Are pressure-redistributing support surfaces effectiveA Cochrane systematic review and meta-analysis†,International journal of nursing studies, vol. 49, no. 3, pp. 345-359. Redelings, M.D., Lee, N.E. & Sorvillo, F. 2005, â€Å"Pressure ulcers: more lethal than we thought?†, Advances in Skin & Wound Care, vol. 18, no. 7, pp. 367-372. Stannard, D. 2012, â€Å"Support surfaces for pressure ulcer prevention†, Journal of perianesthesia nursing : official journal of the American Society of PeriAnesthesia Nurses / American Society of PeriAnesthesia Nurses, vol. 27, no. 5, pp. 341-342. Stechmiller, J.K. 2010, â€Å"Understanding the role of nutrition and wound healing†, Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition, vol. 25, no. 1, pp. 61-68. Sving, E., Idvall, E., Hogberg, H. & Gunningberg, L. 2014, â€Å"Factors contributing to evidence-based pressure ulcer prevention. A cross-sectional study†, International journal of nursing studies, vol. 51, no. 5, pp. 717-725. Wake, W.T. 2010, â€Å"Pressure ulcers: what clinicians need to know†, The Permanente journal, vol. 14, no. 2, pp. 56-60.

Review of related literature and studies Essay

REVIEW OF RELATED LITERATURE AND STUDIES Teenagers and Part-Time Jobs: Benefits, Drawbacks and Tips Adolescence is that difficult period of time when carefree children transition to responsible adults†¦ we hope. That is the goal, after all, for teens to develop into mature, productive, responsible members of the community. One method for assisting this transition is obtaining part-time employment. A job can help teenagers better develop their identities, obtain increased autonomy, achieve new accomplishments, develop work experience, and become more independent from their parents. According to the U.S. Department of Labor, 50 percent of American teenagers hold informal jobs, such as babysitting or yard work, by age 12. Boys tend to begin their jobs at younger ages and work more hours than girls. By age 15, nearly two-thirds of American teens have had some kind of employment. By the time teens graduate from high school, 80% will have held a part-time job at some time during the school year. The average high school student works 20 hours per week, and about 10% work full time (35 hours or more). There are many obstacles to teens obtaining employment. Finding reliable transportation is critical, and that can be difficult if the job is not close by and the teen’s parent(s) work. Fighting stereotypes that employers have about adolescents, such as poor attitudes or lack of skills, can be challenging. In this particular economy, there aren’t very many job opportunities for teens. Teens want to work for a variety of reasons, but more than half report their involvement in work is motivated by the desire to buy things. Typically, teens spend their money on car expenses, recreational expenses, clothing, educational expenses, saving for college, and helping their families with living expenses (e.g., rent, groceries). Researchers have studied and debated the benefits and drawbacks of teens and part-time jobs for more than 2 decades. Many researchers, including those o n government panels like the National Commission on Youth, praise part-time work and say it contributes to the transition from youth to adulthood. Other studies have found significant negative consequences to students working over 20 hours a  week. We will take a close look at both. Benefits of Teens Holding a Part-Time Job There are many benefits to adolescents obtaining employment, including: Obtain valuable work experiences, which are excellent for a resume. Learn how to effectively manage finances. Even if the teen is simply using their earnings to pay for their own expenses, they will learn to budget between clothes, movies, and car expenses. May provide networking possibilities and set a child on a rewarding lifetime career path. Provide constructive use of free time. An after-school job can also provide adult supervision, especially if you work longer hours than those in a typical school day. Employment gives teens less time to engage in risky behaviors. Learn time management skills. Form good work habits. Gain useful, marketable skills such as improving their communication, learning how to handle people, developing interview skills and filling out job applications. Instill new confidence, sense of responsibility and independence. Drawbacks of Teens Holding a Part-Time Job There are also negative consequences of teen employment that may outweigh the positive benefits, such as: Less time for homework. Working students may not have or make the time to complete their work. Higher rates of absenteeism and less school involvement. Employment may place constraints on the student’s study and sleep time. Fatigue or lack of preparation for the day’s academic activities may discourage the working teen from going to school and a job may take the place of extracurricular activities. Lower grades in school. Students who work more than 20 hours a week have grade point averages that are lower than other students who work 10 or less hours a week. More likely to use drugs and alcohol. Research suggests that substance abuse is higher for students who work 20 or more hours per week. Development of negative views of work itself. Early entry into a negative or harsh work environment may encourage negative views of work. This would depend greatly on the maturity level of the teenager and the type of job obtained. Increased stress. Balancing work and school can prove to be too much for any  student. Research seems to suggest that students that work 10 hours or less a week gain the benefits of employment, while students that work over 20 hours a week suffer the negative consequences of work mentioned above. Other factors that affect how students handle employment and school life include the intensity and difficulty of the work done. Summer Employment Summer employment is an excellent alternative, as it does not interfere with schooling and provides teens with a constructive use of their free time. It allows adolescents to garner all the benefits of employment without overtaxing their busy school schedules. Teens should begin looking for summer employment during Spring Break. Possible jobs for teens are: landscaping, delivering newspapers, babysitting, retail stores (such as grocery stores or clothing stores), movie theaters, working at a theme park, being a camp counselor, lifeguarding at a pool, and dog walking. April 2, 2010 by middleearthnj Work careers begin after the completion of formal schooling. This is a fundamental assumption of life course research, which identifies â€Å"the school to work transition† as one of the most critical stages of the early life course. Yet the reality is that most students are also workers. A third or more of high school students are currently employed, as are the majority of college students (Bureau of Labor Statistics, 2005a). The paucity of research on the overlap of student and worker roles and on the occupational structure of teenage workers is almost certainly due to the assumption that most students work in part-time jobs that are unrelated to post-schooling work careers. Indeed, one of the major â€Å"problems† of the first Occupational Change in a Generation Survey (the data source for Blau and Duncan, 1967) was that the measurement of â€Å"first job† may have conflated student employment and post-student employment (Duncan, Featherman, & Duncan, 1972: 21 0–224). 1 However, the high level of labor force participation among students, and the fact that teenagers comprise four percent of the American workforce, suggest the need for more research on the prevalence of work and the structure of employment among adolescents prior to the completion of schooling. In this study, we explore patterns of social stratification of teenage workers. Prior research on teenage employment has focused almost  exclusively on the impact of work on educational outcomes, including grades and dropping out. The primary theoretical and policy issue is the hypothesis that the roles of worker and student are incompatible, or at least incompatible with educational success (Greenberger & Steinberg, 1986). Yet most studies have concluded that there is little observable harm if students work a moderate number of hours per week; indeed, students who work less than 15 h/week generally have better educational outcomes than students who do not work at all (Carr, Wright, & Brody , 1996; McNeil, 1997; Mortimer & Finch, 1986). Students who work longer hours, especially more than 20 or 25 h/week, do have lower grades and are more likely to drop out of school (D’Amico, 1984), however, it is unclear whether high intensity work is a cause, a consequence, or just a correlate of poorer educational outcomes. The hypothesized causal impact of teenage employment on educational outcomes hinges, in large part, on the selectivity of students into employment and different types of jobs. Before addressing this question, we describe the occupational structure of teenage employment and its relationship to the adult labor market. With in the teenage labor market structure, we attempt to identify the dimensions of occupational status and preferable job characteristics. Then we address the question of selectivity of students to jobs within the classic analytical framework of social stratification research. Specifically, we ask if family background and ascriptive characteristics, such as gender, and race and ethnicity, influence teenage employment and the attainment of higher status jobs. Although we refer to teenage employment in general, our empirical focus is on the employment patterns held by several cohorts of high school seniors in a West Coast metropolitan area. Although this is a limited geographical and temporal sample, the patterns reported here are likely to be representative of teenagers more broadly. We find that there is a clear structure between the social backgrounds of students and the jobs they hold. Advantages of family origins and school achievement are positively associated with paid employment, and advantaged students are especially more likely to hold â€Å"good jobs† outside of prototypical teenage concentration in the fast food sector and related service sector jobs. 2. Why do teenagers work? Although there are many reasons why people work, economic necessity ranks  near the top of the list. Most high school students, however, live as dependents in parental households, and very few teenagers have to work to provide their food and shelter. Indeed, state laws â€Å"protect† adolescents from becoming regular workers by limiting the hours and nature of paid employment. The one gray area is family employment, especially when families run small businesses. Families that run small businesses generally depend on the unpaid labor of all family members, including school age children and adolescents, as part of a strategy of economic survival. If teenagers are not working to support their families, the most plausible alternative interpretation is that most students work to support their consumption and related lifestyle activities, such as saving for clothing, a car, or other â€Å"extras† beyond their family’s economic resources or willingness to provide. Another potential explanation is that students work in order to invest in their future. Students may seek jobs that provide opportunities for achievement, exposure to possible career choices, or to develop ties with persons who could serve as mentors. These explanations are not mutually exclusive, and many teenagers may be motivated by both objectives. Regardless of the motivations of students, there must be a job market in which employers seek to, or are at least willing to, hire teenagers. Many teenagers may be working in part-time jobs in the general labor market where there is an insufficient supply of relatively cheap and flexible workers. In these jobs, teenagers can be considered as supplemental workers for adults who are the predominate workforce. For example, teenagers often work as receptionists in offices and as cashiers in grocery stores, but teenagers comprise only a small minority of workers in these positions. There may also be niches of teenage jobs where adolescents comprise a significant share of all workers in an occupation or industry. For example, teenage workers appear to be the mainstay of fast food establishments. The proportional representation of teenage workers (ages 16–19) in the major occupational categories, and their relative share of all workers (employed persons age 16 and above) in each occupation, is presented in Table 1 based on data from the 2005 Current Population Survey. These data do not differentiate teenagers by their enrollment status.

