White oleander Essay Example For Students

White oleander Essay White Oleander, a dramatic fiction by Janet Fitch, was published by Little, Brown and Company in Boston. The story is about a mother and daughter, Ingred and Astrid have a very unusual relationship. Ingred loves her daughter but never asks her what she thinks so therefore doesnt know her daughter too well. Such as she does not know of her daughters yearning for a father. Ingred makes it very clear that she will not allow herself to get close to a man. She is a very brilliant, beautiful poet, who is adored by a man named Barry Kolker. He goes to all of her readings, and asks her out each time. One of the times Barry invites her to go to the Gamelan, an orchestra. Loving the Gamelan, she accepts. Her and Astrid join Barry, and they begin talking more. They start going out more, but each time she makes and stands by regulations, such as he will invite her to eat after an event where they had not planned on eating and she will refuse, because she doesnt like to get attached to men, and d oesnt want to spend anymore time than she had already allotted. All of a sudden, her rules start diminishing. One time, there was a knock at her door, and it was Barry. She thought to herself, how dare he just come without an invitation?. When she opened the door (a knife in her hand), he had a bottle of wine, and bag of something that smelled good. To Astrids surprise she did something least expected. She invited him in. One night Barry said he would be over to her house at 9 and never showed. So the next day, Ingred showed up unannounced at Barrys and she went inside and they made love. Immediately after, he told Ingred she had to leave because he had a date coming. She wanted to seek revenge. She started showing up at every place he was at. She broke into his house. He tried to go to her house and make her stop the nonsense. He tried forcing his way in her house, and she stabbed him in the hand. He left, and the next day she went to his house, where she found he had changed the l ocks. She broke in and placed white oleanders in his milk, oyster sauce and cottage cheese, and one in his toothpaste. She made an arrangement of white oleanders on his table, and scattered blooms on his bed. A police officer came to Ingreds house, and told her that Barry is accusing her of breaking and entering, and trying to poison him. She calmly stated that Barry is angry with her. She broke up with him and that he couldnt get over her. Ingred and Astrid took trip to Tijuana and Ingred bought a bottle of medicine called, DMSO, which helps drugs absorb through your skin (DMSO helps nicotine patches work), and uses that to poison him. He dies. Ingred is eventually placed in jail, leaving Astrid to jump from foster home to foster home. Her first foster home is with a mother named Star. Star is a busty, and leggy, ex-coke addict turned Christian. Star has a boyfriend named Ray, and Astrid falls in love with him. Astrid, 13, has an affair with the 40-something Ray. Star gets jealous of their friendship and gets suspicious. One day, Star comes in, in a drunken rage and shoots Astrid. Astrid is immediately removed and placed in a second home, the home of Ed and Marble Turlock. At this home, she was treated like a slave. She was forced to clean and baby-sit, and was never shown any affection, and was never introduced to anyone. Astrid makes friends with a black neighbor, named Olivia Johnston, who the prejudiced Marble condemns a hooker. When Marble finds that Astrid is friends with her, Marble beats her up, and she once again gets moved, which she finds out at school, with her bags already packed for her, and no chance to say good-byes. The third house, was a big, beautiful estate. Amelia, the foster mother took in girls as slaves, and when she would leave, she would lock the refrigerator, and there was only one phone which no one could use. Astrid was starving, and began digging through the trash cans at school, when someone caught her and made fun of her, she s topped going to school. She started pan handling at liquor stores so she could get change to call her case worker to tell her what had been happening. She finally got a hold of her and was removed from that home. .uf43175ae3ca751a33ff4945f72dc2bcc , .uf43175ae3ca751a33ff4945f72dc2bcc .postImageUrl , .uf43175ae3ca751a33ff4945f72dc2bcc .centered-text-area { min-height: 80px; position: relative; } .uf43175ae3ca751a33ff4945f72dc2bcc , .uf43175ae3ca751a33ff4945f72dc2bcc:hover , .uf43175ae3ca751a33ff4945f72dc2bcc:visited , .uf43175ae3ca751a33ff4945f72dc2bcc:active { border:0!important; } .uf43175ae3ca751a33ff4945f72dc2bcc .clearfix:after { content: ""; display: table; clear: both; } .uf43175ae3ca751a33ff4945f72dc2bcc { display: block; transition: background-color 250ms; webkit-transition: background-color 250ms; width: 100%; opacity: 1; transition: opacity 250ms; webkit-transition: opacity 250ms; background-color: #95A5A6; } .uf43175ae3ca751a33ff4945f72dc2bcc:active , .uf43175ae3ca751a33ff4945f72dc2bcc:hover { opacity: 