Change Management Assignment

Why did the managers at the two organizations have different ethical stances towards their customers? (Hint go to J&J’s website and look at its Code of Ethics)? The key reason of two organizations having different ethical stances towards their customers appears to be that J&J’s managers believed in their company’s ethical values, so that when confronted with an ethical dilemma as in 1982, they consistently followed the credo’s rules when making business decisions. Johnson & Johnson moved immediately to protect the public even though there was little chance that any other supplies of Tylenol were contaminated and the fact that their product was defective and dangerous. At DC in contrast, managers had been just â€Å"going through the motions. † When push came to shove, they protected their own interests and those of their companies in illegal ways. Dow Corning’s managers postponed action and, to safeguard the profits of their company, but they paid the price. Within months of its decision to pull Tylenol from store shelves, however, J&J regained its status as leader in the painkiller market and has since increased its market share because of its enhanced reputation for being a highly ethical company. The behavior of Dow Corning (DC) managers seemed out of character to many people. They had widely publicized and well-developed internal ethics rules that were supposed to reign in and prevent unethical behavior. When confronted with a crisis, their ethics systems did not prevent either company’s managers behaving unethically and illegally. Johnson and Johnson (J&J) also had a system of ethical rules in place. At its center is a credo describing its ethical stance toward customers, employees, and other groups. Outline a series of steps Dow Corning’s directors and managers should have taken to have prevented this problem? Dow Corning’s directors and managers should have taken series of following steps to have prevented this problem: * They should examine the nature of ethics and the source of ethical problems. * They should have had some strong internal ethical system in place to help guide them in making decisions. Had they had a system like J&J, this would have never happened. Dow Corning’s directors and managers should have immediately moved to protect the public / stakeholder interest * They should define rules or guidelines that companies can use to decide whether a specific business decision is ethical or unethical These rules include utilitarian, moral rights, justice, and practical rules, * They should examine the legal environment of business and describe the many kinds of laws, rules and regulations that must be followed, both at home and abroad, if a company is to do business in an honest and ethical way since ethics plays in shaping the practice of business and the life of a people, society, and nation.

A Review of Margaret Wente’s “Inside the Entitlement Generation” Essay

Margaret Wente’s Globe and Mail article on the existence and characteristics of the entitlement generation in Canada is both opinionated and thought provoking. The author strongly supports that the entitlement mindset is quite prevalent in Canada’s universities, has been nurtured by its preceding generation and has led to students’ unrealistic work expectations. Although Wente effectively communicates her opinions regarding the entitlement generation, her arguments are compromised by poor use of appeal to authority and a polarized approach to the topic. Those who have stepped onto one of Canada’s many university campuses may have noticed the student mentality encompassed by its definition. Wente credits Dr. Ken Coates, a professor of history and former Dean at the University of Waterloo, with elucidating the mindset of the entitlement generation— â€Å"the kids who’ve always been told they’re smart, and never pushed too hard† (par. 3). With the assistance of Dr. Coates’ expertise, the author argues that the development and existence of this generation of students has led to their unrealistic work expectations and disappointment post-graduation. She contends that this mentality is derived from student disinterest and laziness, yet nurtured by a former generation. Wente makes her opinion on the topic of the entitlement generation very clear by using a firm tone, which may be misinterpreted as condescending by the wrong audience. She makes implications regarding the entitlement generation and t heir work ethic. Applying these implications to a sizeable population is Wente’s fundamental flaw. Moreover, she bases many of her arguments on the shared opinion of Dr. Coates and does not deviate from this source. Implications that apply to large populations and the use of only a single source leads to generalizations that consequently contribute to error in appeal. These characteristics of Wente’s writing make many of her claims questionable and open to criticism, even though they may be valid arguments. The author uses Dr. Coates’ apparent expertise on the entitlement generation to support her arguments. She reassures her reader that Dr. Coates is an expert on the entitlement generation by indicating that his book, Campus Confidential is â€Å"a guide to the mindset of the entitlement generation† (par. 3). Wente presents Dr. Coates’ opinions as if they were her own, demonstrating her concurrence. Her agreement can be seen in her support of Dr. Coates’ statement that â€Å"[students] bring assignments in late and think that [professors] will mark them without penalty† (par. 4). Wente claims that this attitude is predictable because â€Å"that’s the way it’s been all their lives† (par. 5). Wente’s editorial is riddled with this type of accord, which may be criticized by the reader. The author only introduces the audience to Dr. Coates who is assumed to be the expert-on-the-topic and lacks an indication that there is adequate agreement among other experts. Additionally, there is no mention of the opinions held by Dr. Coates’ students regarding his credibility and competence in his role as a professor. It is possible that his opinion of the students he has encountered during his career has been shaped by their attitude towards his teaching ability, popularity or subject of expertise. Finally, Wente adopts a polarized approach to the topic by implying that students are either a part of the entitlement generation or the top 15 to 20 per cent of their class (par. 10). Wente argues that only the top of the class, can realistically anticipate jobs with a starting annual salary that exceeds $50 000 (par. 11). She implies that the remaining students are encompassed by the definition of the entitlement generation and are considered both uninterested and lazy. Furthermore, the author suggests that only the entitlement generation expressed their desire for unrealistic work/life balance, vacation time and a starting annual in the recent survey of university students (par. 11). She fails to acknowledge the possibility of a group of students who do not achieve a GPA that reserves them a spot at the top of the class yet possess a genuine desire to learn and be challenged. These are the students who might â€Å"[devour] the works of Frantz Fanton, Karl Marx and Gloria Steinem† (par. 7), but may also be involved in extracurricular activities, which take time away from their studies. Dr. Coates and Wente, do not recognize important attributes that students gain from being involved in clubs, sports or organizations. This lack of consideration contributes to the polarized approach adopted by the author. Wente’s holds a firm opinion regarding the entitlement generation and their characteristics. Her article brings public attention to a common mindset of Canadian students, which may help to explain the unrealistic work expectations of the current generation. This information may help employers who draw from Canadian institutions hire candidates that will integrate well into their organization based on their attitude. Employers should be wary, though, of the information presented in Wente’s article as it adopts a polarized approach to the topic of the entitlement generation with poor use of authorities. Works Cited Prinsen, Jean. â€Å"Mind Wide Open: Critical Reading.† Kingston: Queen’s University, 2011. 1-6. Wente, Margaret. â€Å"Inside the Entitlement Generation.† Toronto: The Globe & Mail division of Bell Globemedia Publishing Inc., 17 September 2011. F9.

Explore the extent to which personality traits explain student preferences for specific learning approaches and teaching modalities