Miss Evers’ Boys portrays the emotional effects Essay

Miss Evers’ Boys portrays the emotional effects of one of the most amoral instances of governmental experimentation on humans ever perpetrated. It depicts the government’s involvement in research targeting a group of African American males (â€Å"The Tuskegee Experiment†), while simultaneously exploring the depths of human tragedy and suffering that result, as seen through the eyes of Eunice Evers. The viewer watches as a seemingly innocuous program progresses into a full-blown ethical catastrophe—all the while taking Miss Evers through a moral journey, with her decisions having ramifications on the life and well-being of her best friends—her â€Å"boys. † I. Structure This movie deals with the ethical considerations present in human experimentation. The government, wanting to mimic the Oslo Experiments, intends to study a population of AfricanAmericans inflicted with syphilis. The movie takes place in alternate settings, transitioning between a 1973 Senatorial hearing and the site of the actual study in Alabama, beginning in 1932 and moving forward. Miss Eunice Evers, a nurse at a local Tuskegee hospital, is the centerpiece of the movie. II. Setting & Plot Summary With an ominous lead-in quote, Miss Evers’ Boys begins to tell the tale of an emotionally courageous young woman and her struggle to protect her â€Å"children. † Within the first few frames  of the movie, the viewer is automatically entrenched into the already tenuous history of racial tension in America—except, this time, under the auspices of segregation founded upon disease. The movie begins, placing the viewer as an observer of a 1973 U. S. Senate Hearing, where we are first introduced to Miss Eunice Evers. Miss Evers is testifying as a nurse, one who took the nurse’s oath to protect the health of those in her care. The claimed Senatorial goal is to discover the truth underlying the â€Å"Tuskegee Study. † Miss Evers worked in the study from 19321972. The movie progresses throughout the course of the hearing, with testimony by Miss Evers and reminiscent scenes telling the tale of the study. In the beginning, Miss Evers firmly supports the goal of the initial plan—to provide care and treatment to those suffering from syphilis. â€Å"It was the dawn of a new day,† explains Miss Evers. At this point (pre-study), she believes that the government is sending her patients, and her city, the best funding and medical support available. The viewer is then introduced to Miss Evers’ Boys—a folk music group. 1 The musicians (four of them) are the first patients to provide blood samples, one of them being Caleb, an eventual love-interest of Miss Evers. Each of the men test positive for syphilis. At this point in the movie, everyone (including Miss Evers) is still under that assumption that â€Å"bad blood† is the culprit for the disease. Ultimately, the funding for the initial study disintegrates. After a visit to Washington, various gentlemen confront Dr. Brodus, the head doctor in Tuskegee, with an offer for a new rationale for funding. The gentlemen explain their intentions of studying the African-American population, much like the Caucasian population in the Oslo Experiments (1891-1910). The government then reveals the true nature of the experiment—the proposed study of untreated African-Americans dealing with syphilis. 1 The government promises future treatment and The group names their band after Miss Evers when she drives them to their first musical show. 2 proclaims the future potential of the Tuskegee Experiment, appealing to Dr. Brodus’ pride. Dr. Brodus agrees, naming the study, The Tuskegee Study of Untreated Syphilis in The Negro Male. 412 men, afflicted with syphilis, participate in the study. In a telling interaction involving one of the first patients, Miss Evers suggests that the doctors explain to the study group that they are providing â€Å"back shots. † Through her deceit, Miss Evers thus begins to involve herself in the â€Å"treatment. † The tension she feels manifests itself in her facial features; the viewer can see her apprehension in this instance and throughout the movie. She is torn, but yet continues to help Dr. Brodus conduct the study. As 6-months turns into years, Miss Evers continues to hide the secret behind the study. She urges the men to continue the study, in hope of future treatment—treatment that never comes, even through the eventual availability of penicillin. Miss Evers’ ultimate decision as to how she deals with the care and treatment of her â€Å"boys† will be left to the viewer. With the journey, however, comes a tumultuous story, exposing the hypocrisy of the United States Government through the eyes of Eunice Evers. Throughout the movie, as an audience, we want Miss Evers to defy all conventions and simply provide the necessary medicine to the patients. Yet, she struggles throughout with the pros and cons of such a decision. On one hand, she wants to support the experiment; yet, on the other, she wants to protect and comfort her friends. As we finally see in the end, as seen through Miss Evers’ unique perspective, while one may question Miss Evers, it is the Senators themselves, and the government agents before them, who prove to be more worthy of moral appraisal. III.

Law - Affirmative Action Policies Essay Example | Topics and Well Written Essays - 500 words

Law - Affirmative Action Policies - Essay Example iduals with no consideration of race, sex, color, national origin, religious creed, ancestry, marital status, mental disability, sexual orientation, age, physical disability or learning disability (Schmidt, 2008). Therefore, organizations will not demand for genetic information from its employees or job applicants. The demand for such information leads to discrimination against the person on the foundation of hereditary information in an employment situation (Schmidt, 2008). Furthermore, anyone with a previous criminal conviction will not be discriminated or aligned with the crime in employment conditions. It is therefore, the goal and purpose of action policies to ensure equal opportunities to all. Organizational policies, which entail employment applications, job specifications, job structuring, job qualifications, recruitment practices, counseling, grievances procedures, layoffs and terminations should be undertaken without discrimination of any form (Sander, 2004). In order to ensure that there is no discrimination; affirmative action policies will help monitor the whole process. The hiring difficulties that are experienced by the older persons and those who are physically disabled are recognized by these policies through establishment of a plan of action that eliminates employment obstacles and actively recruit members from the discriminated minority group (Sander, 2004). This is aimed at protecting such group of persons and achieving their full participation in the workplace and therefore, such policies are still needed. Affirmative action policies give favored treatments to the minorities in the society and should be retained because of the desirability of diversity in the society (Sander, 2004). Such diversity will be completely lost if it is left to probability. Through these policies, the disadvantaged in the society will get a boost and thus be able to stand on their own. Furthermore, affirmative action policies represent people at areas of learning