1; transition: opacity 250ms; webkit-transition: opacity 250ms; background-color: #2C3E50; } .uf43175ae3ca751a33ff4945f72dc2bcc .centered-text-area { width: 100%; position: relative ; } .uf43175ae3ca751a33ff4945f72dc2bcc .ctaText { border-bottom: 0 solid #fff; color: #2980B9; font-size: 16px; font-weight: bold; margin: 0; padding: 0; text-decoration: underline; } .uf43175ae3ca751a33ff4945f72dc2bcc .postTitle { color: #FFFFFF; font-size: 16px; font-weight: 600; margin: 0; padding: 0; width: 100%; } .uf43175ae3ca751a33ff4945f72dc2bcc .ctaButton { background-color: #7F8C8D!important; color: #2980B9; border: none; border-radius: 3px; box-shadow: none; font-size: 14px; font-weight: bold; line-height: 26px; moz-border-radius: 3px; text-align: center; text-decoration: none; text-shadow: none; width: 80px; min-height: 80px; background: url(https://artscolumbia.org/wp-content/plugins/intelly-related-posts/assets/images/simple-arrow.png)no-repeat; position: absolute; right: 0; top: 0; } .uf43175ae3ca751a33ff4945f72dc2bcc:hover .ctaButton { background-color: #34495E!important; } .uf43175ae3ca751a33ff4945f72dc2bcc .centered-text { display: table; height: 80px; padding-left : 18px; top: 0; } .uf43175ae3ca751a33ff4945f72dc2bcc .uf43175ae3ca751a33ff4945f72dc2bcc-content { display: table-cell; margin: 0; padding: 0; padding-right: 108px; position: relative; vertical-align: middle; width: 100%; } .uf43175ae3ca751a33ff4945f72dc2bcc:after { content: ""; display: block; clear: both; } READ: Smile And War Essay We will write a custom essay on White oleander specifically for you for only $16.38 $13.9/page Order now She is then sent to the home of Claire and Ron. Claire couldnt have children and loved Astrid as her own. She was behind Astrid all the way with her goals, like drawing and painting. Claire, however, had psychiatric depression and suspected Ron of cheating on her. It got too hard on Claire, and she committed suicide. This had been the longest time Astrid had been in a home. Ron had a business and it had been his idea to adopt Astrid, so that Claire wouldnt be lonely. When Claire killed herself, Ron couldnt take care of her. She was sent to to a shelter where she meets a guy named Adam and they become good friends. She gets adopted by a woman named Reina where there are no rules, but a very dysfunctional house, where, they would drink and do drugs, which Astrid begins to do, too. For survival, Reina and the girls collect and sell belongings like an everyday yard sale. Throughout this time, Astrid keeps in touch with Adam. She turns 18 and decides to leave. She moves in with Adam in Ne w York, and they fall in love. Astrid learns to forgive her mother, and she finally is getting to have a normal life, and put the past behind her. This is an extremely well written book, that will leave you feeling the same emotions as Astrid, from confusion, to terror, to despair, and finally to a restored feeling of hope. I would recommend this book to anyone who likes good dramas. This book is a real page-turner, which leaves you wondering what is going to happen next. Bibliography:

Genocide Thesis essays

Genocide Thesis essays Although, some feel that the actions taken by the colonists towards the Native Americans were justified, in reality, there actions were both brutal and hostile, making them guilty of genocide. Their guilt was visible by events such as the landing of the pilgrims and the attack of Fort Mystic. A person may believe that the English colonists were not guilty of genocide because they did not have straight forward plans to murder every Indian in order to get more land, it just appeared that way. Also, they may think that it wasnt completely the Englishs fault because the Indians would always have to do a retaliation after every attack. These thought are all completely false. The English colonists went into this battle with to intentions of killing every Indian, making it genocide. Also, a retaliation was the only thing the Indians could do to have a chance at staying alive. They did not want to just sit there and let themselves be murdered. As settlers from Massachusetts moved west into the Connecticut River valley, they clashed with the powerful Pequots. Massachusetts Bay Colony dispatched an officer with orders "to kill every Indian male he found. The victims were mostly men, however there where several women and children slaughtered. The Pequots wondered if the killing of these innocent women and children really served a purpose. The English responded by answering Wait and See. In response, the Pequots killed nine settlers. Men, women and children included. The attitude and the actions taken by the English were not only destructive, but unnecessary. By killing these innocent people it was a deliberate act of genocide. These people did not need to die, nor did they need to lose there land. The English were just land lust and did whatever it took to wipe this entire racial group out so they could have there chunk of land. The actions taken by the Pequots to kill the 9 settlers probably was no...