Review of the Literature 1.1 IntroductionTo learn more about education and to be able to improve the system to best provide for the individual needs of its learners, this study aims to investigate the link between an individual’s personality and their preferred learning style and teaching modality. There is a shortage of current research on how a student’s personality influences their learning style and preferred teaching modality. There is however, a large body of research that analyses the relationship between personality and learning. Curry (1983) describes learning as a future focused process that involves adaptation of constructs to bring about a change in an individual’s cognitive, practical, affective, social or moral skills which can be observable as a change in behaviour. The learning approach of an individual reflects the way in which they go about the process of learning with regard to their chosen setting, their internal goals, treatment of information, and desire to succeed. Understanding the motives for these individual differences in ways of learning and how this may apply to disparities in achievement has always been a concern for those studying educational practice. Teaching modalities refer to the way in which information is delivered to the student, and the learning environment that is created by the teacher. Higher Education employs several teaching modalities, including traditional lectures, small tutorial groups and one-to-one mentoring. Teaching modalities can vary as a product of the subject being taught, assessment criteria, and the individual preferences of lecturers, who may emphasise more theoretical or more practical approaches, or a combination of the two (Chamorro-Premuzic, Furnham & Lewis, 2007; Chamorro-Premuzic, Furnam, Dissout & Heaven, 2005). Despite this large scope for variability, there is little research into students’ preferences for different teaching modalities, especially into what factors contribute to these preferences. Fielder (1993) suggested that for the most effective teaching, a variety of approaches to teaching should be recruited in order to appeal to the different learning styles and personalities of the students. This hypothesis is supported by a study showing that a variety of teaching modalities was beneficial in engaging more individual learning styles (Dunn & Dunn, 1979). Whilst there has been debate surrounding whether there is a scientific basis for learning styles (Curry, 1983; Pashler et al., 2009), this evidence appears to highlight their relevance to teaching. The large variation in teaching style, learning approach and academic performance poses several questions. Does student personality and their preferred learning approach account for preference of certain teaching modalitiesWhat is the relationship between personality and an individual’s learning approachIt is therefore important to ask, are certain learning approaches suited to specific teaching modalities? The following hypotheses will be tested to investigate the relationship between student personality, preferred learning approach and preferred teaching modality (a) There is a significant relationship between certain personality characteristics and learning approaches. OR Is there a relationship between student personality traits and preferred learning approach? (b) There is a significant relationship between student personality traits and their preferred teaching modality. OR Is there a relationship between student personality traits and their preferred teaching modality? (c) There is a significant relationship between students’ preferred learning approaches and their preferences for teaching modalities OR Is there a relationship between students’ preferred learning approaches and their preferred teaching modality?1.2 Learning ApproachesRecent research has emphasised the important contribution of students’ learning approaches as determinants of how much knowledge they acquire, and how this translates into academic performance (Duff, 2003; Duff, Boyle, & Dunleavy, 2004). In a series of investigations, Biggs (1987, 1992) conceptualised three major learning approaches to classify the way students approach their learning. These were classified as ‘deep’ surface’ and ‘achieving’. A deep approach to learning is characterised by intrinsic motivation, engagement with subject matter, and the desire to learn more detail and thoroughly understand the subject. Deep learners will aim to make the content of a le sson meaningful and develop a thorough understanding. Conversely, students who adopt a surface approach to learning show less interest in the task, avoid any challenging activities, and aim to pass exams rather than enhance their understanding. These students tend to receive information superficially and memorise isolated and unrelated facts (Biggs & Tang, 2007). The achieving approach to learning is characterised by goal-oriented study strategies; based on competition between other students and ego enhancement. This approach lends to students that are motivated by the desire to achieve the top grades regardless of whether they find interest in the task at hand (Biggs, 1987; 1988). Biggs (1987) further divided each of the ‘deep’, ‘surface’ and ‘achieving’ approaches into ‘motive ‘ and ‘strategy’ as student goals may differ from the ways that these students go about achieving them. Previous research shows support for a direct relationship between student personality characteristics and student’s learning approaches (Zhang, 2003; Disth, 2003;). Zhang (2003) indicated that there are positive relationships between extraversion and surface learning, and between agreeableness and surface learning. This finding is supported in a study by Duff et al. (2004), who demonstrated a positive relationship between extraversion and a deep learning approach. Additionally, individuals with conscientious and open personalities have been shown desire to develop deep learning strategies (Zhang, 2003) and those showing strong openness to experience have shown less propensity to being surface learners. Literature has examined several models of learning styles and proposed criticisms of such tools that purport to measure learning styles. One such tool is the Kolb Experiential Learning Model (ELM) (Kolb, 1976). Kolb’s ELM has received criticism that it is neither valid nor reliable, which has detrimental implications for education that could be if employed (Bergsteiner, Avery & Neumann, 2010; Geiger, Boyle & Pinto, 1993). However, an alternative model, the Learning Styles Questionnaire (LSQ) (Honey & Mumford, 1992) has shown good test-retest reliability. Critics have suggested limitations to the LSQ, suggesting that the tool is useful for those students already interested in a particular career choice and would not be reliable enough for students attending non-vocational courses (Reynolds, 1997). Although there has been a debate as to the scientific basis of learning styles (Curry, 1983, Pashler et al., 2009), studies in the literature have provided irrefutable evidence that learning approaches and personality traits are strongly related. It may also be possible to infer that learning approaches have a distinctive value in explaining human behaviour, as learning is such a pervasive feature of being. This is supported by research from Busato, Prins, Elshout and Hamaker (2000), who assert that a learning styles inventory has a diagnostic value for identifying both strengths and weaknesses in the individual study behaviour of students. The present study will explore the extent to which personality and learning styles influence preferred teaching modalities.1.3 Personality The discovery of the â€Å"big five personality traits† can be interpreted as one of the major accomplishments of psychology in the twentieth century. These traits are agreeableness, conscientiousness, culture, emotional stability (versus neuroticism) and extraversion (Goldberg, 1990). Tokar (1995) proposed that the five-factor model is the one of the most â€Å"prominent and heuristic models of personality structure†. Several studies support Tokar’s view finding that the personality traits of the big five model accounts for a large amount of the variability in personality (Goldberg, 1993; Taylor & McDonald, 1999). McCrae and Costa (1995a) acknowledge that personality has many other dimensions, proposing their ‘Model of Person,’ which uses the term ‘characteristic adaptation’ to explain personality traits that are not fundamental characteristics described by the big factor five. These characteristics adaptations are proposed to develop over time and are influenced by environment and experience, yet mediated by personality traits. These include characteristics such as habits and attitudes. The learning approach construct may well be one of such characteristic adaptation. This has been emphasised by a large research base into personality and how it is influences by a variety of variables. These include intellectual satisfaction, student self-esteem, teachers’ perceptions of their control over their students, teaching effectiveness and course type (Lieberman, Stroup-Bernham, & Peel, 1998; McCaffrey, 1996; Parker, 1997; Rimmer, 1997). Additionally the role and influence of thinking styles has been addressed (Zhang & Huang, 2001; Zhang, 2000a; Zhang 2000b). This emphasises the many possible influences that may be at work on the development of one’s learning approach. The work of Costa & McCrae (1985-1992) has been successful in accommodating the big five personality constructs already assessed by Biggs (1987) and Eysenck (1975). They investigated the NEO Five-Factor Inventory and found that it was able to reliably assess the five personality dimensions. Other research into this inventory showed that it provided both good internal validity (Holden; 1994; Furnham 1996) and external validity using Holland’s (1994) Self Directed Search (Tokar & Swanson, 1995; Fuller, Holland & Johnson, 1999). This is all suggestive that these five predominant characteristics are reliable, replicable and representative of distinct traits. Neuroticism (N) at the extreme end of the scale may be characterised by anxiety nervousness and emotional lability. Individuals high on the N scale tend to have a pessimistic outlook and experience negative feelings that include emotional instability, guilt, embarrassment, and low self-esteem. The extraversion (E) subscale tends to be associated with the sociable and assertive individuals who prefer to work in a team with other people. Openness to Experience (O) is characterised by preference for variety, openness to change and variety, active imagination and independence of judgement. Additionally, people who score high on the O scale tend to be less conservative and traditional, however they also value and respect other people’s beliefs and conventions. Individuals scoring high on the culture (C) scale are characterised as being strong-willed, responsive and trustworthy with a strong sense of purpose. They also tend to be focused on task and goal outcome and are achievement oriented (Goldberg, 1990). Murray-Harvey (1994) observed that some descriptions of learning approaches are best formulated in terms of individual personality. For example, Shabolt (1978) demonstrated that those showing introverted or neurotic personality traits performed in conditions of structured teaching than when exposed to unstructured teaching methods. Eysenck (1978) also noted that personality and learning are closely linked, finding that extroverts tend to socialise during learning periods, are easily distracted from academic work and find concentration more difficult. Eysenck (1978) also postulated that those showing the neuroticism trait tend to let nerves interfere with their work. Furnham (1992) expanded this work, using the Eysenck Personality Questionnaire (EPQ) (Eysenck & Eysenck, 1975; 1991) and the Learning Styles Questionnaire (Honey & Mumford, 1992). Findings revealed that all elements of learning style were related to at least one of the elements of the personality traits, suggesting an ine xtricable link between the two. Furthering this hypothesis, Jackson and Lawtey-Jones (1996) found evidence for a reversal of the relationship, finding that whilst learning styles could be fully explained by personality scales, additionally, all learning styles correlated significantly with at least one personality trait. Furnham (1992) however, suggested that an individual’s learning approach may be interpreted as a derivative of personality rather than a separate entity. Findings from Zhang (2003) strongly suggest reason for further research into the field of personality and learning, finding that the two are related, but are individual constructs (reporting a quarter overlap), whereas Duff et. al. (2004) report an even greater relationship between learning approaches and personality traits. Duff (2004) and Zhang (2003) reported similar associations between openness and a deep approach to learning and neuroticism and surface approach. Extroverts were proposed to adopt a surface approach (Zhang, 2003), however Duff et al. (2004) found that agreeableness purported a surface approach. Furthering this, one may deduce that learning approaches act as indirect influences of personality traits on learning success. This may be highlighted by some personality traits being more strongly related to some learning approaches than others. These mediating factors may be identified through the consideration of how an individual may adapt their behaviour to suit their personality. For example, the surface approach, which accounts for a potential of failure and comparison with others, is related to neuroticism, and openness, which is associated with curiosity, imagination, and intellectual values, is related to the deep approach. Again, the personality trait of conscientiousness is reflected in the thorough nature of the deep approach. Other research highlights that it is a variety of personality traits that are associated with each learning approach and that there is not a single distinct contributing trait per approach (Diseth, 2003). There are arguments to suggest a dubious link between personality traits and learning approaches, with belief that it cannot be modelled (Zhang & Sternberg, 2006) due to the dubious nature of learning approaches. Despite this resistance, others authors have found evidence and argument that the learning approach concept is associated strongly with personality (Furnham, 1992; Gelade 2002; Jackson and Lawty-Jones, 1996). Messick (1994) proposed that learning approaches, when in conjunction with other influence and constructs can be seen to provide a metaphorical bridge between cognition and personality. This implies that learning approaches can act as mediators in bringing learning material to the individual and making it relevant. The connection between personality and learning approach has been under investigation for many years (Jung 1921; Myers & Briggs, 1962), which highlights the importance that has been placed on the understanding of this construct. Information on the relationship between personality and learning approaches allows for insight into the motivations and strategies that may be used by individuals when learning from a very young age. This will be especially useful for those personality traits that show persist throughout life, and will enable tailoring of education and learning advice appropriately. Additionally, it is important to know if personality and learning approaches are distinct psychological constructs and if so whether these can account for students’ teaching preferences. This is important as teaching methods are a strong influence on students’ learning and, in turn, their academic performance.Teaching ModalitiesFischer & Fischer (1979) define teaching style as a â€Å"pervasive way of approaching learners that might be consistent with several methods of teaching†. Conversely, Conti (1989) argued that teaching style is less pervasive, suggesting that it a construct of the personal char acteristics and qualities of the teacher and remains consistent in various situations. Knowles (1970) emphasised the importance of teaching style on the learning experience, asserting that â€Å"the behaviour of the teacher influences the character of the learning climate more than any other single factor†. Teaching itself has been suggested to consist of an instructor’s personal behaviour and the media used to transmit or retrieve data to or from the learner (Gregorc, 1982). The success of teaching style and the accomplishment this data transmission and retrieval may depend largely on matching. Matching is defined in terms of a compatibility of the environment and the interactive effects of the person (Hunt 1979). Early studies carried in the US such as that by Simon (1987) aimed to determine the relationship between students’ preferred learning approaches and their preferred teaching styles of college tutors. He administered the Cranfield Learning styles inventory to 4,000 students. His studies revealed that students indicated a preference for fewer lectures and a more hands on experience. Students showed preference for less faculty directed learning and more student independence, also preferring peer and instructor affiliation. Implications from this study were that instructors should decrease the number of lectures in favour for an increase direct experience where students become more involved in the course and programme direction. One of the strongest measures of learning success is academic achievement (Zimmerman, 1990), therefore the success of learning approaches and teaching modalities may be assessed through individual performance. Personality type has been shown to be a predictor of academic performance, with those with conscientious personality types achieving academic success across a range of subjects (Busato et al. 2000). Additionally, Lieberman, Stroup-Benham and Peel (1998) found that conscientiousness, agreeableness and extraversion correlated with intellectual satisfaction at medical school. When considering this relationship, it is important to consider the influences that personality type has on learning approach and how much this may contribute to the outcome of academic success. There have been many further studies relating to personality and academic achievement, which as discussed above is likely mediated through learning style, however there is an absence of research investigating the infl uence of teaching modalities. Current studies pertaining to academic achievement, learning approaches and teaching modalities found that students whose preferred learning approaches matched with their teacher’s preferred teaching modality received higher grades than those whose did not match (Mathews 1995; Rains, 1978; Hunter 1979). This highlights the importance of matching and concordance between student and teacher. This is supported by research suggesting that teaching modalities and students’ learning approaches interact to affect student learning (Saracho, 1990; Saracho & Spodek, 1994; Taylor, 1994; Wentura, 1985). The current research base would be greatly improved by further investigation into the relationship between learning approaches and students’ preferred teaching styles, especially how these are both mediated by the individual student’s personality. Recent research carried out by Furnham (1996) begins to explore this avenue. 221 students took the Neo Five-Factor Personality Inventory, were assessed on their learning approaches and also their preferred teaching modalities. Personality trait correlated with learning approach, and both of these individually had an effect on preference for certain teaching modalities. The study employed Marton and Saljo’s (1976) strategy to assess teaching modalities and covered students’ approaches, styles, motivations and study methods (Entwistle & Ramsden, 1983; Entwistle, 1997). Conclusions were that emotional stability, agreeableness, and deep learning approaches were associated with preference for interactive teaching and lessons. These personality traits were also negatively related learning via a surface approach. Findings showed that those with a preference for interactive teaching were likely to have a personality which combined emotional stability and agreeableness, and thes e students would prefer a deep learning approach. Bibliography Bergsteiner, H., Avery, G. C., & Neuman, R. (2010) Kolb’s experiential learning model: critique from a modelling perspective. Studies in Continuing Education, 32 (1), 29-46. Biggs, J. B. (1988) Assessing students approach to learning. Australian Psychologist, 23 (2), 197-206. Biggs, J. B. (1987) student approaches to learning and studying. Hawthorn. Australian Council for Educational research. Busato, V.V., Prins, F J., Elshout, J.J., & Haymaker, C. (2000) Intellectual ability, learning style, personality, achievement motivation and academic success of psychology students in higher education. Personality and Individual Differences, 29, 1057-1068. Chamorro-Premuzic, T.,Furnahm A., & Lewis, M. (2007)Personality and approaches to learning predict preferences for different teaching methods. Learning and individual differences, 17, 241-250. Chamorro-Premuzic, T., Furnham, A., Dissout, G., & Heaven. P. (2005) Personality and preference for academic assessment. A study with Australian university students. Learning and Individual Differences, 15 (4), 247-256. Conti, G. J. (1989) Assessing Teaching Style in Continuing Education. New Directions For Continuing Education. San Francisco: Jossey-Bass. Costa, P. T., Jr., & McCrae, R. R. (1992) Revised EO Personality Inventory (NEO-PI-R) and NEO Five-factor Inventory (NEO-FFI): Professional manual. Odessa, FL: Psychological Assessment Resources Inc., Costa, P.T., & McCrae, R.R. (1992) The NEO PI/EO-FFI manual. Odessa, FL: psychological Assessment Resources. Curry, L. (1983) An Organisation of learning styles theory and constructs. Paper presented at the annual meeting of the American Educational Research Association Quebec. Diseth, A. (2003) Personality and approaches to learning as predictors of academic achievement. European Journal of Psychology, 17, 143-155. Duff, A. (2004) The role of cognitive learning styles in accounting education. Journal of Accounting Education. 22, 29-52. Duff, A. (2003) Quality of Learning on a MBA programme. The Impact of approaches to learning on academic performance. Personality and Individual Differences. Educational psychology, 23 (2), 123-139. Duff, A. Boyle, E., & Dunleavy, J. F. 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J., & Minor, L. C. (2001). Characteristics of effective teachers: Perceptions of preservice teachers. Research in the Schools, 8, 45-57. Zhang, L. F. (2003) Does the big five predict learning approachesPersonality and Individual differences, 34, 1431-1445. Zhang, L. F. (2000a) University students’ learning approaches in three cultures: an investigation of the Bigg’s 3P model. The Journal of psychology, 134 (1), 37-55. Zhang, L. F. (2000b) are thinking styles and personalities relatedEducational Psychology, 20 (3), 271283. Zhang, L. F. & Steinberg, R. (2006) the nature of intellectual styles. London: Lawrence Erlbaum. Zhang, L. F. (2002) Thinking styles and the Big Five Personality Traits. Educational psychology, 22 (1), 17-31. Zimmerman, B. J. (1996) Enhancing student academic and health functioning: A self regulatory perspective. School Psychology Quarterly, 11 (1), 47.

Critically assess Wildavksy's theory of the two presidencies (one Essay

Critically assess Wildavksy's theory of the two presidencies (one foreign and one domestic) with reference to at least two spe - Essay Example However, in their domestic and foreign policies, they differed tremendously in goals, strategies, and focuses. Each president faced a different world: President Kennedy encountered a nation in the 1960s in which the United States had to defend itself against the threat of nuclear annihilation and the plague of Communism whereas President Obama faced a society in 2009 ravaged with its worst economic crisis and financial uncertainty in its history. In selecting the inaugural speeches of these two prominent presidents, this paper will analyze Wildavsky’s dual presidency theory, looking both at their domestic and foreign policies. Analysis of the Presidency of John F. Kennedy (1961) The 1960s ushered in an era in American history that would greatly challenge its citizens, who would question on every level the very foundations of the United States. It was a nation that had safeguarded its preeminent position since World War II as the greatest country in the world, which rivaled in power and influence the Union of Soviet Socialist Republics (U.S.S.R). The nation gladly embraced, with open arms and excited anticipation, the election of the energetic and charismatic Catholic senator as their new president, who made them feel young and vibrant and embodied the best hopes of Americans to maintain their national and international preeminence. President Kennedy sought for the United States to assume its global mission of being the leader of the free world and human rights (Whitehouse 2011). In his inaugural speech (See Appendix I) of 1961, President John F. Kennedy, who became the thirty-fifth president of the United States, articulated the fundamental issues and policies that his administration would address during his presidency. His speech embodied three major themes: 1). conciliatory tone, 2). emphasis on foreign issues/policies, 3). patriotic/nationalistic ideals. Analysis of the Inaugural Speech of President John F. Kennedy (1961) The first chief theme of the speech of President Kennedy reflected his conciliatory tone. Employing very effective rhetorical language, he uses conciliatory verbs, such as â€Å"pledge† (which he used over and over again) in his masterpiece. He cites the verb â€Å"pledge† eight times throughout his speech. What message is he trying to convey to his audience by constantly using the verb â€Å"pledge†? â€Å"Pledge† meant to commit strongly to a cause, place, ideal, nation, person, organization, etc. As a promise, vow, or oath, the verb, â€Å"pledge,† represented a word loaded with connotative and denotative meanings. Even the American anthem used the word â€Å"pledge† in its opening sentence, i.e. â€Å"we pledge allegiance to †¦Ã¢â‚¬  President Kennedy employs this rhetorical device to evoke- among his fellow Americans- the sentiments of nationalism and patriotism to the nation. Moreover, by expressing himself with the word â€Å"pledge,† he also shows his conciliatory tone in his speech. What is he pledging to his people? He pledges to maintain a free nation and world. He also employs other mild and conciliatory verbs throughout his speech, for instance, â€Å"ask,† â€Å"explore,† â€Å"begin,† â€Å"offer,† â€Å"formulate,† â€Å"seek,† â€Å"unite,† â€Å"join,† etc. (Kennedy, 1961, pp. 1-3). Why did President Kennedy adopt this conciliatory rhetorical devices