Teaching Plan for Patients with Hypertension Essay

Teaching Plan for Patients with Hypertension - Essay Example These patients are composed of middle aged adults living alone in suburban areas. Setting: Private Doctor’s Office Anticipated Client Outcomes: 1. Patient should be able to keep a record of two blood pressure readings a day. Blood pressure is checked through a digital sphygmomanometer once in the morning and in the afternoon. 2. Patient should be able to keep a monitoring sheet for daily intake of prescribed anti-hypertensive medication. Patients should also be able to verbalize understanding on the precautions in taking medications. 3. Patient should be able to eat a balanced diet with strict avoidance of foods rich in fat and salt. This is measured through cholesterol determination and comparison with previously obtained results. Methodology: Patients will be divided into two groups with a minimum of five members each. Teaching classes are conducted every week. These patients are diagnosed with Stage 1 and Stage 2 Hypertension with systolic blood pressure of 140-179 and dias tolic pressure of 90-109 (McGowan 6). They have been prescribed with a variety of anti-hypertensive medications, all of which are taken every morning. Handouts will be distributed a day prior to discussion so that patients can do an advance reading and prepare questions, hence, fostering active participation. During class, basic information about blood pressure and hypertension will be provided through lecture discussion with the aid of power point and video presentations. The information presented primarily consists of definition, physiology, signs, symptoms, treatment modalities and complications of hypertension. All these information are discussed using mostly layman’s terms to facilitate better understanding among patients. Patients will be taught on the proper use of digital sphygmomanometer. If there is unavailability of sphygmomanometer, it will be suggested to buy the cheapest but reliable ones. If it is unavailable due to financial constraints, patients who live in a neighborhood are encouraged to share the sphygmomanometer amongst them. Record books are provided for each patient. These log books are divided into four columns – the first column is for blood pressure reading in the morning, the second column is for the anti-hypertensive medication, the third is for blood pressure reading in the evening, and the fourth column is for additional remarks. In the fourth column, patients can write their notes such as the symptoms experienced for that day. Proper use of digital sphygmomanometer is taught through demonstration. The nurse will show how to properly apply the BP cuff on a volunteer patient’s arm (5). Pointers will be provided so that patients can easily remember the location of the cuff. Most digital sphygmomanometers require one touch of a button to facilitate reading, so the nurse will focus on discussing the do’s and don’ts while the sphygmomanometer is reading. The nurse will also discuss the normal range fo r blood pressure (8) and the importance of adherence to intake of prescribed medications. Alongside with this, the nurse will emphasize that blood pressure readings of 100/70 and below will require the patients not to take the medication temporarily to avoid sudden drop in blood pressure. In cases like this, close monitoring of blood pressure must be done to avoid sudden hypertensive episodes. Since these patients are living alone, they are also responsible for the preparation and selection of their foods.

Evaluation Essay Example | Topics and Well Written Essays - 250 words - 4

Evaluation - Essay Example e businesses in Canada revealed that the characteristics most observable include a high number of immigrants, tensions and differences between provinces, minimal levels of investment and productivity and susceptible dealings with the United States. These differences form the basic foundation for the drafting of an efficient, detailed and potential marketing plan for Canada (Heather & Weber, 2012, p.12). Research also concludes that many of the chief marketing strategies applied in Canada are similar to those implemented in the U.S. they collectively include technology, patriotism and gender. The roles of women in the society have made a turn for the best and it is evident that they are better performers in the market in comparison to the men and this is a stronghold for the straining country. In addition, women have a more informed decision as they purchase products and this means that concentrating on their opinions ensures increased sales and customer satisfaction. Patriotism is a form of observing consumer behavior and their preference for a particular product locally manufactured and processed and encouraging the population to focus on these products ensures a thriving market. Technology is another throttle hold for Canadian business people where they employ social media in advertising efforts and this ultimately boosts the

Concept note Essay Example | Topics and Well Written Essays - 1000 words

Concept note - Essay Example It is in directive to achieve responsibilities. ‘Alvin Toffler’ first interpreted the word ‘Adhocracy’ in the year 1970 (Mintzberg & McHugh, pp. 160-197, 1985). The origin of the term adhocracy demonstrates that it specifically defines to explain the flexible dealing with daily changing objectives and motives. Nowadays, in the modern culture, these types of operational systems can be under implementation in the firms having high-risk rates to survive and among the blue-collar organizations, and in those organizations that plan to short-term projects or developed on a temporary basis. Similarly, if the organization persists to develop its structure permanently and is aware of the future risks then it has to maintain its bureaucratic structure to fight with the long term business deals. It also helps to maintain the company’s good will and repute in professional market. This term clearly contradicts to the term bureaucracy that refers to set of defined rules and set hierarchy in accomplishing organizational goals (Thatchenkery, pp. 67-74, 2010). It is a method of supple and casual organization and administration instead of unbending bureaucracy. Adhocracy (Dolan, pp. 33-50, 2010) later on revised in some common literature and in governmental pomposity to define a kind of unsystematic answer by politicians to developing issues, generally focused around American fiscal policy and in foreign policy development, unanimously that resembles Lind bloom’s "muddling through" metaphor (Thatchenkery, pp. 67-74, 2010) than a flexible, but determined organizational strategy. In other words, Adhocracy is simply a flat structure organization that does not follow any hierarchy (Dolan, pp. 33-50, 2010). The norms and regulations of such an organization rely upon a typical non-bureaucratic chunk of ideas. Selective decentralization is a specific characteristic of adhocracy that means a focus of control for decision-making. This phenomenon ex ist in functional divisions within the organization for example the decentralization of the pool system in some organizations taking place of centralized culture and also hierarchical system that majorly defines the outlines for responsibilities in the respective areas that helps in capturing errors and biases more easily. In the adhocracy, the business is proficient of rearranging its own structure including vigorously altering the work ?ow, shifting accountabilities and adjusting to changing environments (Aart & Wielinga, pp. 567-599, 2004). Adhocracies are the organizations and systems with a very beautiful concept in which a system operates in a non-hierarchical structure and has no uniform procedures for dealing with daily problems, is low in reinforcement and prearranges a momentary life. The variance between an adhocracy and the dual intent of bureaucracies is that there is a lack of typical job description definition and no classi?cation of programmed circumstances in adhocr acy. Simultaneously, professional bureaucracy and machine bureaucracy (Baum, pp. 29-43, 1987) is an older shape of Adhocracy, when adhocracy takes a growing form, it may lead to these two possible compositions. Machine Bureaucracy (Huber, pp. 50-67, 2006) is an obvious in its rigid observance to the important individualities of Weberian style bureaucracy. It is a preferred model in a constant atmosphere with routinized procedures. In any case, workers within an adhocracy will have to ?nd innovative keys to

History and Political Science Essay Example | Topics and Well Written Essays - 750 words - 13

History and Political Science - Essay Example The industrial revolution which started in Europe was a major trigger for over expansion of economies as several pieces of engineering were developed which are main propellers for the industrial revolution and booming economies. England was the source of the industrial revolution which was started in 1760 and later gained strength till late 19th century where the effects of the industrial revolution can be measured. Savery Engine Steam engine looms and furnaces were the developments which occurred during the industrial revolution. James Watt and Sir Joseph Whitworth were the inventors whose inventions propelled the growth (Crafts, 1985). The industrial revolution further gained strength and momentum with the development of industries and technological innovations which acted as a fuel for growth. The increase in American corporation was witnessed which resulted in the concentration of wealth of the nation into fewer hands leading to disparity among the people. Mechanization was also introduced in the farming process as well, which lead to the production of quality agricultural products, making the United States a pioneer in food production and export. Due to this growth, migration to the United States picked up momentum. This further developed issues as more and more labor were available to help in the production process (Crafts, 1985). Nevertheless, industrialization also lead to some serious third party protests due to the shift of power and changes in policies. The process of industrialization encouraged development and strengthening of political institutions in the economy and as result, the democratic system gained strength. The policies designed by the people underpinned the economic growth. Similarly, Russia was also developing itself; however, the growth witnessed was very slow as compared to other European Countries and the United States. The major obstacle which slowed down the process was the population of Russia. Russia’s major source of indu strialization was the coal and steel production which had quadrupled in the 19th Century. As a result, Russia was able to develop infrastructure and other facilities across the country. However, Debt issues also rose at the same time due to which, Russia was unable to trade with the United States and obtain the benefits of trade (Blackwell, 1968). Europeans rule over colonies of Africa and South Asia Asia has always been of immense interest for the colonials of Europe. The main attraction towards Asia was the existence of rich mineral deposits and agricultural produce. Europeans had been able to develop businesses in these colonies where primary produce was sent back to Europe which was then converted to finished goods. This process of colonization had also become successful because of the technological backing which the Europeans enjoyed due to industrial revolution and innovations in technology and equipment. East India Company, slowly and gradually, strengthened its’ roots in the Asian colonies by starting businesses and developing economic relations with the rulers at that time. Due to the economic and industrial capability of Europeans, they outclassed Asians and gained control over them. They had a powerful army and could deploy their troops anytime they wanted along with heavy artillery.