Re-education Essay Example | Topics and Well Written Essays - 500 words

Re-education - Essay Example ractice was because of the growing concerns about the changes in the health centre particularly the health care delivery system and in the field practice as well. In realizing of the dire need of professional nurses in the health care centre, the faculty decided to re-educate the health care providers on the hand cleaning hygiene practice. To ensure the effectiveness in the health care field, the team carried out a research on hand washing practice using Dettol soap in South Africa for a period of six months. After the research period, in which the assigned students acted as receptor, it was evident that families that washed their hand regularly feel ill less often. As a healthcare practitioner, I would undertake various leadership strategies to ensure the success of the project. One of the essential objectives of health care provider requires is to attain organizational skills and ensure the patient safety. The understanding and skills in leadership ensure that the health care provider offer quality services to patient to provide quality health care (ACCN, 2009). In the research, it was clear that washing hands prevent spread of germs from one person to another. Another reason for the hand-cleaning project was the fact that fundamental rules entail scholarship for evidence-based practice. As such, the health care providers are entitled to translate current evidence into practice thus; the hand-washing project is a confirmation that there was a research carried out regarding the topic. An initial thought of people who should attend my project presentation is the untrained medical practitioners. It is important for them to understand that a crucial element is the intercommunication between health providers, which is important in improving the patient health care due to shared ideas (In Burns, S. & AACN, 2010). The information can assist the researcher to recognize their professionalism and their values such as dignity and integrity. Moreover, they should

It Is Important to Identify and Meet the Individual Needs of Learners Research Paper

It Is Important to Identify and Meet the Individual Needs of Learners - Research Paper Example As a teacher, planning is one of the very essential roles as it helps in directing or guiding me in delivering. My planning depends on the various individual needs identified; that prompt me to apply the necessary teaching strategy. This dependency is due to my requirement to ensure that these needs of my students are all properly attended to within my planning. Without this planning, it would be difficult to meet the individual needs of every of my students, and many of them might not follow in line with the curriculum. Therefore, it may result in dissatisfaction and/or de-motivation to the students and me as the students would feel not well catered for and I may feel I have underperformed in my teaching role as a planner. Also, it is a part of my teaching responsibility to allow the involvement of learners in the planning of assessments. Since learners are not to be subjected to surprise tests, I always involve them in the planning process while giving them chances to make their su ggestions. This way, they may not feel put in overwhelming situations. Furthermore, they will have a feeling of a sense of ownership. That way, the planning process can meet every learner’s individual need, by the consideration of different resources that enhance effective and fair test. It is the responsibility of a teacher that requires me to implement/deliver teaching according to design and plan while including diversity and equality promotion. It is essential for educators to recognize the influence of culture on learning.