Reaction Paper On The Picture Wind Chime After Dream By Pierre Huyghe Essay

Reaction Paper On The Picture Wind Chime After Dream By Pierre Huyghe - Essay Example This picture was taken from a horizontal close-up position, thus clearly capturing the tree trunks at horizontal positions and the suspended chimes at an elevated angle. From the photographer’s angle, one can see only six of the 47 chimes mounted on the trees. In addition to the mentioned contents, the root section of each tree is covered with dried vegetation as opposed to the rest of the lawn, which is covered with green grass. Tree trunks and branches are dark and gray while the leaves are greenish-yellow in color. Behind the trees are five whitish structures of what appears to be concrete pillars. Having acknowledged the visible contents Pierre Huyghe’s picture, subsequent sections of this report analyze individual elements of art as they appear on the portrait. Keen focus on each element forms the basis of critical analysis in the art. It is through appraisal of individual components of the picture that one conclude on the success or failure to meet its aesthetic objectives. Basically, elements of art include line, texture, shape, and color among others. Each of these elements plays a significant role in creating unique attributes of a portrait. Variation of lines and texture allows an artist to manipulate contents in order to achieve the desired meaning. Variation of lines and shape enables the audience to develop concrete perceptions of space. On the other hand, manipulation of texture and color unearths aspect of time, which enhances the creation of intended theme by an artist.... Tree trunks and branches are dark and grey while the leaves are greenish-yellow in color. Behind the trees are five whitish structures of what appears to be concrete pillars. Having acknowledged the visible contents Pierre Huyghe’s picture, subsequent sections of this report analyze individual elements of art as they appear on the portrait. Keen focus on each element forms the basis of critical analysis in art. It is through appraisal of individual components of the picture that one conclude on the success or failure to meet its aesthetic objectives. Basically, elements of art include line, texture, shape and color among others. Each of these elements plays a significant role in creating unique attributes of a portrait. Variation of lines and texture allows an artist to manipulate contents in order to achieve a desired meaning. Variation of lines and shape enables audience to develop concrete perceptions of space. On the other hand, manipulation of texture and color unearths a spect of time, which enhances creation of intended theme by an artist. These elements must appear in every piece of artwork, whether it is two-dimensional or three-dimensional. In this regard, Pierre Huyghe’s picture incorporates some of these elements in depicting the wind chimed field. Elements of Art in the Picture Line and Shape Pierre Huyghe’s wind chime picture adopts a combination of both horizontal and vertical line techniques. These two techniques cumulatively facilitate creation of a path where viewers can perceive the aspects of space. Horizontal lines in the picture delineate those sections of the lawn and trees which extends into the adjacent space outside the camera’s coverage. In this context, Pierre

Martin Luther King Jr Essay Example | Topics and Well Written Essays - 250 words

Martin Luther King Jr - Essay Example Many union leaders were arrested while others died during protests (Brands et., p766). Despite, the hardship, their spirits never died. No matter how long it took, US now enjoys equal rights and even has a black president. The journey to womens rights has faced many challenges since independence (Brands et., p785). Before the 1990s, the number of top jobs women held was less than three percent of those available (Brands et., p786). However, by 1998, the number had increased tremendously. By 2009, the womens wages were established to be eighty percent of the earnings given to men (Brands et., p786). There has been a wide perception on the rights given to the gay community throughout US history. In the administration of Bill Clinton, it was an issue with the pentagon on the acceptance of the act in the military (Brands et., p789). However, in the arrival of the new century, the Supreme Court in 2000 ruled that all rights should be given to all civil unions. Presently gay unions receive a continuous acceptance in several parts of the

Marketing Orientation in Telecommunication Company Essay

Marketing Orientation in Telecommunication Company - Essay Example A deep analysis of the company has been made within this report. Also based on the study of the company and its competitors, recommendations have been set out for the management. The plan that has been set down which includes the benefits that Etisalat can gain from the recommendation of starting an e-Commerce website. This study has been based on a secondary research. The information collected is mainly from the secondary sources, which include various sources, studies, articles, newspapers, and websites. Secondary data refers to information published by others and which is already available1. It is also data collected by other people rather than the researcher who is carrying out the study2. There has been a through research conducted to gain all the information of this Etisalat. Great care has been taken while choosing the sources from the Internet and it has been ensured that the works chosen from the Internet are from published writers. As Berry refers to the Internet in his books, â€Å"an open door to nonsense to appear, and one way of checking on this is knowing about the author†3. The telecom industry of the Middle Eastern countries has seen a continuous growth. A forecast by Informa Telecoms and Media shows that the year 2009 will continue to see a constant growth, with almost 28.68 million net inclusions into the mobile market this year. The market is very wide and has as many as almost 250 million mobile subscribers and is expected to reach as high as 250.79 million by the end of 20094. Etisalat is one of the oldest telecom providers in UAE. It is headed by Mohammad Al Qamzi, the CEO. The company was incorporated in 1976 and has become a part of the Financial Times Top 500 Corporation. In terms of the capitalization and revenues, this company stands on the 6th position in the Middle East.  

Asperger's syndrome and how it affects the developing child Research Paper

Asperger's syndrome and how it affects the developing child - Research Paper Example Asperger’s Syndrome is one of a group of neurological disorders. This is a group of five closely –related disorders which also include Autistic Disorder, Pervasive developmental Disorder not otherwise specified, Childhood Disintegrative Disorder and Rett’s Disorder. All these disorders as Phetraswan, Miles and Mesibov (2009) explain have atypical patterns of development that affect multiple areas of functioning. These five disorders have some very similar symptoms that make it difficult sometimes to distinguish between them. This is especially so for Autism Disorder and Asperger’s Disorder which are sometimes confused for each other. Some describe Asperger’s Disorder as high functioning Autism Disorder. The terms are not always used with definite distinction made between Autism Disorder and Asperger’s Disorder and they are discussed together as Autism Spectrum Disorder where Asperger’s Disorder is included in the discussion. However it is important to distinguish between these two and know the subtle differences. Generally Asperger’s Disorder displays less severe autistic behavior. There is a more subtle impairment of language; there is not the delay in language development that is commonly seen in Autism Disorder. Also there may not be any cognitive delays; children with Asperger’s Disorder have normal IQs. The major characteristics of Asperger’s Disorder are social impairment and patterned, repetitive and focused behavior. Typically children with Asperger’s Disorder have underdeveloped social skills. This is manifested in their difficulty in forming friendships and relating to peers. Gibbons and Goins (2008) describe it as a â€Å"lack of understanding of social cues, which may lead to difficulty understanding the purpose of social interactions†. These authors go on to explain some of the other characteristics of Asperger’s Disorder or the difficulties

Protection or Free Trade for International Trade Essay

Protection or Free Trade for International Trade - Essay Example While both protectionism and free trade have their own advantages and disadvantages, the cost by far outweighs the benefits of protectionism. The arguments made in favor of protection are that the foreign producers have a â€Å"comparative advantage†, that protection helps the local infant industries flourish, that without protection importers would recklessly â€Å"dump† goods in the market, that protection protects the local producers, and finally, that protection prevents an imbalance of trade. However, each of these â€Å"perceived benefits† of protectionism comes at long-term costs which are far greater than the short-term benefits as explained below. The â€Å"comparative advantage† argument assumes that exporters from other countries have a strong competitive advantage that makes local producers less competitive thereby driving local companies out of business. For example, the labor cost in a developing country compared to that in a developed countr y puts some of the labor intensive local industries at a relative disadvantage. However, by moving to free-trade, countries are able to specialize in some other field where they have a comparative advantage. With such a specialization, the countries are able to take advantage of efficiencies generated from economies of scale and increased output. Also, free international trade increases the size of a firm’s market, resulting in lower average costs and increased productivity, ultimately leading to increased production. In the last few year, while China and India have taken up more work on the labor intensive industries, businesses in the developed countries have been able to actually take advantage of the lower cost and focus on their comparative advantage and invest more on research and development, and other high value added jobs. Besides, the comparative advantages do not last forever. Sooner or later, the advantage fades away. For example, according to Lyndesy Romick of gl obal envision, in China labor accounted for only about 2 percent of a manufacturing company’s total costs in 2000 but 2010 it was closer to 12 percent. That protectionism helps grow the infant industries is a misplaced fallacy. Government subsidizing of a new industry may channel too many resources into that industry, and can render the industry permanently inefficient and vulnerable to competition. Besides, most infant industries are at a competition from domestic competitors and not necessarily only importers. In the last few decades, the "infant" plastics, television, and computer industries have made out very well without any protection. Next, we consider the argument of dumping. Dumping may be defined as the overflow of cheap priced goods in order to under-cut the competition and gain market share. Now, if an importer starts dumping goods in a market, it would actually be good for the customers, and for the government in terms of revenue it makes no change. The only bad effect of dumping is for local producers. Logically, no firm can enjoy â€Å"dumping† as a sustainable strategy – selling below cost in the long-term would drive them to bankruptcy. Also, according to Rothbard, â€Å"†¦historical investigation has not turned up a single case where predatory pricing, when tried, was successful, and there are actually very few cases where it has even been tried.† The next pro-protectionism claim that it protects local producers is also at a huge cost. By protecting the local producers, there is no

Compare and Contrast Nike vs. Adidas' Business Operations Research Paper

Compare and Contrast Nike vs. Adidas' Business Operations - Research Paper Example The founder of the company, Adi Dassler intended to offer superior quality equipments to every single athlete. The product offerings of Adidas ranges from apparel to footwear to accessories related to every kind of various sports. However, the company designs products that are mainly associated with football, training, running and basketball. The brand was acquired by Salmon group in the year 1997 and the company came to be known as Adidas-Salmon AG. In the year 2006, the group acquired Reebok which was perceived to be highly advantageous for Adidas. Reebok was also a well known name in the sports industry. With the combination of two such reputed brands, the new group was expected to attain a higher degree of competitive advantage in the industry. The group was expected to cater with an increased variety of products accompanied with a strong existence across athletes, leagues, teams and events. The Adidas group engages above 42,000 employees across the globe. The group also has abov e 170 subsidiaries which assures the availability of its products across the world. The group’s sales along with distribution of products have been categorized in four global regions which are North America, Latin America, Europe/Emerging markets and Asia/Pacific. The group deals in sportswear and footwear as well and is known to be amongst the biggest suppliers of Europe. The group is also observed to dominate quite a number of sports events being reputed as the ‘Olympic brand’ in Sydney. The sale of the group was stated to reach a record high in the year 2000 (Adidas Group, â€Å"At a Glance the Story of the Adidas Group†). 1.2. Nike Nike Corporation deals with developing, designing and global marketing of products ranging from apparels and accessories to footwear and sport equipments. The company is known to cater about 18,000 retail stores with its products across the United States. It also makes available its products in about 200 different countries with the combination of independent licensees, distributors and subsidiaries. The athletic footwear range of Nike is particularly designed for the use of athletes; however, few of the products from this range are used for leisure as well as informal purposes. The company designs its products for all age group of women, men and children. The popular group of products that has the highest sales is basketball, cross-training, running, women’s and children’s shoes. The company also designs and markets footwear that are required for outdoor actions like golf, baseball, bicycling, wrestling, aquatic activities, other recreational and athletic uses, tennis, soccer, football, volleyball, cheerleading and hiking among others. Nike is also involved with selling sports related equipments which entails majority of the mentioned groups, lifestyle wear that are athletically enthused and others. The competitive advantage of the company is stated to be its constant innovations in the field of apparels, footwear and equipments as well. The company attains this competitive edge with the help of its Research and Development team which is technologically quite advanced (Dermesropian & Et. Al. â€Å"NIKE†). 2.0. Sales & Supply Chain Management 2.1. Sales & Supply Chain of Adidas The suppliers of Adidas are trained in a way so that they comprehend the significance of setting up and synchronizing the organizational system of management along with ways and methods of proper communication. The easy and

Apple I-tunes Case Study Example | Topics and Well Written Essays - 2250 words

Apple I-tunes - Case Study Example Surveys have proven that over the years the demand for digital music has increased by manifolds. Apple iTunes' market entry strategy into the UK is more likely to succeed if carried out with much more concentration on customer satisfaction and value creation fronts while at the same time focusing on a market penetration pricing strategy coupled with incremental growth strategies in niche market centric operations (www.apple/tunes.com). Apple i-tunes digital music company is in an oligopoly market with limited number of competitors including Sony, Warner, BMG and so on. Oligopoly is a market form where there are a few number of suppliers with similar identical products. Thus the digital music industry is evolving very fast. There is always the threat of a new company introducing something totally new to the market such as wireless technology that could replace the need for a physical music player. It's of paramount importance for Apple iTunes to invest a lot in research, and development and marketing in order to keep up with other companies that could introduce newer products to the market. Apple iTunes could improve the quality of their products. Then due to the greater quality of their music files, manufacturers of MP3, 4, 5 players would be compelled to manufacture their products to make them compatible with these files, because customers would be lured to buy Apple iTunes as they are of superior quality. The po pularity of iPod and Apple Mac are subject to demand. If economies are negatively affected the demand for these products would fall. However customer's interests change often. There is a possibility that a new company might come up with a totally new innovation and thus the demand for Apple iTunes may drop. In fact Apple i-tunes Company as in the oligopoly market requires strategic thinking unlike other market forms in the market such as perfect competition, monopoly and monopolistic competition. In fact oligopolistic competition can provide different range of outcomes. In some cases firm may employ trade practices that are restrictive. In other situations, competition between sellers in an oligopoly market can be relatively low prices and high production. There is always a threat to Apple iTunes from other manufactures who manufacture inferior quality music files at low cost and also the creation of pirated digital music (Presswire, 2007). Customers might be lured to buy these products as they cost less. Other substitutes such as Satellite radio for music, Entertainment media, media and music alternative sources for videos (cable, broadcast) and alternative means to acquire music (Music CDs, DVDs) are potential threats. Thus this could lead to an efficient outcome approaching perfect competition. However the competition in an oligopoly industry can be higher when there are more firms in an industry if, for instance, the firms were only regionally based and did not compete directly with each other.According to the behavior of the oligopolistic market, firm has to face a kinked demand curve at the existing market price for its widgets (products). In this scenario suppliers do not have the tendency to increase the price, because other competitors in the industry would not follow