Ethical Argument Research Paper Example | Topics and Well Written Essays - 3000 words

Ethical Argument - Research Paper Example Finally, too much testing is compromising the emotional health of students, causing them severe anxiety and interfering with the learning process. With these elements to consider, too much testing is not an effective method of learning and major changes must be implemented soon in order to promote better learning and outcomes among students. Testing Anxiety in Schools Introduction Testing is one of the ways by which schools evaluate and assess the efficacy of the learning process among students. The process of testing includes short quizzes and long periodic examinations with varying states of intensity and duration. These tests naturally cause moments of anxiety among students who often have to go through moments of stress with each test. The stress also often lasts from the time the tests are announced to the time the results are released. In between these tests, these students also have to endure the constant strain of studying, of doing projects, finishing homework, and the possi bility of unannounced tests. The age and the maturity of students in dealing with these school demands do not seem to be a major concern among some educators. In recent years, concerns about too much testing and too much homework have been pointed out by parents, teachers, and by students themselves. They also point out that too much testing is causing much anxiety among students, often compromising their learning and emotional development. Not everyone shares their concerns however, with other parents and educators arguing that testing is an essential part of the learning process and that the number of testing is sufficient for effective learning. Based on these contrasting arguments, this paper shall discuss the thesis: Too much testing in schools is compromising the students’ learning and emotional development. This essay will first provide a literature review on the development of this issue. Secondly, it will present the supporting ideas for this argument. Each reason or argument shall be presented in ascending order based on strength. Thirdly, possible arguments and arguments to these supporting arguments will also be discussed and rebutted. Finally, this paper shall end with a conclusion, further reiterating the main arguments of the paper and providing a clear answer and support for the current position in this thesis. Literature review A Los Angeles Times (2011) editorial discussed that the federal policy No Child Left Behind has become a very rigid policy because it emphasizes the need to carry out standardized tests for English and Math. This article also pointed out how the tests do not focus on the essential learning processes which students can apply in their lives. In effect, these tests do nothing more than cause anxiety to students, and do not contribute significantly to the overall academic development of students (Los Angeles Times, 2011). In a study by Barton (1999), the author discussed that there are some negative trends in the Ame rican educational testing system. This trend has been on the proliferation of standardized testing, which has increased in number and frequency. Barton (1999) emphasized that increase in standardized testing has made the educational process and system quantitative in approach. However, the schools and the learners are short-changed in terms of the information which students need in order to claim

Bank Accounts Essay Example for Free

Bank Accounts Essay Saving a/c savingsare meant to promote the habit of saving among the citizens while allowing them to use their funds when required. The main advantage of Savings Bank Account is its high liquidity and safety. On top of that Savings Bank Account earn moderate interest too. The rate of interest is decided and periodically reviewed by the Government of India. Presently, the rate of interest is 3. 5% compounded half yearly. Savings Bank Account can be opened in the name of an individual or in joint names of the depositors. Savings Bank Accounts can also be opened and operated by the minors provided they have completed ten years of age. Accounts by Hindu Undivided Families (HUF) not engaged in any trading or business activity, can be opened in the name of the Karta of the HUF. The minimum balance to be maintained in an ordinary savings bank account varies from bank to bank. It is less in case of public sector banks and comparatively higher in case of private banks. In most of the public sector banks, minimum balance to be maintained is Rs. 100. In accounts where cheque books are issued, a minimum balance of Rs. 500/- has to be maintained. For Pension Savings Accounts, minimum balance to be maintained is Rs. 5/- without cheque facility and Rs. 250/- with cheque facility. Things to Consider While Opening a Savings Account It is advisable to seek the following information from bank before opening the account: †¢Minimum balance requirements. Penal provisions in case the balance falls below the minimum stipulated amount †¢Penalty in case of return of cheques issued or instruments sent on collection. Collection facilities etc. offered and charges applicable. †¢Details of charges, if any for issue of cheque books and limits fixed on number of withdrawals, cash drawings, etc. Document Required For Opening a Savings Account †¢Two passport size photographs.