Reflective account - Personal Development Plan Essay

Reflective account - Personal Development Plan - Essay Example rform effectively in their allocated work, they will achieve professional advancement both hierarchically and importantly at the personal or mental level. When an employee performs and develops optimally more than their fellow employees, he/she will be given leadership position, utilizing which they can develop their leadership capabilities. As when they develop their leadership skills, employee or individual should also need to develop certain qualities or traits, and one among them is time management. Time management with apt incorporation of quality standards is a key trait. Likewise, if the individual need to develop extra skills like new language acquisition, then they have to do that as well as part of optimal development of leadership. So, this paper will analyze, how I developed my leadership skills and as part of that development followed key traits of time management as well as new language acquisition. The known is, from time immemorial, the success or failure of an organization or any other human activity depends on the role, the leader plays. According to me, if the leader follows a set of positive traits and performs effectively, he/ she can ‘sprinkle’ or even ‘pour’ success on many lives, including the workers in his/her organization. Normally, the leadership traits should be visible and should be put to effective use when the leader, as a ‘builder’ builds a group and as a ‘founder’ launches an organization. However, in my case, a situation to develop my leadership skills arose when I got a chance to preside over or manage an on going project in my organization. As the building or recruiting of the ‘group’ of workers as well as the installation of infrastructure, set up, etc needed for the specific project has already taken place, my was only to lead and manage the team. This job of taking an existing set up and managing it is not an easy job because it brings in set of challenges, mainly involving the employees. I did not

Hip Fracture Treatment in Older Patients

Hip Fracture Treatment in Older Patients 1.1 Background Hip (neck of femur) fractures are a common, serious and well-defined injury affecting mainly older people. As global populations age, projections for hip fracture numbers over the coming decades will rise. Delays to surgery are associated with increased post-operative complications, prolonged recovery and length of stay (LOS), and with increased morbidity and mortality (Trpeski, Kaftandziev, and Kjaev, 2013). In addition, the cost burden of hip fractures is substantial. The process of caring for people with hip fractures is complex, long, and involves several diagnostic, therapeutic and administrative activities. These activities occur in AE and orthopaedic departments, operating theatres, and in the community. They involve a range of health professionals and support staff. When this coordination fails, patients may suffer from avoidable delays and suffering. In the United Kingdom (UK), the bed occupancy rate for hip fractures was more than 1.5 million days, which represent 20% of th e total orthopaedic beds (Compston et al., 2009). The lifetime risk of sustaining a hip fracture in the UK from age 50 is around 11% for women and 3% for men (Van Staa et al., 2001). Many of those who recover suffer a loss in mobility and independence: approximately half of those previously independent become partly dependent, while one-third become totally dependent (Myers et al., 1996). 1.2 Current Process Watford General Hospital (WAT) treat 450 patients for hip fractures every year. Hip fractures are one of the most common complex trauma problems orthopaedic surgeons face. Patients are often seriously ill, elderly and frail, which can result in poor outcomes. Hip fractures generally result from a fall, patients present at AE where imaging tests are used to make a diagnosis and pain medication is administered (Appendix A). When possible, patients are moved from the emergency department to a ward. Ideally, patients will have surgery within 72 hours of arrival at hospital, provided they are in a stable condition. A pre-operative assessment is carried out to establish the patients overall health to make sure they are ready for surgery. They also have an anaesthetic assessment. Two main types of anaesthesia are used: general anaesthetic and spinal or epidural anaesthesia. A team of healthcare professionals will perform the surgery, including an orthopaedic surgeon. The National Hip Fracture Database (NHFD) produce an annual report that includes an analysis of 30-day mortality rates for hip fracture patients who are over 60 years old within the UK. WAT were alerted by the NHFD that they were an outlier, with 12% mortality over 3 years. In the UK the overall mortality rate within 30 days of hip fracture in 2014 was 7.5%   (Johansen, 2016). High mortality rates are a signal to hospitals that they should investigate to identify and resolve quality issues. Figure 1Funnel Plot of Crude and Adjusted Mortality Rates 2014 (Source: Johansen, 2016) Effective strategies are needed to reduce the burden on healthcare providers and to improve patient quality of life and outcomes after a hip fracture. Staff at WAT want to develop an action plan to analyse performance and instigate improvement programmes. This included questioning what elements of care could have been delivered better to ensure that high-quality care is delivered throughout the patients treatment, to improve 30-day mortality rates and functional outcomes for patients. 