Respect Essay Example for Free

Respect Essay I have been told that I need to write a 1000 word essay on disrespecting a Non Commissioned Officer. But it is really hard to write about this because I am having a hard time wondering how I disrespected them. So, where do I start on this and what do I say about it. As far as this essay goes I am just going to write how I feel about respect and how respect works both ways. It is wrong to disrespect a Non Commissioned Officer because they are appointed above me to guide me to the right place and things to do. But it is really hard to respect someone when they do not respect you. Respect works both ways and if that person or leadership does not respect you trying to respect them is difficult. No matter what is said it is disrespect. For example: I am writing this because I was called about a meeting that my squad leader decided he wanted to spring on the squad after we were released for the day. When I asked the squad leader was the meeting about something that we could have discussed the next business day, he replied no, with a sly smirk on his face. As he began to talk it was clearly the same information that was put out at the end of business. I do not know how that was disrespect when it was the truth. In regards to this essay I am not sure what to say about disrespect other then it works both ways. They tell you to respect the rank not the person but when that person abuses the rank it is really hard to respect it. I think that in today’s United States Army no one respects anybody the way that they should be. They are too quick to say that you are disrespecting them and that they are just trying to make you better but they are disrespecting you in the processes. How can you work for someone or some place when all that they do is disrespect you and everything that you do no matter what it is? When I first came in the United States Army a Non Commissioned Officer would work with you on how to be a good soldier and actually sit with you and respect you on what you were doing if you did a good job and worked hard they didn’t try to beat you down to where you just give up on everything. I used to respect everyone that was above me because they cared about you as a person they respected you and helped you with the hard things that were thrown at you and made sure that you were good not just quick to demote them and kick them out of the United States Army. They had an interest in you as a person and if they had something to learn from you then they would respect you enough to ask for help and respect you enough to talk to you. Respect and disrespect is a hard topic because I am a strong believer in respect someone and you will receive respect back or treat someone the way that you want to be treated. The whole time that I have been back in the United States Army the Non Commissioned Officers that were above me were basically like new privates. They were new to the job and they didn’t know a lot about it. I know that I have been in the United States Army for only a short time and I am only a specialist, I have worked with someone above me disrespecting me not just as a soldier, but as a human being. I feel that leadership should stop turning what people say into disrespect it was not that way AT ALL. I was just asking a questioning and stating the obvious, not disrespecting that person. You know they always preach about disrespect but they do not give respect at all. So as far as this essay goes how do I write it to what they want because no matter what is said in here they will one way or another say it is disrespect or some other form of berating them. 1 Respect and disrespect is an important part of a soldier Non Commissioned Officer relationship and needs to be enforced upon not only the soldier but also the Non Commissioned Officer and Officers. I have had a really hard time in this company because I think that people just think that I am just disrespecting them instead of getting to know their soldiers and how their soldiers talk and phrase things. They are quick to just say HA you disrespected me. I have seen way worse disrespect then what I have ever done to anyone. In my eyes disrespect is if you just plainly say hell no or fuck off. I have never done that and yet they automatically think that if you are asking them why you are told to do something it is disrespect but in fact is not disrespect it is that the soldier is trying to learn from them. If I remember correctly the Non Commissioned Officer Creed states â€Å"Competence is my watchword. My two basic responsibilities will always be uppermost in my mind-accomplishment of my mission and the welfare of my soldiers. I will strive to remain tactically and technically proficient. I am aware of my role as a Noncommissioned Officer. I will fulfill my responsibilities inherent in that role. All soldiers are entitled to outstanding leadership; I will provide that leadership. I know my soldiers and I will always place their needs above my own. I will communicate consistently with my soldiers and never leave them uninformed. I will be fair and impartial when recommending both rewards and punishment. † But it seems that only a few of the Non Commissioned Officers respect the lower enlisted. Why should soldiers’ words get twisted and why is that NCO’s are not respecting the soldiers and their needs. We need to be respected that is one of the many needs of the soldiers of today. That is why a lot of soldiers act out against Non Commissioned Officers. Ok so disrespect is all on what that person thinks is being said to them not really how and what is being said. When someone makes a statement and the other person comments on it, it is not disrespect it is just informing them on what they think. How is that disrespecting them? There is also a little thing that Non Commissioned Officers should do and that is lead by example and not respecting a soldier is not leading by example it is showing that that what is good for the goose is good for the gander or do as I say and not as I do! 2