Analysing Recruitment Strategies Of Brunt Hotels English Language Essay

Analysing Recruitment Strategies Of Brunt Hotels English Language Essay Brunt Hotels, owns more than 30 hotels throughout the United Kingdom. They recently acquired a small hotel chain headquartered in France. Brunts chief executive decided that half of the new hotels in France would be retained and rebranded as part of the Brunt Hotels Group. The other half will be sold. This will support Brunts strategic objective of growing the organization slowly to make sure that new ventures are well supported and opened on time and on budget. The organization has decided to use an ethnocentric approach and send some of their existing UK-based managers to France to lead the changeover of the new hotels and then manage them after they re-open. If this new overseas venture is successful, Brunt may decide to acquire other small hotel groups in other European countries. The organization has never owned hotels outside the UK before, and has hired a team of independent management consultants to advise them on how to proceed. The hotel management asked you if they should look only internal candidates who are parent country nationals or recruit host country nationals. Explain the legal and ethical obligations in recruitment procedures. The point of a recruitment and selection procedure is to make sure that the best and most suitable candidate is recognized and recruited. The aim of the recruitment and selection procedure is to provide a structure for managing recruitment and selection inside the workplace, in a professional, efficient and fair way, ensuring that the best possible candidate will be selected for the job. This structure will further ensure that no unlawful discrimination occurs throughout the recruitment and selection process and that equality of opportunity is an essential part of the procedure. Any recruitment of family, friends or close associates must be confirmed and reviewed through the appropriate procedures. There should be a methodical and reliable search process and the selection process should be valid. Integrity must be given consideration in recruitment and promotion of employees. Ethics is a bottom-line matter in how managers carry out their responsibilities and how they will train, rewa rd and promote the best employees. Those employees will, in turn, assist to ensure that the company has the most effective and efficient work force promising to achieve its business goals. In our case, the organization has decided to use an ethnocentric approach and send some of their already existing managers from the UK to France to lead the new hotels and manage them after the re-open. However, the hotel management should hire new employees from the host country in order to complete all the positions in the hotel. The organization as for the recruitment of the new workforce will have to think about several factors concerning ethical and legal obligations. An ethical dilemma arises in our situation and this dilemma is: to send employees from the UK or to keep the previous employees of the hotel or to hire new employees and if they keep or hire employees, will be the appropriate ones. To send managers from UK to lead the hotels is not completely wrong, because they already know the philosophy of the organization but is unethical as for the previous employees of the hotels who will probably lose their jobs. Under The Human Rights and Equal Opportunity Commission Act 19 86 every employee must have the same opportunity for the job. If the management wishes to keep the ethical procedures, the best solution is to follow the recruitment procedures as for the new staff and interview the previous ones and after the selection of the best qualified persons to send them for a short period to UK to work in the belonging hotels. With this process the new employees will be introduced to the organizations philosophy and policies which will assist after to a better communication with the managers from UK. This approach will also help the managers to maintain confidence and trust among the new employees. The management has also to consider and to prevent some other ethical and legal issues that might arise. Such issues are: -Sex discrimination which anyone can face in the workplace should be prevented. Management in recruitment procedures should be free of prejudice and discrimination because all have the same human rights and opportunities. -Racial  harassment is a very common unethical issue in the workplace and has to do with any verbal or physical act which is based on a persons color, physical characteristics, country of origin and nationality. Management should not influenced from all these and should treat to all the candidates equal. -The hiring, training or promoting candidates based on favoritism should be prevented because friendships and relatives are the ones who cause managers the most problems. -Equity and Justice: employees should be treated fairly from the management and not abused or exploited. Justice is concerned with preventing the abuse of power. -Respect for People: employees should be treated within the workplace as individuals with rights to be pleased and defended. Respect empowers others to assert their rights and to attain their potential. The Code of Conduct is based on ethics, values and behaviors outlined in the Code of Ethics which consists of policies, rules that identify the specific actions or procedures appropriate to employees for a range of specific ethical issues. The objectives of the Code are to: assist staff in dealing with ethical issues in ways that reflect the values and standards, provide staff with guidance in ethically unclear situations and encourage staff to do the right think. Appraise the value of the selection interview and the interview techniques. The purpose of interview provides the opportunity for two-way communication and interaction to determine fit between candidate and employer. By the interview the first impression is made and the impression is based on personal appearance, articulation, eye contact, personality and handshake. Interviews are a vital element of the recruitment process for almost all the organizations. Their principle is to give the selector an opportunity to assess the candidates and to reveal their abilities and personality. The interview gives the employer the opportunity to assess them and to make sure that the organization and the job are right for the candidate. Interview structure improves the reliability and validity of the selection interview and entails standardization of processes, including question selection and response evaluation. The selection process for the majority of organizations follows a common subject: Application and CVs are received and candidates are short-listed and invited for interview. The interview format can vary and may contain an assessment centre or tests. Some companies are satisfied after one interview, while others will want to recollect additional shortlist of applicants for more. In case that the interview is successful at the final stage, an official job offer is sent to candidate, the interview format is usually determined by the nature of the company, but there are various standard formats. Employers can avoid hiring mistakes by spending a little more time preparing for the interview in advance. The process of selecting the correct person for the right position through an interview should be followed by several standardized procedures: -Pre interview preparation is the first step and concerns the preparation of the interviewer as for the job requirements and what are the required skills for the position. The interviewer should also have company information available for the candidates and detailed information about the candidates. Review applications in advance to be familiar with the applicants background and to recognize gaps in the information or areas which need special attention. Applications include personal data such as: age, family status etc. and candidates qualifications such as: experiences, languages, diplomas etc. -During the interview, the interviewer has the first contact with the candidate and makes the first impression. He should give details for the organization, and give a general description of the job. At this point, the candidate should have enough information to make a opening determination as to whether he/she is interested in the job. Throughout the interview, the interviewer ask questions that are broad, open-ended, objective, job-related, clear, direct, , meaningful, understood and related to gather as more information from the candidate as possible. He should use questions to force the applicant to tell him what he needs to know to compare the applicant to his ideal applicant profile. Ask for examples whenever appropriate. The interviewer should be open and honest and tell the candidate what to expect in the hiring process. The interviewer should tell to the candidates what the companys expectations are as for the duties, experience expected, career advancement etc and show them where they would fit into the company. -The next step for the interviewer is to insure that a common ground have concluded with the candidate. Ask the candidate if he/she has any questions and at the end of the interview be friendly and honest and inform him/her if you are interested and give special attention to not give false encouragement. After the interview the interviewer should take time to add details to his notes while the information is still fresh and to prepare the information for the next candidate. -The last step is to discuss the candidates reactions and answers and rate them as potential employees. The interviewer should make a decision by comparing applicants to his ideal applicant profile. Communicate your decision to the selected applicant as well as to those who are not selected. By following this process, the interviewer can decide more easily which of the candidates are the most suitable for the job. There are several techniques that the interviewer can use which will help him to get as more information as possible: Closed questions: A closed question can be answered with a single word or a short phrase as well as with a yes or no. closed questions gives you fact, they are easy and quick to answer and help the interviewer to keep the control of the conversation. For example: How old are you?, Do you have previous experience in the hospitality industry?, Where do you live? Open questions: An open question is probable to receive a long answer. These questions require from a person to reflect on upon, a particular point in his own way. For example: What you did in your last position?, Why I should consider you for this position? Probing questions: ask for more detailed and specific explanations of a candidates work experience, knowledge, skills and competencies. Probing questions are, in essence, follow up questions that ask for further information, ask for the person expand on what she has said, or request the person to go deeper. Probing questions can be helpful in increasing understanding, while a great number of people need to be encouraged to go beyond what they have said to help someone understand their deeper feelings and opinions. Play-back questions: checks if the interviewers have understood of what a candidate has said by playing back. Hypothetical questions: putting a hypothetical situation to candidates and asking how they would response. Explain the advantages and disadvantages of interview. Advantages of an interview: Top Management Middle Management Office / Administrative -The interview enables a face-to-face meet to take place which will help the interviewer to make an evaluation of how the candidate might fit in the organization and what they would be like to work with. -The interviewer can describe the job and the organization by providing the candidate more detailed information. -Give the interviewer the opportunity to ask probing questions about the candidates experience, knowledge, skills and competencies. -Provide the candidates the opportunity to ask his/her questions about the position and clarify issues. -More than one interviewer can assess the candidates, if it is necessary. Disadvantages of an interview: -The interview process relies on the skills and the abilities of the interviewer to make the interview successful but usually many people do not have the abilities needed for interviewing. -There is a possibility that the interviewer will not succeed to assess directly competence in carrying out the several tasks that are included for the position. -After the end of the interview, the interviewer can be lead to subjective judgments. Assess the different interview types. There are various different types of interviews. An interviewer should has a familiarity with one or more of the situations described below. When an interviewer schedules an interview, he should try to get as much information about the candidate who will be meeting. It is unusual to have only one interview prior to a job offer. Most employers will evaluate a candidate many times to be sure that the possible employee will fit into the company culture. Face-to-Face Interview à ¢Ã¢â€š ¬Ã‚ ¢ The mass of the interviews are face-to-face and the most common is a one-on-one conversation. à ¢Ã¢â€š ¬Ã‚ ¢ The candidate should pay great attention to the person who asking questions and keep an eye contact, listen and respond once a question has been asked. à ¢Ã¢â€š ¬Ã‚ ¢ The candidate should aim to establish a link with the interviewer and show him that his/her qualifications will help the company. Panel/Committee Interview à ¢Ã¢â€š ¬Ã‚ ¢ In this type of interview is more than one interviewer may perform in this part of the selection process. This is the chance for the candidate to put his/her presentation skills on display. à ¢Ã¢â€š ¬Ã‚ ¢ In these pre designed standard questions ranging overall aspects of the job are asked. They focus directly on elements of person specification. à ¢Ã¢â€š ¬Ã‚ ¢ The candidate the time that his is responding to a question should keep eye contact with the panel member who asked the question. Behavioral Interview à ¢Ã¢â€š ¬Ã‚ ¢ This type of interview concerns the past behavior of the candidate and is the best predictor of your future actions. These kinds of questions may be asked in any interview: panel, one-on-one, telephone. à ¢Ã¢â€š ¬Ã‚ ¢ If the interviewer asks behavior-oriented questions, he is no longer asking hypothetical questions but the behavior-oriented questions must be answered based on facts. à ¢Ã¢â€š ¬Ã‚ ¢ Through a behavioral question, the interviewer is looking for results, not just an activity list. He is listening for names, places, dates, results and especially what the candidates role was in achieving that result. Case Interview à ¢Ã¢â€š ¬Ã‚ ¢ In several interviews the interviewer may ask from the candidate to demonstrate his problem-solving skills. The interviewer will outline a situation or provide the candidate with a case study and ask him to prepare a plan that deals with the problem. à ¢Ã¢â€š ¬Ã‚ ¢ The interviewers are looking for how the candidate applies his knowledge and skills to a real-life situation. à ¢Ã¢â€š ¬Ã‚ ¢ The candidate before answer the case interview question should prepare himself to ask the interviewer many questions for informational purposes à ¢Ã¢â€š ¬Ã‚ ¢ The more the candidate is able to analyze and divide the case study, the more he will likely impress his interviewer. Telephone Interview à ¢Ã¢â€š ¬Ã‚ ¢ Many companies conduct interviews through telephone to narrow a field of candidates. Telephone interviews may also be used as a pre- interview for candidates who live far away from the job site. à ¢Ã¢â€š ¬Ã‚ ¢ In this kind of interview is important for the candidate to treat as he/she would in a face-to-face connection. à ¢Ã¢â€š ¬Ã‚ ¢ The candidate should be focused on the conversation and listen to the questions carefully before he answers. Group Interview à ¢Ã¢â€š ¬Ã‚ ¢ A group interview is planned to expose the leadership potential of prospective managers and employees who will be dealing with customers. à ¢Ã¢â€š ¬Ã‚ ¢ The preferred applicants are gathered together in an informal, discussion type interview. A topic is introduced and the interviewer will start off the discussion. à ¢Ã¢â€š ¬Ã‚ ¢ The aim of the group interview is to see how the candidate interact with others and how he/she use his/her knowledge to influence others. Lunch/Dinner Interview à ¢Ã¢â€š ¬Ã‚ ¢ The same rules apply at a meal as those in an office. à ¢Ã¢â€š ¬Ã‚ ¢ The candidates can use the interview to develop common ground with his/her interviewer. Stress Interview à ¢Ã¢â€š ¬Ã‚ ¢ In this interview the interviewer deliberately creates stress to see how an applicant operates in stress situation. The stress interview is usually an on purpose attempt to see how the candidate handles him/herself under pressure. à ¢Ã¢â€š ¬Ã‚ ¢ The interviewer may be argumentative or sarcastic, or may keep you waiting. The candidate must calmly answer each question. à ¢Ã¢â€š ¬Ã‚ ¢ The interviewer may also to stay silent during the questioning and this may be an attempt to unnerve the candidate.