1.3 Perceived Issues with the Current Process In the present study, the incidence and mortality and functional outcomes in hip fracture patients was studied. The relationships between admission and treatment times, pain management drugs and anaesthesia, and their effect on the patients length of stay (LOS) in hospital were assessed and the following issues were found: Admission time from AE to treatment is high High level of opiate usage to manage pain Routine use of general anaesthesia 1.4 Value Adding Activities Admission to surgery times Pain management Days spent in hospital 1.5 Scope Older people with hip fractures aged 60 or over are in scope for this project.       1.6 Problem Statement 30-day mortality rates for older hip fracture patients at Watford General Hospital have been 12% for 3 consecutive years, 4.5% higher than the national average (NHFD). 1.7 Goal Statement Reduce 30-day mortality rates in older hip fracture patients to 8.5% by the end of June 2017. 2.1 Process Map Figure 2 Process Map 2.2 Process Narrative      Ã‚   The person arrives at the AE department by ambulance or car. The triage nurse assesses the patients condition. Patients are classified by severity of injury (red, yellow, or green). Patients presenting with suspected hip fractures are commonly assigned a yellow classification, which indicates an emergency but not of a life-threatening nature. An AE doctor or nurse checks the patients vital signs, records their pre-fall health condition, and administers pain medication (generally opiates). Subsequently, in consultation with an AE doctor (if available), several basic tests (blood tests) and X-rays (hip and often chest) are ordered and performed. The patient is transferred to the radiology department for x-ray. The AE doctor or nurse then reviews the test results. If a hip fracture is diagnosed, the patient is deemed admissible and an intravenous (IV) drip is started. The patient is transferred to the orthopaedic ward for admission when a bed becomes available. Admission times are curre ntly 13.4 hours. On admittance to the orthopaedic ward an orthopaedic surgeon will review the test results. If the patient is deemed suitable for treatment the medical assessment team will assess if the patient has any existing medical issues that may affect treatment. If pre-existing medical conditions with the potential to affect treatment are found patients are referred to palliative care and discharged. If no pre-existing conditions are found patients are assessed by the anaesthesia team. Patients deemed suitable for surgery are placed on the trauma list, surgery generally takes place within 72 hours. Patients deemed unsuitable are referred to palliative care and discharged. Patients go to theatre, they are anesthetised using general anaesthetic and receive surgery. They are subsequently transferred back to the orthopaedic ward for ward-based management. Patients are discharged once they are mobile. 2.3 Identification of Problems, Weaknesses, and Change Areas High level of opiate use by AE staff for pain management Admission times of 13.4 hours Surgery wait times of up to 58.6 hours Routine use of general anaesthetic in surgery 3.1 Key Strategic Elements for Improvement Patients with hip fractures often require complex and challenging care, this is provided by a number of professionals in several departments, crossing a number of service boundaries. These patients are often frail, and their outcomes depend on how effectively their care pathway is managed. Pain management medications, avoidable delays, anaesthesia choices and post-operative care affect functional outcomes and mortality. The key strategic elements towards improving outcomes for older hip fracture patients are: Reducing morbidity and mortality rates Achieving better functional outcomes for patients Increasing discharge rates to original place of residence Increased value from the healthcare budget They can be achieved by: Altering pain management practices Altering anaesthetic management Reducing admission and treatment times 3.1.1 Pain Management Despite recent advances in the care of hip fracture patients, significant morbidity and mortality persists. Some of this is attributable to the pain medication administered in hospital. Opiates are the preferred pain management drug at WAT currently (Appendix A). Opiate use can cause nausea, constipation, and confusion (delirium) in the older patients (Coruhlu and Pehlivan, 2016). Effective