Teaching Upper Intermediate Students To Take Notes English Language Essay

Teaching Upper Intermediate Students To Take Notes English Language Essay 1.1. Introduction The purpose of this assignment is to report on an EAP course design simulation. I have decided to focus on EAP for two reasons. Firstly, I am currently teaching at a university in Turkey where I have the task of preparing students for life in an English-medium learning environment. This assignment provides me with an opportunity to examine this learning context and identify factors that influence learning. Secondly, I conducted a similar project whilst completing an MA in Applied Linguistics. During this project, I designed a pre-sessional EAP course for a group of multi-lingual students entering a university in England. I now work predominantly with mono-lingual groups in a non-English speaking country and am interested in investigating how these factors influence course design. 1.2. Theories and Principles EAP rose to prominence in the 1970s (Jordan 1997) and its importance has since increased with the emergence of English as the lingua franca of the global academic community (Hyland Hamp-Lyons 2002). EAP has been defined as the teaching of English with the goal of enabling learners to use that language to study or conduct research (Flowerdew Peacock 2001) and involves helping students to develop linguistic, academic and cultural competence (Gillett Wray 2006). EAP courses may be taught in English speaking contexts, or in countries in which English is used as a foreign or second language (Jordan 1997). EAP is categorised as a form of English for Specific Purposes (ESP) and a distinction has been made between English for General Academic Purposes (EGAP) and English for Specific Academic Purposes (ESAP) (Blue 1988). EGAP courses, like the one employed in my own context, teach a common core of language and academic skills that all university students require. In contrast, ESAP courses focus on the language and skills needed in one particular academic discipline. However, despite this divide, analyses of EAP courses have revealed that they generally share the following defining features (Robinson 1991: 2): They are goal directed. They are based on the needs of the students. The duration of the course is clearly specified. The students tend to be adults over the age of 18. A high level of English proficiency is not necessarily required. The need to develop academic as well as linguistic competence has received considerable attention in EAP literature (Ballard 1996; Sowden 2003). Ballard (1996) argues that foreign students often require help adjusting to the distinctive academic culture of western universities. For instance, she identifies students struggle to adapt to the critical approach to learning expected of them in western universities. This argument applies to my own teaching context because many of the lecturers are either from or have been educated in western countries and, consequently, have particular expectations about how students should behave. The need to incorporate both linguistic and academic skills into EAP courses has lead many writers to consider the type of syllabi to employ during these courses. Task-based or process syllabi are centred on the cognitive acts students perform at universities. These syllabi emphasise the use of authentic activities and English is viewed merely as the medium through which these activities are performed (Ballard 1996). Similarly, skills-based syllabi, as employed in my own institution, advocate the development of skills that students need to succeed at university. In contrast, content-based syllabi emphasise the material students study at university. These syllabi promote the analysis of language within relevant discourse (Spanos 1987). Likewise, text-based or genre-based syllabi facilitate the examination of language within authentic contexts (Feez 2002). Importantly, Flowerdew (2005) highlights that, depending on student needs, elements of different syllabi can be combined to create an integrated course. 1.3. My Own Experiences My current teaching position is my first classroom exposure to EAP and EAP students. Research conducted into this group of students suggests that they have a number of defining characteristics. For example, Todd (2003) identifies that these students are usually more mature and motivated. Waters and Waters (1992) suggest that successful university students are able to think critically and logically, are self-aware and self-confident, and are willing and able to take responsibility for their own learning. Unfortunately, in my own context, the students have generally just finished high school and have not yet fully developed these characteristics. For instance, many students expect teachers to tell them what to do and are unsure about how to manage their own personal study time. Therefore, teachers must help students develop personal traits as well as linguistic and academic skills. My previous experience of designing an EAP course highlighted the enormity of the task. Whilst analysing the needs of the students, I listed the skills and sub-skills successful university students employ. On completion, I had created an unmanageable list of skills and a pre-sessional course could not explicitly address all of them. Therefore, the course I eventually designed employed a task-based syllabus that allowed students to experience and reflect on the learning activities they would participate in at university. They then built their weaknesses into long-term development plans. 1.4. Implications of the Literature and My Experience Based on the literature and reflection on previous experiences, I believe the following implications are relevant to the design of the EAP course and the needs analysis process. The needs analysis must identify the academic departments the students will be entering. If the students are studying similar subjects, an ESAP approach may be adopted. However, if they are studying different subjects, an EGAP has to be used. The needs analysis must examine the students needs in relation to their linguistic, academic and cultural competency. The needs analysis must be used to identify the students main areas of weakness. It will not be possible to teach all of the various skills and sub-skills that the students need to succeed at university. Instead, the course must prioritise the primary weaknesses. A decision will have to be made regarding the most appropriate syllabus type to meet the needs of the students. 2. Needs Analysis 2.1. Group Profile To promote a learning-centred approach, a questionnaire (see Appendix 1) was used to collect data about learner needs (Hutchinson and Waters 1987). A questionnaire was the most practical method to collect this data. The results (Appendix A) are summarized below: Learner Characteristics 21 students (13 males and 8 females). The average age is 20 (ranging from 18 26). 18 Turkish and 3 Iraqi students. The students are entering various departments at an English-medium university. Sport, films and music are common interests. Learner Preferences Both deductive and inductive approaches. Working on their own, in pairs and in groups. Having input into what and how they learn. Both teacher and self-assessment. Self-Assessment The students perceive reading and speaking as their stronger skills. Listening and writing are skills they need to improve. The students also completed a learning styles questionnaire (Appendix 2). They favour a combination of visual, auditory and kinesthetic activities (Appendix B). 2.2. Identifying Needs Needs analysis (NA) is the process teachers use to determine and prioritize the needs for which a particular group of learners require a language (Richards 2001). These needs may originate from the students or from other stakeholders such as the institution. To assess the needs of this class, I performed a target situation analysis (TSA) to identify the skills students require when they enter the university (Munby 1978). I examined the syllabus used within my institution. This was the most practical method because this syllabus was created following a language audit and, thus, provided a comprehensive breakdown of target needs. The TSA highlighted my institution employs a skills-based approach. As discussed in section 1, successful university students must employ a vast range of sub-skills. Consequently, I performed a present situation analysis (PSA) (Richterich Chancerel 1980) to enable me to identify and prioritize gaps between the students current skill-set and those they require. I used diagnostic tests to collect information about reading, listening and writing because they are the most practical method to obtain accurate quantitative data about students knowledge (Hughes 2003). I used classroom observations to test speaking because this was the most practical way to collect information about a large number of students. Following the findings of the TSA, I employed a skills-based approach and assessed the students listening, reading, writing and speaking skills. 2.3. Diagnostic Testing Diagnostic tests are conducted at the beginning of a period of study to collect data about students current state of language development (Hughes 2003). To ensure the students perceived these tests as being useful; thus satisfying the condition of face validity (Gronlund 1998), I replicated activities the students perform in the institutions examinations. This also satisfied the condition of content validity. Skill Procedure Listening Students took notes while listening to a lecture and then answered comprehension questions using their notes (Appendix 3). Reading Students answered comprehension questions about an academic text requiring them to scan, skim and infer meaning (Appendix 4). Writing The students wrote an academic paragraph (Appendix 5) that was marked for grammar, vocabulary, content and organisation. To increase scorer reliability, a colleague checked the grades (Hughes 2003). Speaking The students were observed in class and marked on grammar, vocabulary, fluency and pronunciation. Once again, a colleague checked the grades. Grammar and Vocabulary These items were assessed indirectly through writing and speaking. 2.4. Results 2.4.1. Present Situation Analysis The diagnostic tests revealed that, on average, the students achieved passing marks (above 60%) in reading and speaking, but failed in listening and writing (Appendix C.1). This matches the students self-assessment. The writing scores highlighted the greatest difficulties concern grammar, vocabulary and organisation (Appendix C.2). The students struggled to use a range of lexis and had problems with grammatical and lexical accuracy (e.g. Appendix 6). However, during feedback, the students self-corrected the majority of their grammar mistakes. This suggests they were performance rather than linguistic errors. The students said they have problems studying vocabulary and usually just translate from L2 to L1. The students also had difficulty using cohesive devices and organising their writing to meet academic conventions and answer questions directly. The note-taking sheets (e.g. Appendix 7) revealed the students struggled to isolate important information and recorded redundant information. The students failed to employ strategies to help them record information quickly. Interestingly, when the students completed the listening test as a while-listening task, they had little difficulty answering the questions. This suggests the students problems concern note-taking rather than listening. The students explained they have had little experience of this task. This supports the notion that these students must develop academic competency. 2.4.2. Target Situation Analysis The syllabus of the institution revealed successful students must be able to use a variety of skills and strategies when taking notes from lectures and writing (Appendix D). To investigate these skills further, the students completed a self-assessment questionnaire (Appendix 8). This questionnaire performed the dual function of collecting data about the students abilities, and increasing their awareness of the skills and strategies needed to succeed at university (Allright 1982). The results showed they are not particularly confident about writing and note-taking sub-skills (Appendix E). 2.5. Priorities for the Planned Course The course will teach EGAP because the students belong to different faculties. The results of the diagnostic tests revealed taking notes from lectures and writing to be common weaknesses. This confirms the students self-assessment of their needs. The course will focus on these skills and provide the students with opportunities to develop and practice strategies they can employ when taking notes. The course will also raise awareness of the organisation of academic writing and promote effective vocabulary use and error correction. Finally, as mentioned in section 1, because the majority of students have just finished high school, the course will aim to increase awareness of university study. 3. Course Proposal 3.1. Course Proposal In accordance with the NA, this EGAP course will focus on taking notes from lectures and, academic writing. It will be taught over 1 week and consists of 20 hours of classroom time with 4.5 hours of additional writing tutorials (3 extra tutorial hours will be available if extra teaching is needed). It will supplement the 8-week course the students are currently taking. The course will enable the students to reflect on, intensively practise, and consolidate the skills and strategies they have already started developing. This will allow the students to address weaknesses and develop confidence in preparation for next course. As such, the supplementary course will be taught at the end of the students current course. 3.2. Goals and Objectives Curriculum designers state the goals and objectives of courses to imbue their creations with purpose and direction (Graves 2000). Goals can be defined as statements concerning the general purposes of a course while objectives are specific statements describing how goals are to be realised (Richards 2001). The goals of this course are to develop the students abilities to write academic essays and paragraphs and, take notes from lectures. The course also aims to increase the students confidence of taking notes and raise their awareness of how to succeed in academic life. To achieve these goals, I have formulated 19 objectives: 4 listening objectives (LO1-LO4), 4 note-taking objectives (NO1-NO4), 8 writing objectives (WO1-WO8), 1 vocabulary objective (VO1), 1 grammar objective (GO1) and 1 affective objective (AO1). For full details of the goals and objectives see Appendix 9. 3.3. Approach As identified in sections 1 and 2, the students need to develop an awareness of what life is like in university departments (Sowden 2003). Consequently, the course will employ an integrated skills approach that simulates the canonical sequence of university study (Appendix F). The lectures the students will listen to and take notes on will provide lexical input about the topics they will write about. The students will supplement this input through further reading and vocabulary study outside class (e.g. Appendix F, Day 1). This self-study responds to the students learning preferences and encourages them to take responsibility for their learning, a characteristic crucial for academic success (Waters and Waters 1992). Based on the analysis of learner needs, a variety of different approaches will be employed in the classroom. First, the listening and note-taking component will include awareness raising and reflection activities. The students have little experience of this task and these activities remedy this. Secondly, both inductive and deductive learning will be employed because the students enjoy both. Thirdly, the course will incorporate individual, pair and group work. For example, the students will brainstorm ideas for writing tasks in pairs before sharing with the group. The students will perform the writing individually. Finally, the course will employ both P-P-P and T-T-T lesson shapes depending on whether the students are encountering concepts for the first time or revisiting them. 3.4. Course Content The listening and note-taking component of the course builds from part to whole (Richards 2001). The diagnostic tests revealed the students have difficulty identifying important information and using note-taking strategies. This course allows the students to increase their awareness of and practise listening and note-taking strategies in isolation before having opportunities to use them, first, in tandem and, then, holistically (e.g. Appendix F, Day 1). Moreover, the students will practise these strategies whilst reading before applying them when listening. This componential approach recycles objectives and, allows students to automatise strategies separately so, when using them holistically, they find it less cognitively challenging (Field 2008). The writing component of the course builds from simple to complex (Richards 2001). The diagnostic tests revealed the students have difficulty answering questions directly and developing ideas logically. Consequently, the students will practise this skill in body paragraphs before progressing to full essays. The writing component will also develop from whole to part (Richards 2001) with students examining the organisation of full texts before analysing and practising writing the individual components (e.g. Appendix F, Day 2). The students identified they enjoy inductive learning and this methodology facilitates this. The students will complete the writing outside class. This removes the pressure of time limits and emphasises the writing process rather than product (Walker and PÃ ©rez RÃ ­u 2008). The grammar and vocabulary teaching will be reactive as the diagnostic tests highlighted the students difficulties mainly concern performance rather than linguistic errors. The students writing will be marked with grammar and vocabulary mistakes highlighted using an error code. The students will then re-write and self-correct their texts in the tutorials. The students enjoy both teacher and self-correction, and both inductive and deductive learning. This methodology responds to these needs. The tutorials will contain fewer students so the students will have greater access to a teacher if they need to ask questions. 3.5. Materials The materials to be used in this course have been designed for the purposes of English teaching (Appendix F). The language is graded and, in the lectures, the rate of speech is slower. This will allow the students to focus on developing the targeted skills and strategies instead of worrying about language. It also responds to the students affective needs. They are extremely anxious about taking notes and, if exposed to authentic lectures, might be overwhelmed (Guariento and Morely 2001). The use of inauthentic material is also offset by the authenticity of the tasks. The students will have to take notes and write essays in their departments so they are likely to be motivated (Long and Crookes 1992). Unfortunately, the use of graded material limits the topics to those in the coursebooks. I have chosen lectures on the topics of health, society and relationships. These topics are accessible to all of the students and the TSA revealed they feature in the coursebooks and exams of the inst itution. 3.6. Institutional Constraints A number of institutional constraints have influenced the design of this course. Firstly, the availability of teachers affected the tutorials. Ideally, the tutorials would contain a maximum of five students. However, this would require in excess of 5 teachers and this was not possible. Consequently, two teachers will conduct the tutorials and the class will be halved. Secondly, the institutions examinations influenced the methodology used on the course. The students will sit a skills-based examination shortly after participating in this supplementary course. Consequently, I decided to use comprehension questions to measure note-taking ability. The students perform similar tasks in their exam so they will probably be more motivated because they can apply the strategies they practise during this course. 4. Assessment 4.1. Assessment Principles Assessment is an umbrella term referring to the collection of data about the abilities or achievements of learners taking a particular course (Brindley 2001). It may occur formatively (during the course) or summatively (at the end of the course). Assessment can be performed using both quantitative and qualitative methodology (Jordan 1997). Qualitative methodology may include classroom observation or interviews while the main quantitative method is testing. Tests may be employed at various stages during a course. Proficiency and diagnostic tests are administered at the beginning of a course to provide information about learners existing abilities (Hughes 2003). In contrast, achievement tests are used formatively or summatively to assess students progress and identify what they have learnt from a particular course (Brindley 2001). In order to be effective, tests must be both valid and reliable (Hughes 2003). Validity concerns the ability of tests to measure what they are supposed to while reliability is the extent to which tests can be repeated achieving consistent results (Brindley 2001). 4.2. Monitoring Learner Progress Progress in the listening and note-taking component will be assessed through comprehension questions and self-assessment (Appendix 10, Days 1, 3 and 5). This assessment is integrated into the course and will be conducted in the final block of note-taking days. The comprehension questions include multiple choice and short open-ended questions. The self-assessment requires the students to reflect on their use of strategies practised and rate themselves (e.g. Appendix 11). The students will also collect their note-taking sheets, comprehension questions and self-assessment sheets in a Learning Portfolio (LP). These will function as records of their learning processes and, be used for summative assessment and reflection purposes (Nunes 2004). Progress in the writing component will be assessed through the completion of three writing tasks: one paragraph and two essays (Appendix 10, Days 2, 4 and 5). The students use of grammar and vocabulary will be assessed indirectly through these tasks. The students will write a first and second draft for each task and both drafts will be marked and graded. The first drafts are to be completed outside class. The second drafts will be started in writing tutorials and finished outside of class. Both drafts of each task will be included in their LPs. 4.3. Assessing Learner Outcomes The students LPs will form the basis of the summative assessment (Appendix 10, Day 6). The students will reflect on their work and self-assess their progress in each of the objectives (Appendix 12). In one to one tutorials, the students will discuss this self-assessment and form long-term development goals to respond to their weaknesses. This assessment will be low stakes because the students will soon be taking a high stakes examination in the institution and do not need further pressure. The decision to use both teacher and self-assessment in the formative and summative assessment responds to the students learning preferences. Self-assessment also encourages students to be more active and take responsibility for their learning (Harris 1997). The use of LPs combines formative and summative assessment, and this helps students to better understand their strengths and weaknesses (Lam Lee 2009). It also allows the students to monitor their development in note-taking; thus, increasing their confidence. 4.4. How Assessment Principles Influenced Assessment Methodology The assessment methods aim to conform to the principle of validity. Adopting a skills-based approach achieves construct validity. The TSA revealed my institution advocates this theory and the assessment methods of this course reflect this. The students will be assessed on their ability to employ skills and strategies when taking notes from lectures and, writing paragraphs and essays. The course also follows theoretical developments in written assessment. The use of LPs rather than timed exams emphasises the writing process rather than the product (Walker and PÃ ©rez RÃ ­u 2008). The use of skills-based assessment also satisfies the conditions of both content and face validity. The assessment tasks mirror those performed on this course and, during regular courses and examinations. Consequently, the students are likely to view the course and assessment techniques as appropriate (Gronlund 1998). The assessment methods also aim to conform to principle of reliability. The listening and note-taking component of the course will be assessed using multiple choice and short open-ended questions and, these will be marked using a standardised answer key. This will increase scorer reliability. The written tasks will be marked using the writing criteria of the institution. These criteria are regularly standardised. Therefore, although subjective, scorer reliability will be enhanced. 4.5. Constraints and Opportunities Whilst planning how to assess this course, I encountered a number of constraints. Firstly, I decided to use comprehension questions to assess listening and note-taking because this is how my institution assesses these skills. The students are familiar with this form of assessment so, had I chosen a different method, I may have experienced negative backwash with students failing to value my choice of methodology (Hughes 2003). Moreover, by using comprehension questions, I can exploit backwash from the examinations positively to motivate the students. Secondly, I faced practicality problems with the written assessment. The students will complete their writing tasks at home and have tutorials about them the next day. Therefore, to allow for marking, tutorials would have start at 10am with regular classes being taught in the afternoon. The students will submit their work via e-mail by 8am. This provides the teachers sufficient time to mark and, also imposes deadlines on the students. Suc h deadlines are part of university study and the students must take responsibility for meeting them. 4.6. Course Evaluation Evaluation is the process of collecting information about a course, both formatively and summatively, with the purpose of determining how effective it is and to guide decisions about teaching and learning (Murphy 2000). The evaluation methods to be used on this course are summarised in Appendix 13. In this course, LPs play a crucial role in evaluation. The data in these portfolios will help me make both formative and summative judgments about whether objectives are being met. The formative judgments will be particularly useful because they will help me to decide whether to use any of the free tutorials to provide additional teaching. In addition, the students will complete a questionnaire to evaluate the course summatively (Appendix 12). This questionnaire will allow the students to rate the usefulness of the activities, materials, teaching and assessment methods, and make open-ended comments about the course. 5. Conclusion 5.1. Conclusion Studying at university is an extremely complex process requiring students to participate in a variety of learning activities and, use a vast array of skills and sub-skills (Munby 1978). The task of EAP practitioners, who help students acquire these skills, is unenviable because, in addition to teaching linguistic competence, they also have to help students develop academic and cultural competence and, personal characteristics. When designing my course, I responded to this challenge, by conducting an analysis of the students needs. This analysis enabled me to identify and prioritise the most pressing weaknesses of the students. Therefore, I was able to maximize the benefit that the students would receive from what is a relatively short course. I believe that, having taken the course, the students will, not only be better equipped to take notes from lectures and, write paragraphs and essays, they will also feel more confident about doing so. The task of designing an EAP course for my students was made even more challenging because most of them have just finished high school and are unfamiliar with university study. Therefore, I believe that my decision to design the course to simulate university study will be particularly valuable to them in the long-term. Although the students will still have a lot more to learn about academic study, I believe that, when they enter their departments, they will be more aware of what is expected of them both inside and outside of class. Moreover, I feel that, through being exposed to the use of LPs as a method of learning and assessment, the students will have taken a huge step towards to becoming more self-aware and responsible for their own learning. These characteristics will play a fundamental role in their lives as successful university students.