Relationship Between Business and IT Strategies at PRASA

Relationship Between Business and IT Strategies at PRASA 1 Introduction 4.1 BACKGROUND TO THE RESEARCH PROBLEM For almost three decades practitioners, academics, consultants, and research organizations have identified â€Å"attaining alignment between IT and business† as a pervasive problem, Luftman and Kempaiah (2007). Gutierrez,Nawazish,Orozco,Serrano and Yazdouni (2007) add that despite the wide acceptance of strategic alignment (the strategic use of Information Technology), there is no consensus on how to achieve alignment and with few references that detail the process, there is no common agreement on the term alignment. Terminology such as linkage Henderson and Venkatraman (1993) harmony, integrated, linked, and synchronocity Luftman and Kempaiah (2007) have been suggested and used. Steiner (1979b) points out that there no consensus as to the meaning of strategy in the business world. An example of the definitions which he uses include the following Steiner (1979a): Strategy is that what executives do they that empower the organization. Strategy is the direction the organization takes which is aligned with it’s purposes and missions. Strategy consists of the important activities necessary to realize these directions. Strategy answers the question: What should the organization be doing to achieve success? Strategy answers the question: What are the means to end? Mintzberg (1994), says that people use strategy in several different ways, the most common being: Strategy is a plan, a how, a means of getting from here to there. Strategy is a pattern in actions over time; for example, a company that regularly markets very expensive products is using a high end strategy. Strategy is perspective, that is, vision and direction. Strategy is position; that is, it reflects decisions to offer particular products or services in particular markets. Porter (1998) states that strategy positioning attempts to achieve sustainable competitive advantage by preserving what is distinctive about a company and that strategy, is the creation of a unique and valuable position, involving a different set of activities, requires that trade-offs be made in competing, to chose what not to do and involves creating â€Å"fit† among a company’s activities. Fit has to do with the ways a company’s activities interact and reinforce one another. To improve the strategic management of information technology, Henderson and Venkatraman (1993), developed a framework which they called the Strategic Alignment Model (SAM). This model was defined in terms of four fundamental domains of strategic choice namely business strategy, information technology strategy, organizational infrastructure and processes and information technology infrastructure and processes. The model is defined in terms of two fundamental characteristics of strategic management namely the strategic fit (the interrelationship between external and internal components) and functional integration (integration between business and functional domains). Luftman (2001) improved on the Henderson and Venkatraman (1993) SAM model by developing the Strategic Alignment Maturity Model (SAMM). The model measures IT–business alignment maturity. Six interrelated components for assessing alignment maturity are identified. These are communications, value, governance, partnership, scope and architecture and skills. The scores an organization achieves for these six components of maturity are then compared to a five-level maturity model to denote the organization IT-business alignment maturity Luftman (2001).The levels range from level one to level five where level five is the highest level of maturity. A higher alignment maturity correlates with higher firm performance measures Luftman (2001). Tying performance measures to strategic goals is a critical step Fonvielle and Carr (2001). A tool to measure performance and to align strategic goals within organisations is the Balanced Scorecard (BSC). The BSC was developed by Kaplan and Norton (1992) to overcome the business’s reliance on financial measures. They contend that reliance on only financial measures does not give a complete overview of the organisations measures. The BSC provided a framework to look at strategy, used for value creation from four different perspectives these being financial, customer, internal business process and innovation and learning Kaplan and Norton (1992).One of the principles recommended by the authors, is that for an organization to be focused on strategy, there needs to be alignment among departments to the strategy of the organisation. The alignment sequence recommended by Kaplan and Norton (2006) starts when the corporate headquarters articulates enterprise value proposition that wil l create synergies among operating units, support units and external partners. This sequence includes aligning IT strategy with the business strategy. 4.1 STATEMENT OF RESEARCH PROBLEM Business and IT strategies at PRASA need to be better aligned. 4.1 What is passenger rail agency of south africa (PRASA)? Appendix A, gives a comprehensive overview of the historical context and the introduction of PRASA taken from the companie’s business plan. Following is a summary of the key issues PRASA was created by Government to advance its agenda for the transformation of the public transport system into a vibrant, efficient one, As part of its strategy, PRASA (2009), to secure the future of its business, PRASA will focus its resources and energies during the current medium term expenditure framework (METF) on the following three Strategic Priorities: Service Excellence within Metrorail, Shosholoza Meyl and Autopax Property and Asset Development, and Technology Upgrade or Modernization of its key transport systems The key objectives identified by Government in addressing the challenges of passenger rail transport moving forward PRASA (2009) are as follows: Sustainable passenger rail service delivery; Improved performance of passenger rail services in terms of the quality and levels of services to passengers; Improved efficiency in the delivery of services; Improved effectiveness of asset management; Effective targeting of subsidies to achieve desired socio-economic transport objectives; Improved oversight by Government; and Improved accountability to the users. 4.1 Why prasa? PASSENGER TRANSPORT CHANGE IMPERATIVES 1..1 The Public Transport Challenge After many years of neglect, the existing commuter transport system, inherited from the apartheid past, has reached saturation levels and is unable to satisfy passenger demands while its infrastructure is not able to meet the requirements of a rapidly changing and modern society. The dysfunctional institutional arrangements have meant poor accountability in the provision of public transport services, which were found to be largely disempowering. Government’s socio-economic and transport policies could not be supported adequately by such institutional arrangements. The country is seeking to move away from the current commuter-based transport provision into a more integrated public transport system that meets growing and changing passenger demands in an efficient, effective and sustainable manner. The twin challenges for public transport is to simultaneously transform through meaningful integration whilst at the same time enhancing capacity through upgrading and modernization to meet long-term need PRASA (2009). 1..2 Inadequate Passenger Service Provision Passenger rail in South Africa faces many challenges as a result of a long history of inadequate investment in rail rolling stock, infrastructure and operations as well as the loss of appropriate managerial and technical (engineering) skills within the industry. The shortage of such critical skills has a direct negative impact on the delivery of services. In the urbanising metropolitan areas the provision of new rail corridors has not kept pace with the rapidly changing urban landscape resulting in limited coverage in key areas of urban expansion with the consequential loss of significant market share. Over time, commuter rail services have continued to fail to respond adequately to changing passenger demands PRASA (2009). 1..3 Customer-Centric Delivery A dynamic and customer-centric public transport system is required where passengers contribute to and shape the service delivery agenda. The need for a Passenger or Quality Charter and the emergence of strong, vibrant structures championing both the interests of passengers and public transport transformation are vital to the development of a public transport system that will effectively respond to the travelling needs of passengers. The past few years has seen the emergence of vibrant, community-based structures championing public transport transformation and demanding quality services from Government and transport service providers. This movement seems to be growing and shows the determination of South Africans to participate in the construction of a transport system that will effectively respond to their demands PRASA (2009). 4.1 PRASA Vision, Mission Values Vision A provider of integrated public transport solutions for improved mobility Two fundamental principles underpin the vision:- Integration – PRASA should facilitate integrating individuals and communities, enabling a better quality of life through access to socioeconomic opportunities Mobility Solutions – PRASA should connect individuals and communities through the provision of public transport solutions that are founded on an integrated network of mobility routes PRASA (2009) Mission Sustainable Public Transport Solutions through Service Excellence, Innovation and Modal Integration PRASA (n.d.) The mission reflects four key intentions:- Service excellence – superior performance that is safe, reliable and affordable, that makes a lasting impression, and builds brand loyalty – both internally (employees) and externally (customers) – that adds benefit to the passenger. Sustainability a focus on sustainable development in business that considers not just the financial ‘bottom line’ of prosperity and profit, but also the other ‘bottom lines’ of environmental quality and social equity. Mobility solutions – reframing the basis of business delivery, favouring innovation, integration and partnerships Integration – safe, seamless dignified travel experiences across all modes of public transport, PRASA (n.d.) Values The values that will guide PRASA, which will underpin the performance ethos of the organization derived from and are guided by the fundamental and progressive human values of the Constitution of the Republic of South Africa:- Service Excellence, Participation, Integrity, Fairness and Innovation, PRASA (2009) 4.1 OPPORTUNITY FOR Passenger Services 1..1 Commuter Rail Services The provision of efficient and affordable public passenger transport services is integral to Government’s drive to create employment opportunities, stimulate economic development and reduce levels of poverty. Enhanced mobility will facilitate greater access to socio-economic opportunities for the urban and rural poor whilst contributing to an efficient transport system to the benefit of all South Africans – highlighting the need for a vibrant public passenger transport network to support sustainable growth and development PRASA (2009). Commuter rail has the potential to be the most efficient, affordable and safe mode of travel. It plays a significant role in key Metropolitan areas such as Cape Town and has the potential to become an important public transport player in all metropolitan areas, significantly contributing to an efficient and reliable public transport system in these areas. Despite the acknowledged increase in the growth of car-ownership and usage, public transport and walking continue to dominate the mobility needs of the majority of South Africans and this is likely to continue for the next decade. Metropolitan areas in South Africa are experiencing rapid urbanization. Rail is in a unique position to facilitate greater integration between land use planning and transport infrastructure provision, and providing security, to private and public sector investment, of stable long-term public transport provision. This is vital to creating sustainable communities where peoples access to economic and social o pportunities is improved. In this context, railway lines need to be positioned, located, aligned with evolving spatial developments and formalised within the statutory planning processes undertaken primarily by local government. The creation of PRASA and the integration of rail and road-based transport services will, over time, provide the user with public transport choices – moving away from a market of captive users to one where dignified travel choice is a real option PRASA (2009). 