pain management is a primary goal in hip fracture treatment. Research suggests fascia iliaca compartment blocks (FIB) is an alternative for pain management in hip fractures. Intravenous opioid therapy is used frequently (Appendix A). However, opioid side effects, such as nausea, vomiting and delirium, are common. Regional analgesic techniques have been shown to provide similar analgesia to opioids. FIB is reported to effectively block cutaneous lateral femoral and femoral nerves in adults (Nie et al., 2015). Studies have suggested superior analgesic effect with pre-operative FIB. They provided superior analgesia to intramuscular morphine in a randomised controlled trial of hip fracture patients (Callear et al., 2016). FIB is a safe and simple technique that can be administered by junior doctors and specialist nurses with training (Hanna et al., 2014). FIB administered in AE provided significant decreases in pain when compared to opiates. Post block analgesic requirements for patients in the FIB group were minimal. A study conducted by Callear and Shah (2016) concluded that a single dose of FIB given in the pre-operative period significantly reduced the post-operative and total analgesic requirements in the hip fracture patient. Patients also experience lower rates of delirium and were discharged faster. This reduces the cost of providing inpatient hospital beds and improves quality of life for older patients. 3.1.2 Anaesthetic Management Anaesthetists have an essential role in the preoperative, operative and postoperative management of hip fracture patients. Complications arising from anaesthesia in hip fracture surgery is influenced not only by the type of anaesthetic used, but also by patient comorbidities and the delays between admission and surgery. Approximately 25% of hip fracture patients display at least one episode of cognitive dysfunction during hospitalisation (Heyburn et al., 2012). A systematic review published by SIGN (2009), suggests that the use of spinal anaesthesia may reduce the incidence of postoperative confusion. 3.1.3 Time to Surgery At present admission times are 13.4 hours (NHFD statistics show the national average is 9.3 hours) and surgery wait times are 58.6 hours. Current guidelines recommend surgery to be carried out within 24 hours of injury (BOA, 2014). Observational studies suggest better functional outcomes, shorter hospital stays, duration of pain, and lower rates of complications and mortality are achieved by performing surgery earlier. Pre-operative delays increase mortality and, in those who survive, prolongs post-operative stay. For every additional 8 h delay to surgery after the initial 48 h, an extra day in hospital results (Colais et al., 2015). Currently WAT fall far short of the ideal to provide optimal care for hip fracture patients. 3.1.4 Multidisciplinary Approach The management of hip fractures requires complex, connected care from presentation at AE, through all departments. A study of 116 patients found that dedicated nurse specialists are effective at fast-tracking hip fracture patients to surgery by securing hospital beds, organising care, operating theatre lists and acting as a liaison with all other relevant departments (Larsson and Holgers, 2011). Many published guidelines recommend a multidisciplinary approach to the treatment of hip fractures, in addition to, a good care environment to promote best outcomes. The Scottish Intercollegiate Guidelines Network (SIGN, 2009), the National Institute for Clinical Excellence (NICE, 2013), and the British Orthopaedic Association in cooperation with the British Geriatric Society (BOA, 2014), have all produced guidelines supporting a multidisciplinary team approach to deal with hip fractures in older people. Figure 3 Multidisciplinary Team (Source: Orthopaedics and Trauma) Rieman and Hutichson, (2016) It is recognised that a team approach with excellent communication between all the members is essential. The multidisciplinary team looking after hip fracture patients is large (Figure 2), and each role is important in the jigsaw of care. 3.1.5 Clinical Pathway Clinical pathways should be used to aid the multidisciplinary team. They provide a description of the expected interventions and outcomes throughout the patient journey following a hip fracture. The use of clinical pathways ensures everyone knows the next step in the process and this minimises unnecessary variations in practice (Chudyk et al., 2009). A study of 1193 older hip fracture patients conducted at 6 hospitals in the Limburg trauma region of the Netherlands concluded that the use of a multidisciplinary clinical pathways (MCP) for patients with hip fractures tends to be more effective than usual care (UC). Time to surgery was significantly shorter in the MCP group when compared to the UC group. The mean length of stay was 10 versus 12 days. In addition, the MCP group had significantly lower rates of postoperative complications (Kalmet et al., 2016). 