Role Expansion of Support Staff in the NHS

Role Expansion of Support Staff in the NHS Abstract In this dissertation we examine the various aspects of role expansion of support staff within the confines of the NHS. We consider it on both a broad front and also make specific examination of those issues that concern staff connected with the operating theatres. We consider the background and political pressures that make role expansion desirable and possible. We also consider the implications of expansion in the NHS on both a professional and practical level. The issues are discussed in both specific and general terms. We illustrate three types of role expansion by reference to specific professional examples. One example is of the expansion from a caring role to that of the specialist provider, the second can be considered an example of role extension within a professional setting and the third is a natural expansion of the role which is required as technology and practice evolve. Methodology The methodology of this exploration was primarily by literature research. Progressive lines of enquiry were identified, researched and recorded. New lines of enquiry were identified as research progressed, and these were also examined for relevance and researched if considered appropriate to the theme of the dissertation. The literature search was mainly from library facilities. Local University, Post-Graduate hospital and public library facilities were extensively used together with some Internet based investigation. Some personal email enquiries were made from individuals who had experienced professional expansion and advice was taken in regard to both literature and direction of research. Introduction There is little doubt that the role of support staff has changed within the working lifetime of professionals currently working in the NHS. The thrust of this dissertation is to examine the means, the mechanisms and the degrees by which their role has changed. It barely needs stating that the NHS has changed. The political climate in which it operates has seen the NHS occupy varying positions of political prominence. Politicians are frequently seen publicly promising various sums of money for various projects of modernisation, expansion or generally to improve services. Every so often there is a major structural realignment of the management focus and mechanisms which, inevitably percolate through the tiers of control until the changes are felt at the level of the worker. In addition to this there are the technological changes which are largely independent of the politicians and the management structure. The rate of change in techniques, technology, support equipment and expertise appears to be increasing at an exponential rate. It clearly follows that the professional requirements of the support staff must keep pace with these changes and the training that they receive must inevitably reflect the needs of the ever changing working environment. (Ashburner L et al 1996) Evidence of change In any rational discussion, it is vital to work from a firm and secure evidence base. (EHC 1999). This requires careful and critical appraisal of the evidence and a decision as to just how applicable it is to the situation under consideration. In this dissertation we shall therefore be presenting evidence to support this evidence base together with appropriate assessments and judgements as to its validity. Most professionals working in the NHS would attest, if asked, to a perception of a continuous pace of change. Such anecdotal evidence, although interesting, is of little value to any form of critical appraisal. There are a number of reasonably â€Å"hard† statistics that give us much firmer evidence of change in the NHS. Let us consider some of the employment statistics published by the Department of Health for the NHS (whole of UK) and refers to non-medical staff. In 1997 the total number of NHS hospital and community based staff was 935,000. Of these 67% were direct care staff and 33% were management staff. The 67% direct care staff could be broken down into 330,620 nursing, midwifery and health visiting staff (246,010 being qualified) 100,440 scientific, therapeutic and technical staff 17,940 healthcare assistants 21,430 were managers the rest were estates, clerical and administrative staff 79% were women and 6% were from ethnic minorities (NSO 1998) If we compare this with the situation in 2000 by looking at the same parameters we can see: 346,180 nursing, midwifery and health visitor staff (256,280 were qualified). 110,410 scientific, therapeutic and technical staff 62,870 support staff and 23,140 healthcare assistants. 68% were direct care staff and 32% were management and support staff. 79% were women and 7% from the ethnic minorities (NSO 2001) And in 2001 we find a further difference, which is rather more dramatic: 458, 580 nursing, midwifery and health visitor staff (330,540 were qualified) 139,050 scientific, therapeutic and technical staff 23,140 healthcare assistants. 82% were women and 6% from the ethnic minorities (NSO 2002) If we go further back we can find evidence of 93,950 scientific, therapeutic and technical staff were employed, and there were 13,090 healthcare assistants in 1995 (NSO 1996) If we consider the documented trends in support staff we can trace 1995 93,950 1997 100,440 2000 110,410 2001 139,050 Over a comparatively short time there has clearly been a demonstrable increase in terms of numbers employed , nearly a 50% increase on the 1995 levels in six years. Reasons for change In opening this dissertation we made anecdotal reference to the political agenda that shaped the NHS. The NHS has historically been high in the public’s perception of a tangible measure of a Government’s success in delivering its regularly promised higher standard of living. It is partly for this reason, that successive governments have felt it politically expedient to invest increasing sums of money in measures for both expansion and improvement together with various drives aimed at increasing efficiency. (Ham C 1999) In the recent past there have been a raft of measures that have been produced which have all played their part in the evolution of the NHS to its current configuration and in doing so have expanded the role of not only the support worker but virtually all of the workers in the NHS at the same time. One of the first measures which was an overt indication of the forthcoming changes in working practice was the introduction of the performance indicators (Beecham L 1994) These were progressively introduced form 1992 onwards and in some respects could be considered the forerunner of the move towards National Service Frameworks. The original performance indicators imposed a duty or obligation on Trusts to carry out certain procedures within a specified maximum time. For example the indicators introduced in 1994-5 were on waiting times for first outpatient appointment and also for charters in General Practice. Although there were clear obligations on medical and nursing staff to make available sufficient sessions in order to see the patients, it is clear that the increased throughput of patients would clearly impact on the working practices (and work load) of the support staff. To a large extent, this can be seen from the figures presented at the beginning of this work. The 50% increase in staffing levels amongst the support staff reflects, in a large part, the changes that were consequent on the imposition of the performance indicators. The initial indicators proved to be quite onerous in terms of achieving compliance even though the later ones gave tighter requirements still. For example the 1994 indicators set a target of 90% of patients seen by a consultant within 26 weeks of a written referral letter being received from the General Practitioner in the major specialities of general medicine, general surgery and dermatology. (Editor BMJ 1994) It follows that this target is not quite as innocuous as it might at first appear. If we accept the fact that a substantial number of patients were already waiting for considerably longer than 26 weeks it represented a major shift in working practices to meet this particular deadline. Once the patients were seen it followed that they then had to have whatever treatment was thought to be appropriate. An increase in outpatients seen inevitably means an increase in patients waiting for inpatient treatment. So either the waiting lists go up further for inpatient treatment, or there is also a change of working practice to accommodate an increase in demand. This inevitably also impacts on the support staff as much as it does on the medical staff. (Langham S et al 1997) We shall consider this particular phenomenon in greater depth later when we consider the expansion of the nurse to specialist endoscopist and the running of one-stop clinics. Some novel methods were invoked to try to accommodate this shift in demand. There was a substantial increase in the frequency of day case surgery. Not only were a greater variety of surgical procedures being routinely carried out as day cases but it also resulted in more patients being assessed as suitable to undergo day case surgery. (HSE 2001) The same phenomenon of knock on effects arose form some of the other performance indicators. One of the original indicators was the percentage of patients seen within 5 mins of entering the casualty department. It follows that as hospitals strove to increase their performance indicators and the percentage of patients seen promptly rose, having been seen they then had to be treated and the same argument applies. Either there is an increase in the number of patients awaiting treatment in the A E departments, or there is a change in working practice to accommodate them and also to get them treated sooner. The organisation and efficiency of this system falls heavily on the support staff who clearly had to be able to accommodate this increased demand. (Langham S et al 1997) The indicators eventually began to involve inpatient statistics as well as outpatient ones. One, introduced in 1996, was on the number and availability of emergency operating theatres. More evidence of the reasons for this change comes from a paper by Scally and Donaldson (1998). We note that it was actually written by Liam Donaldson when he was a Regional Director of the NHS before he subsequently became Secretary of State for Health, so his comments can be taken with suitable gravitas. A critical analysis of the paper shows that it makes a number of points that are really overtly political, but it outlines the trend of change of emphasis where the improvements expected through clinical governance will not only be an â€Å"ideal goal† but will become a statutory requirement. This clearly pre-empts the changes prescribed in the NHS Plan. The paper outlines new goals â€Å"in which financial control, service performance, and clinical quality are fully integrated at every level† are behind the major thrust of the piece. Careful reading of the paper strongly suggests that inherent in the restructuring plans is a change in emphasis onto expansion of professional roles and greater working flexibility between professions which is fundamental to our considerations here. (Gray C 2005). We also note that the â€Å"stage was being set† for the potential role change of healthcare professionals in general and the four main precepts of this paper impact on that belief, namely: Clinical governance is to be the main vehicle for continuously improving the quality of patient care and developing the capacity of the NHS in England to maintain high standards (including dealing with poor professional performance) It requires an organisation-wide transformation; clinical leadership and positive organisational cultures are particularly important Professional self regulation will be the key to dealing with the complex problems of poor performance among clinicians New approaches are needed to enable the recognition and replication of good clinical practice to ensure that lessons are reliably learned from failures in standards of care It is clearly significant that all of these points were implemented and indeed, expanded, when Donaldson was appointed to the office of Secretary of State for Health and they can be seen as both enhancing and reinforcing the points that we have presented relating to the guidance from the Nursing Midwifery Council about the expansion of professional roles. Because of their seminal importance in the examination of our subject, let us consider the background to these points further. We note that Donaldson was originally recruited from a business background and the record shows that he has chosen to apply a great many sound and proven business principles to both the structuring and the workings of the NHS. Many of his strategies and perhaps ideas, have a clear ancestry in the Cadbury Report (1992) which effectively analysed the overall impact of governance and issues of changing working practices and consequent responsibility in the business world. The report focused on the issues surrounding an expansion of responsibility and a consequent failure to take responsibility for one’s actions, frequently passing on the implied responsibility to another employee in the same company. It found this practice to be both counterproductive and inefficient and frequently would lead to defensive stances and attitudes being adopted. When problems arose, they were therefore far more difficult to actively solve. (Lakhani M 2005) Donaldson was instrumental in applying this strategy to a clinical setting within the working practices of the NHS. This particular paper takes the view that by promoting individual professional responsibility he would be encouraging a system that would allow:- NHS organisations to be accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. By implication this argument extends to the expansion and role realignment in general terms throughout the NHS. We shall consider the elements in this paper which are of relevance to these arguments. Staff self-esteem is of great value to an organisation. Frequently this is associated with increased responsibility and a firm professional footing. (Davies HTO et al. 2000). Donaldson and Scally clearly espouse the virtue of professional responsibility at all levels in an organisation and encourage staff to take, rather than to devolve responsibility for their actions and indeed seek to ideally provide a ambience that is conducive to expansion of responsibility which therefore generally benefits the whole organisation. Tools of change Although we are primarily considering the support worker in this dissertation we must first broaden the agenda in order to set our examination in an appropriate context. There have been a number of Government White Papers, consultative documents and advisory initiatives that have concerned the workings of the NHS. Some have greater practical significance than others. There appear to have been significantly more in the last decade than previously and anecdotal and observational evidence would seem to suggest that these too, are increasing at an exponential rate. One of the landmark plans in recent years has been the NHS Plan. It has been compared by some commentators as being on comparative magnitude as the original inception of the NHS in 1948 (Shortell SM et al 1998). It is quite possible that a cynical appraisal of the Plan would see it is little more than the result of political rhetoric and pre-emptive manoeuvring as a response to the perceived public disquiet about the state of the NHS. On the other extreme the optimist might view it as a positive plan for major improvement. (Moss et al 1995). Having the benefit of hindsight, there is no doubt that it has been the catalyst for a number of significant changes in the NHS, it is, of course, totally dependent upon your own particular viewpoint as to whether these changes are regarded as beneficial or otherwise. One has to be extremely careful in evaluating such comments as clearly it depends on the criteria chosen for evaluation as to whether the reform will appear to be positive or negative. (Bilsberry J. 1996) One only has to consider the debacle which ensued after the introduction of the Griffiths Report in the 1980s (Griffiths Report 1983). This was considered to be a major reform of the management structure of the NHS. There was general agreement that the management had become to unwieldy, detached and inefficient with too many layers of management. (Davies,C et al. 2000), The Griffiths Report was commissioned with the specific purpose of streamlining the management profile and was charged with the specific responsibility of improving both efficiency and accountability. The subsequent plan was unveiled and introduced piecemeal. In the words of the Government appointed reviewer of the episode :- These were a set of reforms that were designed to â€Å"streamline the administration â€Å" of the NHS. It involved a major change in emphasis in the way that the NHS was run, and in short, it was badly conceived, patchily implemented and introduced piecemeal. By any critical analysis it proved to be a complete disaster. (Davidmann 1988) It is not actually possible to pass judgement on whether the plan would have been successful or not as its method of introduction was generally seen to be its downfall. In essence, its introduction was not managed in any contemporary sense of the word, it was simply imposed and the chaos that ensued prompted the government to institute another report to glean what lessons it could form the whole affair. (Davidmann 1988). It is fair to comment that the majority of reforms that have been introduced since that time have been far more professionally managed and their introduction (whatever their eventual outcome) have generally been comparatively smooth and uneventful (Bennis et al 1999) The area of change management as a science and discipline is both extremely involved and complex. Changing the structure of a massive and established organisation such as the NHS is clearly difficult with established attitudes, working practices and inherent inertia. The lessons learned from the Griffiths Report appear to have been successfully applied to the introduction of the NHS Plan (Bryant 2005) In specific consideration of the NHS plan we should note that the specific stated aims of the plan were to:- Increase funding and reform Aim to redress geographical inequalities, Improve service standards, Extend patient choice. These aims have been, to some extent translated into reality. Let us examine each in detail. The increased funding was specifically delivered in the March 2000 budget settlement and has been honoured in successive budgets since. The Chancellor of the Exchequer stated that the money made available would ensure that the NHS would grow by one half in cash terms and by one third in real terms in just five years. Our examination of staffing levels (above) would seem to suggest that this trend has been successfully established. In addition, he promised a  £500 million â€Å"performance fund† for specific areas which were to be identified by separate investigation as being in particular need of assistance. (Halligan et al 2001) This certainly directly impinges upon our considerations of support staff and we shall return to this point later. The geographical inequalities and service standards are specifically addressed in the introduction of the National Service Frameworks which are mechanisms for specifically addressing inequalities and setting of both targets and goals of performance and excellence on a National rather than a local level, (Rouse et al 2001) and have been progressively rolled out across the country. These measures have been established in collaboration with assistance and guidance from bodies such as the National Institute for Clinical Excellence (NICE) which has a remit to examine both practices and facilities with the specific aim of achieving national standards. ( viz. NICE 2004) (NHS KSF 2004) It has made a number of recommendations which appear to have a firm evidence base. (Berwick D 2005) We should perhaps take this opportunity to note that the Institute, although undoubtedly set up in response to a worthy ideal, is already finding itself short of funding to do the job that it was originally conceived for. Spokesmen have already commented that it is short of money to achieve the research necessary to justify its continued activity (Shannon 2003) Patient choice is a far more complex issue that it might originally appear. Initial examination might suggest that to give patients the freedom to go where they wish to get their medical care is a fine objective, but closer examination of the issue would reveal that it has numerous pitfalls. In the specific terms of the NHS plan, it actually means that the patient’s primary healthcare team has a more wide-reaching choice of where they choose to refer the