1..2 Inter-City / Regional Passenger Services Historically, long distance rail and road based services have not received the attention required to make them demand responsive in key market areas including migrant workers, students, tourists and occasional travellers. The Department of Transport’s Public Transport Strategy Action Plan notes that: There is a significant potential for the growth in migrant worker long distance public transport provision. The dominant generators of migrant movement are Gauteng and KZN The increase in tourism provides opportunities for segmenting the market that build upon the strengths of both long distance rail and coach operations. Rural areas in South Africa are undergoing a process of economic and social restructuring with a shift in emphasis towards rural trade and agro-processing. These factors reinforce the need for a public transport service sector that responds to the emerging needs of these rural / regional development nodes since transport links between the rural trade areas and t he rural regions (hinterlands) remains unreliable, rendering access to services and emerging economic opportunities extremely difficult. This lack of access will continue to trap many in the poverty cycle. Government’s decision to consolidate passenger rail entities and road-based long distance bus services into a single entity, PRASA, reporting to the Department of Transport are underpinned by a number of key drivers. The recognition by Government that rail consolidation was required to deal with the under-performance of rail passenger services as well as the historical under-investment in the passenger rail business. Institutional arrangements did not promote efficiency and accountability and significant change was required to overcome the inherent institutional dysfunctions that had been created. Confusion existed between the contractor and regulatory functions implicitly embodied in the SARCC/Transnet relationship PRASA (2009). The critical need for sustainable funding to reverse the decline in commuter rail levels of service being experienced by commuters has been identified. This funding profile was captured in the National Rail Plan, which was accepted by Cabinet in December 2006, where the funding and investment requirements were identified for passenger rail over the following ten years PRASA (2009). 4.1 PRASA Objective PRASA (n.d.) primary objective is: To ensure that at the request of the Department of Transport, rail commuter services are provided within, to and from the Republic in the public interest; and To provide, in consultation with the Department of Transport, for long haul passenger rail and bus services within, to and from the Republic in terms of the principles set out in section 4 of the National Land Transport Transition Act, 2000 (Act No.22 of 2000)†.. 4.1 Strategy of prasa PRASA (2009) objectives are supportive of the Board of Control’s (BOC) key performance areas as seen in figure 2 below Figure 2 Key Performance Area and Strategic Objectives 4.1 CHALLENGES FACING PRASA 1..1 Consolidation / Turnaround / Restructuring The sequential amalgamation, in quick succession, of the SARCC, Metrorail, Shosholoza Meyl and Autopax bring with it the normal challenges that are posed when merging disparate organizations in related but different operational arenas. A key driver in Government’s decision to consolidate these entities into a single delivery arm of the DOT was to effect operational and asset â€Å"turnaround† of what were acknowledged to be declining businesses, albeit, some with the potential for growth. Linked with both these processes is the need to internally restructure the various businesses to align them with the new mandate given to PRASA through the amendment to the Legal Succession Act that was promulgated on 23 December 2008 PRASA (2009). 1..2 Sustainable Funding The ability to provide the requisite level of funding (substantial) to address both the investment capital and rapidly expanding operational requirements to affect the mandate is fundamental to the successful performance of PRASA. The integrated passenger transport plan requirements will need to be developed. Fully motivated funding requirements, covering both operations and investment capital, in line with the 5-year financial plan requirements of the various Integrated Transport Plans (ITPs), will be developed to begin to align the funding requirements with statutory plan requirements. The approved funding base makes no provision for two key activities that need to be accommodated: The incorporation of Autopax, an operating company that is currently materially dependent upon Transnet Limited for funding to re-capitalize and sustain the business going forward. The acquisition of new rolling stock. Analysis has indicated that the rolling stock refurbishment and upgrading programs are not maintaining pace with the requirements to buy time before the inevitable purchasing of new fleet becomes unavoidable. While the profile reflects a rising trend in investment funding support, the allocation of these funds to the different asset classes (Rolling Stock Infrastructure) will need to be reviewed. A careful balance needs to be struck to ensure that the sustainability of the asset base is not compromised PRASA (2009). 1..3 Ageing Rolling Stock and Infrastructure PRASA (2009) reports that the prolonged under-investment in passenger rail of almost thirty years is manifestly experienced in the deterioration of the general rail asset i.e. Rolling Stock and Infrastructure (Signalling and telecommunications, electrical systems, perway). This has resulted in a situation where services are experiencing continued decline, primarily due to poor availability and reliability of rolling stock and ageing infrastructure. The lack of investment in the asset base has also had a negative impact in the skills base of the passenger rail industry over a period of time. For example, the average age profile of commuter coaches is 40 years and has been left behind by international advancements in rail technology over the past few decades. The life expectancy of railway rolling stock is of the order of 54 years. The railway industry norms are that the coaches will be upgraded at half life (27 years) and overhauled every 9 years, so as to ensure the structural and su b-systems integrity is not compromised by metal fatigue, age, wear and tear or environmental condition. Thirty-three percent (33%) of the commuter rail fleet is already above 36 years and therefore would be uneconomical to upgrade. 1..4 Human Capital Development Human capital development is generally understated and under-rated in supporting the development of an organization. It is a multi-faceted process that requires clear understanding to enable human capabilities to be built that will support the key performance drivers of the business and ultimately the business results that can be expected from that performance. The key challenge for PRASA is to formulate human capital development processes that facilitate and fast-track the appropriate human capital capabilities at all levels within the organization that will enable delivery on the key drivers of which, in the case of PRASA are : increased productivity (operational efficiencies), improved service quality (service excellence), customer focus and innovation in the provision of integrated public transport solutions The nature of the various operational divisions, while related and providing synergistic opportunities for service co-operation and delivery, are by their very nature, different business environments, each requiring a specific set of human capabilities to perform optimally. PRASA needs to provide guidance in the process framework that delivers this requirement PRASA (2009). 1..5 Change Management The finalisation of the PRASA consolidation process, the turnaround and restructuring necessitate that a number of parallel change management processes are undertaken. Numerous change management processes will be identified that are needed to combine the five organizations into a consolidated organization. The very ability of PRASA to ensure effective implementation of such processes becomes critical as is the capacity of the organization (including divisions and subsidiaries) to manage them successfully PRASA (2009). 1..6 Leadership Skills Development There is currently an acknowledged shortage of key skills as well as a lack of depth of skills in critical areas within the organization. For PRASA to meet the expanded mandate of supporting government’s socio-economic and transport objectives in both urban and rural contexts, the organization will need a focused approach to human capital development, on leadership development, talent management and the progressive training of a strong base of key skills that will lay the foundation for sustaining rail passenger transport sector PRASA (2009). 1..7 Rail Technology Development PRASA, of necessity, will need to become a technology based organization that blends best practice policies with intelligent asset management philosophies to leverage organisational productivity and efficiency gains to provide shareholder value. PRASA recognises that technology upgrade is critical to the modernisation of South Africa’s railways and is well aware that the capacity for technology upgrade may not be immediately available in South Africa or the African Continent as a whole. Technological obsolescence is a major factor that will inhibit PRASA from delivering on its mandate. A rail technical strategy that guides technological renewal, upgrading, replacement and development over the next 30 years is a critical requirement. The average age of the metropolitan rail commuter networks/system in South Africa ranges between 60 80 years and still supports 1940/50’s technology. The system in SA is showing serious age related condition decline with increasing systemic risks and technological obsolescence. Railway systems are designed for an extended economic life, but it is acknowledged that the current ad hoc investment flows into the ageing system in South Africa are not productive in terms of future demand, operational performance requirements and escalating maintenance costs. Global technology advancement in rail has moved beyond the limited application of heavy rail, regional and long distance passenger rail. Various new rail based technologies of alternative applications have evolved globally to ensure the competitiveness and attractiveness of rail solutions. If South Africa is serious about ensuring environmentally friendly and energy efficient transportation for its cities to counter growth in private vehicle travel, congestion and spiralling cost of fossil fuels, a selective conversion of appropriate new and improved rail based and mass transit technologies needs to be evaluated, introduced, and established in South Africa ensuring that these take their place in the hierarchy of public transport service provision. The technological needs of PRASA over the next 30 years need to be clearly articulated and incorporated into PRASA’s long-term planning if passenger rail is to be sustained over the longer-term. The development of a rail technology strategy, together with the appropriate migration requirements over this period will assist in guiding decision-making in much critical technology upgrade or replacement areas within the organisation. The phased implementation of the strategy will be captured in each of the Business Plans roll-outs over time PRASA (2009). 4.1 RESEARCH AIM, QUESTION, SUB-QUESTIONS AND OBJECTIVES Research Aim The aim of this research is to understand to what extent alignment between Business and IT strategies exists, at the Passenger Rail Agency of South Africa (PRASA). Research Questions The research question derived from the problem statement is What can PRASA do to improve business and IT strategies, alignment? The sub questions to answer the main question are: What are business and IT strategies? What is alignment between business and IT strategies? What factors contribute to an alignment gap between business and IT strategies? What factors contributes to an improved alignment between business and IT strategies? Objectives of the research Based on the sub questions the objectives of the research are to 1. Analyse the Business’s and IT strategy 2. Carry out a literature review on the alignment between Business and IT strategies. 3. Analyse the factors that contribute towards Alignment Gap 4. a. Establish strategic alignment best practice. b. Formulate a methodology for aligning Business and IT strategies. c. Propose recommendations to improve PRASA’s Business and IT strategies alignment. 4.1 CURRENT STATUS OF THE RESEARCH AREA The literature review will be based on the research into alignment of business and IT strategies. There is a plethora of research available on the alignment of business and IT strategies. Chan and Reich (2007) have carried out comprehensive research on this topic. 4.1 Business and IT strategies 1..1 Business Strategies Croteau and Bergeron (2001) define business strategy as â€Å"the outcomes of decisions made to guide an organisation with respect to the environment, structure and processes that influence it’s organisational performance†. Hambrick (1980) states that business strategies may be textual, multivariate or typological. Henderson and Venkatraman (1993) architects of the SAM model, view strategy as involving both strategy formulation (decisions pertaining to competitive, product market choices) and strategy implementation (choices that pertain to the structure and capabilities of the firm to execute it’s product market choices).The SAM model presents two business strategy perspectives where business strategy is the driver namely strategic execution, and technology transformation. figure 3 presents the key attributes of these perspectives. Figure 3 Attributes of Business Strategy perspectives (Henderson Venkatraman 1993) One of the six components of the SAMM Luftman and Kempaiah (2007), is partnership which includes IT’s role in defining the business’s strategies. Both of these models (SAM and SAMM) are about aligning business and IT strategies and can be criticised because it does not define what business strategy is. Kay (1996) says that there is much debate on the substance but that