patient. (Wierzbicki et al 2001). A patient may consider any number of factors which may influence their choice of hospital including such factors as the general look of the buildings, the geographical site in relation to their friends and family and what they have read or heard anecdotally about the hospital. None of these factors have any major bearing on the treatment that they will receive. It may be that they will discover that the waiting list is shorter at hospital A than hospital B. what may well be less obvious to the patient is that hospital A may have a shorter waiting list because the local primary healthcare teams know that it has a number of serious shortcomings and so they tend to refer their patients to hospital B which consequently has a longer waiting list. Of course , we mustn’t ignore the possibility that hospital A is actually more efficient that hospital B or that hospital C provides a more comprehensive, courteous and efficient service with greater expertise than hospital D, but the primary healthcare teams are generally best placed to see the outcomes of their local hospitals and will generally know where their patients are served better in each individual circumstance. (after Donaldson L 2001) In the context of our examination here, all four of these aims have potential impact on our subject as each of these objectives are effectively resolved by expanding, and in some cases changing, the roles of staff within the NHS. Clearly the impact will vary between different disciplines and indeed, different geographical areas, but the overall objective of improving the efficiency and introduction of patient orientated goals has largely been met by the three expedients of: a) making more money available b) adopting progressive management strategies c) increasing staffing levels and redefining some roles within the NHS ( after Dixon et al 2003) It is perhaps useful to consider the whole of the NHS Plan as part of a reform continuum which has shaped the evolution of the NHS since its inception. We have already highlighted the Griffiths Reforms, but other landmark reforms that impact upon our considerations of change must include the Agenda for Change (2004) which is primarily staff and employment orientated and is concerned with a number of measures including staffing levels, staff role descriptions and staff pay levels. It has only recently been implemented (September 2005) and, for our purposes here, should be viewed in conjunction with another Government White Paper which is the complimentary NHS Knowledge and Skills Framework (KSF 2004). This particular paper targets the need for both recognising and rewarding specific speciality orientated enhancement of both skills and knowledge that are actually relevant to professional performance in both designated areas and in professional performance generally. Reading of the provisions reveals that the general provision of  £280 million over a three year period to â€Å"develop specific designated staff skills†. One of the proposed mechanisms is to set up individual learning accounts which will be worth  £150 per year. It is not yet clear what the impact will yet be on support staff in either specific or general terms. The impact of these reforms seems to be felt on many levels. There appears to be a move towards the redesignation of roles, flexible working, skill mix and the redesignation of professional boundaries. The NHS Plan itself calls for a number of changes to be made in working practices, both general (conceptual) and specific. It also calls for a change in the actual roles of some healthcare professionals, including support staff. It goes into great detail about the need for some of these changes need to be established but it also has to be observed that there is actually very little detail in the Plan as to how these changes are either to be introduced or managed. It refers to the changes in general terms, there is actually very little detail relating to what it expects these changes to actually be in reality. (Krogstad et al 2002) If one were to produce an analysis of the pre-2000 structure of the NHS one could conclude that it had three major problems which were not consistent with the function, structure and organisation of a typical 21st century industry a lack of national standards old-fashioned demarcations between staff and barriers between services a lack of clear incentives and levers to improve performance over-centralisation and disempowered patients. (Nickols 2004) One observation that is also relevant to our considerations here is the phrase â€Å"seamless interface† appears very frequently throughout the document. Although it is primarily applied to the interface between primary and secondary care, it is also, both explicitly and by implication, applied to the interface between different groups of professionals within both aspects of the service. (Rudd et al 1997) In direct consideration of our subject, we can take this to mean that there is a requirement for seamless interaction between all factions of the operating theatre staff and between them and the other professionals in the hospital. (Dixon et al 2003) Other significant milestones in the changes in the role of support staff were the introduction of the National Service Framework. These are a series of recommendations, stipulations and targets which are designed to raise the performance to the level of the best across the nation rather than to have pockets of excellence surrounded by a sea of mediocrity (White M 2005). The issues surrounding the National Service Frameworks are huge, as they collectively cover most of the major therapeutic areas in medicine. The reason for their inclusion in this particular consideration, is because of their collective impact on the role of the support staff, who have to expand their role and skills in order to comply with their requirements. It is completely impractical to consider all of the implications of the National Service Frameworks so, as a representative â€Å"sample† we will consider just one, the National Service Framework for the elderly. In distinct contrast to our comments in relation to the Griffiths Report earlier in this piece, the introduction of the National Service Frameworks could be considered nothing short of exemplary. There have been consultation periods, pre-implementation pilots and possibly most importantly, a well publicised and staged National roll-out programme which was designed to implement each of the strategies in a graded and controlled fashion with the intention of trying to ensure smooth implementation across the country. (Nickols F.2004). If we consider as an exploratory example, a small portion of the National Service Framework for the elderly Standard Two, this states that it should ensure that: Ensure that older people are treated as individuals and that they receive appropriate and timely packages of care which meet their needs as individuals, regardless of health and social services boundaries. One could perhaps reasonably hope that such aspirations would have been unnecessary, but behind the actual words are a number of other concepts that are central to our consideration to the expanding role of the support staff. The concept of â€Å"Person Centred Care† is a central precept of the Standard Two. It is described with the intention of trying to allow the elderly to feel entitled to be treated as individuals and also to allow them to retain responsibility for their own choices for their own care. The expansions of the roles of the support staff comes primarily in the adoption of the main tenet of the concept of Person Centred Care and that is the introduction of the Single Assessment Process (SAP). This recognises that there are effectively a great number of support agencies that potential can be involved to look after the needs of the elderly, both in hospital and after discharge. Prior to the introduction of the National Service Framework, it was common practice for each agency to separately make contact with the patient and make their own assessment in terms of their own distinct considerations. We shall discuss this point later in the context of insularity of specialities. The end result of this process was the fact that, very commonly, the same (or similar) facts are repeatedly elicited on different occasions with all the implications that this type of duplication has on inefficient working and waste of resources. (Fatchett A. 1998). The SAP is designed so that any member of the health care team can assemble the information in such a way and in such a format that it will be of use to the other members of the team, or for that matter any of the agencies who might have a legitimate need for the information. This particular role expansion is designed to assist in reducing the amount of red tape that appears to be an inevitable encumbrance of many of the measures that are designed to assist the elderly patient, and only appears to finish up by hampering them. (Gott M 2000). The adoption of the Single Assessment Process is no more than one example, perhaps not so much of an expansion of the role, but a realignment of the role of support staff. It is still a fairly new concept and is central to the aims of the National Service Framework that the needs and wishes of the patient should be at the heart of the whole process. Because it is new, the extent to which it can accommodate these aims and aspirations alongside the day to day practicalities of service provision still has yet to be fully assessed. (Mannion R et al 2005) In some ways, this new role expansion can be viewed in parallel with the concepts of seamless interfacing and multidisciplinary team working which we have examined elsewhere in this dissertation. Given the fact that the Single Assessment Process has only been operational since April 2004, but the move towards multidisciplinary team working and the concept of the seamless interface has been apparent and espoused for some years (Mason et al 2003). The latter were effectively translated into reality without major upheaval, one can be reasonably confident that the same will eventually be said for both the Single Assessment Process and its implications for both staff and patients. We have described this particular example of role expansion more as a realignment because, at first sight, its implications are quite subtle when compared to other examples that we shall be considering, but equally they are quite fundamental, as they impinge upon the role Role Expansion of Support Staff in the NHS Role Expansion of Support Staff in the NHS Abstract In this dissertation we examine the various aspects of role expansion of support staff within the confines of the NHS. We consider it on both a broad front and also make specific examination of those issues that concern staff connected with the operating theatres. We consider the background and political pressures that make role expansion desirable and possible. We also consider the implications of expansion in the NHS on both a professional and practical level. The issues are discussed in both specific and general terms. We illustrate three types of role expansion by reference to specific professional examples. One example is of the expansion from a caring role to that of the specialist provider, the second can be considered an example of role extension within a professional setting and the third is a natural expansion of the role which is required as technology and practice evolve. Methodology The methodology of this exploration was primarily by literature research. Progressive lines of enquiry were identified, researched and recorded. New lines of enquiry were identified as research progressed, and these were also examined for relevance and researched if considered appropriate to the theme of the dissertation. The literature search was mainly from library facilities. Local University, Post-Graduate hospital and public library facilities were extensively used together with some Internet based investigation. Some personal email enquiries were made from individuals who had experienced professional expansion and advice was taken in regard to both literature and direction of research. Introduction There is little doubt that the role of support staff has changed within the working lifetime of professionals currently working in the NHS. The thrust of this dissertation is to examine the means, the mechanisms and the degrees by which their role has changed. It barely needs stating that the NHS has changed. The political climate in which it operates has seen the NHS occupy varying positions of political prominence. Politicians are frequently seen publicly promising various sums of money for various projects of modernisation, expansion or generally to improve services. Every so often there is a major structural realignment of the management focus and mechanisms which, inevitably percolate through the tiers of control until the changes are felt at the level of the worker. In addition to this there are the technological changes which are largely independent of the politicians and the management structure. The rate of change in techniques, technology, support equipment and expertise appears to be increasing at an exponential rate. It clearly follows that the professional requirements of the support staff must keep pace with these changes and the training that they receive must inevitably reflect the needs of the ever changing working environment. (Ashburner L et al 1996) Evidence of change In any rational discussion, it is vital to work from a firm and secure evidence base. (EHC 1999). This requires careful and critical appraisal of the evidence and a decision as to just how applicable it is to the situation under consideration. In this dissertation we shall therefore be presenting evidence to support this evidence base together with appropriate assessments and judgements as to its validity. Most professionals working in the NHS would attest, if asked, to a perception of a continuous pace of change. Such anecdotal evidence, although interesting, is of little value to any form of critical appraisal. There are a number of reasonably â€Å"hard† statistics that give us much firmer evidence of change in the NHS. Let us consider some of the employment statistics published by the Department of Health for the NHS (whole of UK) and refers to non-medical staff. In 1997 the total number of NHS hospital and community based staff was 935,000. Of these 67% were direct care staff and 33% were management staff. The 67% direct care staff could be broken down into 330,620 nursing, midwifery and health visiting staff (246,010 being qualified) 100,440 scientific, therapeutic and technical staff 17,940 healthcare assistants 21,430 were managers the rest were estates, clerical and administrative staff 79% were women and 6% were from ethnic minorities (NSO 1998) If we compare this with the situation in 2000 by looking at the same parameters we can see: 346,180 nursing, midwifery and health visitor staff (256,280 were qualified). 110,410 scientific, therapeutic and technical staff 62,870 support staff and 23,140 healthcare assistants. 68% were direct care staff and 32% were management and support staff. 79% were women and 7% from the ethnic minorities (NSO 2001) And in 2001 we find a further difference, which is rather more dramatic: 458, 580 nursing, midwifery and health visitor staff (330,540 were qualified) 139,050 scientific, therapeutic and technical staff 23,140 healthcare assistants. 82% were women and 6% from the ethnic minorities (NSO 2002) If we go further back we can find evidence of 93,950 scientific, therapeutic and technical staff were employed, and there were 13,090 healthcare assistants in 1995 (NSO 1996) If we consider the documented trends in support staff we can trace 1995 93,950 1997 100,440 2000 110,410 2001 139,050 Over a comparatively short time there has clearly been a demonstrable increase in terms of numbers employed , nearly a 50% increase on the 1995 levels in six years. Reasons for change In opening this dissertation we made anecdotal reference to the political agenda that shaped the NHS. The NHS has historically been high in the public’s perception of a tangible measure of a Government’s success in delivering its regularly promised higher standard of living. It is partly for this reason, that successive governments have felt it politically expedient to invest increasing sums of money in measures for both expansion and improvement together with various drives aimed at increasing efficiency. (Ham C 1999) In the recent past there have been a raft of measures that have been produced which have all played their part in the evolution of the NHS to its current configuration and in doing so have expanded the role of not only the support worker but virtually all of the workers in the NHS at the same time. One of the first measures which was an overt indication of the forthcoming changes in working practice was the introduction of the performance indicators (Beecham L 1994) These were progressively introduced form 1992 onwards and in some respects could be considered the forerunner of the move towards National Service Frameworks. The original performance indicators imposed a duty or obligation on Trusts to carry out certain procedures within a specified maximum time. For example the indicators introduced in 1994-5 were on waiting times for first outpatient appointment and also for charters in General Practice. Although there were clear obligations on medical and nursing staff to make available sufficient sessions in order to see the patients, it is clear that the increased throughput of patients would clearly impact on the working practices (and work load) of the support staff. To a large extent, this can be seen from the figures presented at the beginning of this work. The 50% increase in staffing levels amongst the support staff reflects, in a large part, the changes that were consequent on the imposition of the performance indicators. The initial indicators proved to be quite onerous in terms of achieving compliance even though the later ones gave tighter requirements still. For example the 1994 indicators set a target of 90% of patients seen by a consultant within 26 weeks of a written referral letter being received from the General Practitioner in the major specialities of general medicine, general surgery and dermatology. (Editor BMJ 1994) It follows that this target is not quite as innocuous as it might at first appear. If we accept the fact that a substantial number of patients were already waiting for considerably longer than 26 weeks it represented a major shift in working practices to meet this particular deadline. Once the patients were seen it followed that they then had to have whatever treatment was thought to be appropriate. An increase in outpatients seen inevitably means an increase in patients waiting for inpatient treatment. So either the waiting lists go up further for inpatient treatment, or there is also a change of working practice to accommodate an increase in demand. This inevitably also impacts on the support staff as much as it does on the medical staff. (Langham S et al 1997) We shall consider this particular phenomenon in greater depth later when we consider the expansion of the nurse to specialist endoscopist and the running of one-stop clinics. Some novel methods were invoked to try to accommodate this shift in demand. There was a substantial increase in the frequency of day case surgery. Not only were a greater variety of surgical procedures being routinely carried out as day cases but it also resulted in more patients being assessed as suitable to undergo day case surgery. (HSE 2001) The same phenomenon of knock on effects arose form some of the other performance indicators. One of the original indicators was the percentage of patients seen within 5 mins of entering the casualty department. It follows that as hospitals strove to increase their performance indicators and the percentage of patients seen promptly rose, having been seen they then had to be treated and the same argument applies. Either there is an increase in the number of patients awaiting treatment in the A E departments, or there is a change in working practice to accommodate them and also to get them treated sooner. The organisation and efficiency of this system falls heavily on the support staff who clearly had to be able to accommodate this increased demand. (Langham S et al 1997) The indicators eventually began to involve inpatient statistics as well as outpatient ones. One, introduced in 1996, was on the number and availability of emergency operating theatres. More evidence of the reasons for this change comes from a paper by Scally and Donaldson (1998). We note that it was actually written by Liam Donaldson when he was a Regional Director of the NHS before he subsequently became Secretary of State for Health, so his comments can be taken with suitable gravitas. A critical analysis