A Massive Project For The Benefit Of Mankind: A Look At The Human Geno :: essays research papers fc

A Massive Project for the Benefit of Mankind: A Look at the Human Genome Project Scientists are taking medical technology to new heights as they race to map all of the genes, nearly 100,000, in the 23 chromosomes of the human body. Along the way, they hope to understand the basis of, and maybe even develop methods of treating certain genetic diseases, such as Alzheimer’s and Muscular Dystrophy. They plan to do this by identifying the DNA sequence of an abnormal gene in which a disease originates and comparing it with the data of a normal or healthy gene. The entire research project is entitled "The Human Genome Project." "The Human Genome Project" is a large scale project being conducted by more than 200 laboratories, with even more researchers and labs having joined in. Most of the labs and researchers are located in France and the United States. The project started in 1990 and was slated to take 15 years and cost $3 billion in U.S. money for the entire project coming to roughly $200 million per year. Federal funding for the project is nearly 60% of the annual need. This has created some funding problems for the project. There also have been technological advances and discoveries that have helped to speed up the project. This automation may help to reduce the cost and help the project to meet its objectives ahead of schedule. The project was estimated to have detailed maps of all of the chromosomes and know the location of most of the human Genes by 1996. Researchers have successfully located the gene and DNA sequence for Huntington’s Disease on Chromosome 4 and have created a genetic test to determine if a person carries this gene. "The child of a person with Huntington's has a 50% chance of inheriting the gene, which inevitably leads to the disease." Once an individual acquires the gene, it is only a matter of time before they acquire the disease. Because the medical costs of treating such persons in terminal illnesses are extremely high, insurance companies who want to stay in business see this genetic test, and others like it, as an opportunity to screen prospective clients for the probability of such diseases. Some people feel that this information gives insurance companies unfair advantage over those covered by medical insurance and point out that release of genetic information to insurance companies puts a severe disadvantage on the person who is screened, as well as violates the patients right to privacy. If this genetic information is not safegua rded as confidential for the patient’s and doctor’s knowledge alone, then the patient can be labeled as undesirable and