of the paper shows that it makes a number of points that are really overtly political, but it outlines the trend of change of emphasis where the improvements expected through clinical governance will not only be an â€Å"ideal goal† but will become a statutory requirement. This clearly pre-empts the changes prescribed in the NHS Plan. The paper outlines new goals â€Å"in which financial control, service performance, and clinical quality are fully integrated at every level† are behind the major thrust of the piece. Careful reading of the paper strongly suggests that inherent in the restructuring plans is a change in emphasis onto expansion of professional roles and greater working flexibility between professions which is fundamental to our considerations here. (Gray C 2005). We also note that the â€Å"stage was being set† for the potential role change of healthcare professionals in general and the four main precepts of this paper impact on that belief, namely: Clinical governance is to be the main vehicle for continuously improving the quality of patient care and developing the capacity of the NHS in England to maintain high standards (including dealing with poor professional performance) It requires an organisation-wide transformation; clinical leadership and positive organisational cultures are particularly important Professional self regulation will be the key to dealing with the complex problems of poor performance among clinicians New approaches are needed to enable the recognition and replication of good clinical practice to ensure that lessons are reliably learned from failures in standards of care It is clearly significant that all of these points were implemented and indeed, expanded, when Donaldson was appointed to the office of Secretary of State for Health and they can be seen as both enhancing and reinforcing the points that we have presented relating to the guidance from the Nursing Midwifery Council about the expansion of professional roles. Because of their seminal importance in the examination of our subject, let us consider the background to these points further. We note that Donaldson was originally recruited from a business background and the record shows that he has chosen to apply a great many sound and proven business principles to both the structuring and the workings of the NHS. Many of his strategies and perhaps ideas, have a clear ancestry in the Cadbury Report (1992) which effectively analysed the overall impact of governance and issues of changing working practices and consequent responsibility in the business world. The report focused on the issues surrounding an expansion of responsibility and a consequent failure to take responsibility for one’s actions, frequently passing on the implied responsibility to another employee in the same company. It found this practice to be both counterproductive and inefficient and frequently would lead to defensive stances and attitudes being adopted. When problems arose, they were therefore far more difficult to actively solve. (Lakhani M 2005) Donaldson was instrumental in applying this strategy to a clinical setting within the working practices of the NHS. This particular paper takes the view that by promoting individual professional responsibility he would be encouraging a system that would allow:- NHS organisations to be accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. By implication this argument extends to the expansion and role realignment in general terms throughout the NHS. We shall consider the elements in this paper which are of relevance to these arguments. Staff self-esteem is of great value to an organisation. Frequently this is associated with increased responsibility and a firm professional footing. (Davies HTO et al. 2000). Donaldson and Scally clearly espouse the virtue of professional responsibility at all levels in an organisation and encourage staff to take, rather than to devolve responsibility for their actions and indeed seek to ideally provide a ambience that is conducive to expansion of responsibility which therefore generally benefits the whole organisation. Tools of change Although we are primarily considering the support worker in this dissertation we must first broaden the agenda in order to set our examination in an appropriate context. There have been a number of Government White Papers, consultative documents and advisory initiatives that have concerned the workings of the NHS. Some have greater practical significance than others. There appear to have been significantly more in the last decade than previously and anecdotal and observational evidence would seem to suggest that these too, are increasing at an exponential rate. One of the landmark plans in recent years has been the NHS Plan. It has been compared by some commentators as being on comparative magnitude as the original inception of the NHS in 1948 (Shortell SM et al 1998). It is quite possible that a cynical appraisal of the Plan would see it is little more than the result of political rhetoric and pre-emptive manoeuvring as a response to the perceived public disquiet about the state of the NHS. On the other extreme the optimist might view it as a positive plan for major improvement. (Moss et al 1995). Having the benefit of hindsight, there is no doubt that it has been the catalyst for a number of significant changes in the NHS, it is, of course, totally dependent upon your own particular viewpoint as to whether these changes are regarded as beneficial or otherwise. One has to be extremely careful in evaluating such comments as clearly it depends on the criteria chosen for evaluation as to whether the reform will appear to be positive or negative. (Bilsberry J. 1996) One only has to consider the debacle which ensued after the introduction of the Griffiths Report in the 1980s (Griffiths Report 1983). This was considered to be a major reform of the management structure of the NHS. There was general agreement that the management had become to unwieldy, detached and inefficient with too many layers of management. (Davies,C et al. 2000), The Griffiths Report was commissioned with the specific purpose of streamlining the management profile and was charged with the specific responsibility of improving both efficiency and accountability. The subsequent plan was unveiled and introduced piecemeal. In the words of the Government appointed reviewer of the episode :- These were a set of reforms that were designed to â€Å"streamline the administration â€Å" of the NHS. It involved a major change in emphasis in the way that the NHS was run, and in short, it was badly conceived, patchily implemented and introduced piecemeal. By any critical analysis it proved to be a complete disaster. (Davidmann 1988) It is not actually possible to pass judgement on whether the plan would have been successful or not as its method of introduction was generally seen to be its downfall. In essence, its introduction was not managed in any contemporary sense of the word, it was simply imposed and the chaos that ensued prompted the government to institute another report to glean what lessons it could form the whole affair. (Davidmann 1988). It is fair to comment that the majority of reforms that have been introduced since that time have been far more professionally managed and their introduction (whatever their eventual outcome) have generally been comparatively smooth and uneventful (Bennis et al 1999) The area of change management as a science and discipline is both extremely involved and complex. Changing the structure of a massive and established organisation such as the NHS is clearly difficult with established attitudes, working practices and inherent inertia. The lessons learned from the Griffiths Report appear to have been successfully applied to the introduction of the NHS Plan (Bryant 2005) In specific consideration of the NHS plan we should note that the specific stated aims of the plan were to:- Increase funding and reform Aim to redress geographical inequalities, Improve service standards, Extend patient choice. These aims have been, to some extent translated into reality. Let us examine each in detail. The increased funding was specifically delivered in the March 2000 budget settlement and has been honoured in successive budgets since. The Chancellor of the Exchequer stated that the money made available would ensure that the NHS would grow by one half in cash terms and by one third in real terms in just five years. Our examination of staffing levels (above) would seem to suggest that this trend has been successfully established. In addition, he promised a  £500 million â€Å"performance fund† for specific areas which were to be identified by separate investigation as being in particular need of assistance. (Halligan et al 2001) This certainly directly impinges upon our considerations of support staff and we shall return to this point later. The geographical inequalities and service standards are specifically addressed in the introduction of the National Service Frameworks which are mechanisms for specifically addressing inequalities and setting of both targets and goals of performance and excellence on a National rather than a local level, (Rouse et al 2001) and have been progressively rolled out across the country. These measures have been established in collaboration with assistance and guidance from bodies such as the National Institute for Clinical Excellence (NICE) which has a remit to examine both practices and facilities with the specific aim of achieving national standards. ( viz. NICE 2004) (NHS KSF 2004) It has made a number of recommendations which appear to have a firm evidence base. (Berwick D 2005) We should perhaps take this opportunity to note that the Institute, although undoubtedly set up in response to a worthy ideal, is already finding itself short of funding to do the job that it was originally conceived for. Spokesmen have already commented that it is short of money to achieve the research necessary to justify its continued activity (Shannon 2003) Patient choice is a far more complex issue that it might originally appear. Initial examination might suggest that to give patients the freedom to go where they wish to get their medical care is a fine objective, but closer examination of the issue would reveal that it has numerous pitfalls. In the specific terms of the NHS plan, it actually means that the patient’s primary healthcare team has a more wide-reaching choice of where they choose to refer the patient. (Wierzbicki et al 2001). A patient may consider any number of factors which may influence their choice of hospital including such factors as the general look of the buildings, the geographical site in relation to their friends and family and what they have read or heard anecdotally about the hospital. None of these factors have any major bearing on the treatment that they will receive. It may be that they will discover that the waiting list is shorter at hospital A than hospital B. what may well be less obvious to the patient is that hospital A may have a shorter waiting list because the local primary healthcare teams know that it has a number of serious shortcomings and so they tend to refer their patients to hospital B which consequently has a longer waiting list. Of course , we mustn’t ignore the possibility that hospital A is actually more efficient that hospital B or that hospital C provides a more comprehensive, courteous and efficient service with greater expertise than hospital D, but the primary healthcare teams are generally best placed to see the outcomes of their local hospitals and will generally know where their patients are served better in each individual circumstance. (after Donaldson L 2001) In the context of our examination here, all four of these aims have potential impact on our subject as each of these objectives are effectively resolved by expanding, and in some cases changing, the roles of staff within the NHS. Clearly the impact will vary between different disciplines and indeed, different geographical areas, but the overall objective of improving the efficiency and introduction of patient orientated goals has largely been met by the three expedients of: a) making more money available b) adopting progressive management strategies c) increasing staffing levels and redefining some roles within the NHS ( after Dixon et al 2003) It is perhaps useful to consider the whole of the NHS Plan as part of a reform continuum which has shaped the evolution of the NHS since its inception. We have already highlighted the Griffiths Reforms, but other landmark reforms that impact upon our considerations of change must include the Agenda for Change (2004) which is primarily staff and employment orientated and is concerned with a number of measures including staffing levels, staff role descriptions and staff pay levels. It has only recently been implemented (September 2005) and, for our purposes here, should be viewed in conjunction with another Government White Paper which is the complimentary NHS Knowledge and Skills Framework (KSF 2004). This particular paper targets the need for both recognising and rewarding specific speciality orientated enhancement of both skills and knowledge that are actually relevant to professional performance in both designated areas and in professional performance generally. Reading of the provisions reveals that the general provision of  £280 million over a three year period to â€Å"develop specific designated staff skills†. One of the proposed mechanisms is to set up individual learning accounts which will be worth  £150 per year. It is not yet clear what the impact will yet be on support staff in either specific or general terms. The impact of these reforms seems to be felt on many levels. There appears to be a move towards the redesignation of roles, flexible working, skill mix and the redesignation of professional boundaries. The NHS Plan itself calls for a number of changes to be made in working practices, both general (conceptual) and specific. It also calls for a change in the actual roles of some healthcare professionals, including support staff. It goes into great detail about the need for some of these changes need to be established but it also has to be observed that there is actually very little detail in the Plan as to how these changes are either to be introduced or managed. It refers to the changes in general terms, there is actually very little detail relating to what it expects these changes to actually be in reality. (Krogstad et al 2002) If one were to produce an analysis of the pre-2000 structure of the NHS one could conclude that it had three major problems which were not consistent with the function, structure and organisation of a typical 21st century industry a lack of national standards old-fashioned demarcations between staff and barriers between services a lack of clear incentives and levers to improve performance over-centralisation and disempowered patients. (Nickols 2004) One observation that is also relevant to our considerations here is the phrase â€Å"seamless interface† appears very frequently throughout the document. Although it is primarily applied to the interface between primary and secondary care, it is also, both explicitly and by implication, applied to the interface between different groups of professionals within both aspects of the service. (Rudd et al 1997) In direct consideration of our subject, we can take this to mean that there is a requirement for seamless interaction between all factions of the operating theatre staff and between them and the other professionals in the hospital. (Dixon et al 2003) Other significant milestones in the changes in the role of support staff were the introduction of the National Service Framework. These are a series of recommendations, stipulations and targets which are designed to raise the performance to the level of the best across the nation rather than to have pockets of excellence surrounded by a sea of mediocrity (White M 2005). The issues surrounding the National Service Frameworks are huge, as they collectively cover most of the major therapeutic areas in medicine. The reason for their inclusion in this particular consideration, is because of their collective impact on the role of the support staff, who have to expand their role and skills in order to comply with their requirements. It is completely impractical to consider all of the implications of the National Service Frameworks so, as a representative â€Å"sample† we will consider just one, the National Service Framework for the elderly. In distinct contrast to our comments in relation to the Griffiths Report earlier in this piece, the introduction of the National Service Frameworks could be considered nothing short of exemplary. There have been consultation periods, pre-implementation pilots and possibly most importantly, a well publicised and staged National roll-out programme which was designed to implement each of the strategies in a graded and controlled fashion with the intention of trying to ensure smooth implementation across the country. (Nickols F.2004). If we consider as an exploratory example, a small portion of the National Service Framework for the elderly Standard Two, this states that it should ensure that: Ensure that older people are treated as individuals and that they receive appropriate and timely packages of care which meet their needs as individuals, regardless of health and social services boundaries. One could perhaps reasonably hope that such aspirations would have been unnecessary, but behind the actual words are a number of other concepts that are central to our consideration to the expanding role of the support staff. The concept of â€Å"Person Centred Care† is a central precept of the Standard Two. It is described with the intention of trying to allow the elderly to feel entitled to be treated as individuals and also to allow them to retain responsibility for their own choices for their own care. The expansions of the roles of the support staff comes primarily in the adoption of the main tenet of the concept of Person Centred Care and that is the introduction of the Single Assessment Process (SAP). This recognises that there are effectively a great number of support agencies that potential can be involved to look after the needs of the elderly, both in hospital and after discharge. Prior to the introduction of the National Service Framework, it was common practice for each agency to separately make contact with the patient and make their own assessment in terms of their own distinct considerations. We shall discuss this point later in the context of insularity of specialities. The end result of this process was the fact that, very commonly, the same (or similar) facts are repeatedly elicited on different occasions with all the implications that this type of duplication has on inefficient working and waste of resources. (Fatchett A. 1998). The SAP is designed so that any member of the health care team can assemble the information in such a way and in such a format that it will be of use to the other members of the team, or for that matter any of the agencies who might have a legitimate need for the information. This particular role expansion is designed to assist in reducing the amount of red tape that appears to be an inevitable encumbrance of many of the measures that are designed to assist the elderly patient, and only appears to finish up by hampering them. (Gott M 2000). The adoption of the Single Assessment Process is no more than one example, perhaps not so much of an expansion of the role, but a realignment of the role of support staff. It is still a fairly new concept and is central to the aims of the National Service Framework that the needs and wishes of the patient should be at the heart of the whole process. Because it is new, the extent to which it can accommodate these aims and aspirations alongside the day to day practicalities of service provision still has yet to be fully assessed. (Mannion R et al 2005) In some ways, this new role expansion can be viewed in parallel with the concepts of seamless interfacing and multidisciplinary team working which we have examined elsewhere in this dissertation. Given the fact that the Single Assessment Process has only been operational since April 2004, but the move towards multidisciplinary team working and the concept of the seamless interface has been apparent and espoused for some years (Mason et al 2003). The latter were effectively translated into reality without major upheaval, one can be reasonably confident that the same will eventually be said for both the Single Assessment Process and its implications for both staff and patients. We have described this particular example of role expansion more as a realignment because, at first sight, its implications are quite subtle when compared to other examples that we shall be considering, but equally they are quite fundamental, as they impinge upon the role