3.2 Proposed Strategy Establish a designated Hip Fracture Unit within the main orthopaedic unit. Appoint a multi-disciplinary team to be based on the ward comprised of: Physio /Occupational Therapist Orthopaedic /Orthogeriatric Doctor Specialist Hip Fracture Nurse Nursing staff Establish a Hip Fracture Pathway. Establish a protocol-driven, fast-track admission of patients with hip fractures through AE AE bleep specialist hip fracture nurse FIB administered by nurse for pain management and patient centred care Patients are admitted to the hip fracture ward within 6 hours Appropriate, medically fit patients receive surgery within 24 hours Use of spinal anaesthesia when appropriate Continuous tracking/live data systems that regularly update patient and logistical data may improve management by identifying patients location, delays in treatment and relevant clinical information. 3.3 Potential Process Improvement Tools 3.3.1 Continuous Quality Improvement Continuous Quality Improvement (CQI) is a quality management tool that encourages all members of the health care team to continuously ask, How are we doing? and Can we do it better? (Edwards et al., 2008). It focuses on improvement for the patient and the practice by asking questions like, can we do things more efficiently? Can we be more effective? Can we do it faster? CQI uses a structured planning approach to evaluate the current processes and improve those processes to achieve the desired outcomes. Tools commonly used in CQI help team members identify the desired clinical or administrative outcome and the evaluation strategies that enable the team to determine if they are achieving that outcome. The team can adjust the CQI plan based on continuous monitoring of progress through an adaptive, real-time feedback loop (NLC, 2013). A CQI approach can help improve patient care. There is a strong link between organisations with explicit CQI strategies and high performance (Levin, 2016). Figure 4 CQI Framework Model (Adapted from NLC) Structure examines the characteristics of resources, staff and consultants, physical space, and financial resources. Process -   the activities, workflows, or tasks carried out to achieve an output/outcome. Output the immediate predecessor to a change in the patients status. Not all outputs are clinical e.g. business or efficiency goals. Outcome the end result of care. Can be change in the patients current and future health status. Feedback Loop represents its cyclical, iterative nature. 3.3.2 Lean Management Lean is a process improvement method developed by Toyota in the 1950s. Lean management principles have been used in manufacturing for many years, however, these principles can be used in healthcare too. According to Womack and Jones, there are five key lean principles: value, value stream, flow, pull, and perfection. Lean drives out waste so that all work adds value from a customer perspective. Lean thinking focuses on how efficiently resources are being used, it looks at each step in the process and asks what value is being produced? Value from a patients perspective can be defined as timeliness of treatment, reduced stress, or better functional outcomes. The NHS defines value as anything that helps treat the patient. Everything else is waste (Jones and Mitchell,2006). Figure 5 Lean Principles Identify customer value in healthcare value is any activity that improves the patients health. Manage the value stream the value stream is the patients journey. Identify process that deliver value to patients. Create Flow align processes to facilitate the smooth flow of patients and information Establish Pull provide care on demand and utilising resources effectively. Seek Perfection optimise the process through continued development and adjustment to meet patients needs. Optimal delivery of high-quality care to reduce mortality in hip fracture patients is an achievable goal. There are numerous opportunities to enhance the quality of care: reduced length of stay, reduced institutionalisation, reduced mortality and better functional outcomes for patients. Better quality care minimises treatment delay, promotes recovery and facilitates a speedier discharge. Cost and quality are not in conflict providing high quality hip fracture treatment is a lot cheaper than poor quality treatment. Lean inspired and clinical pathway related process improvement efforts make inconsistent and inefficient practices in health care more visible. The implementation and adherence to evidence based standards will considerably improve the care and management of older patients with hip fractures, this will result in significantly improved outcomes for patients and the healthcare system. 5.1 Appendix A References       BOA (2014) BOA standards for trauma (bOASTs). Available at: http://www.boa.ac.uk/publications/boa-standards-trauma-boasts/ (Accessed: 5 December 2016). Callear, J., Shah, K., Hospital, J.R. and Oxford (2016) Analgesia in hip fractures. Do fascia-iliac blocks make any difference?, BMJ Quality Improvement Reports, 5(1), pp. 210130-4147. doi: 10.1136/bmjquality.u210130.w4147. Chudyk, A., Jutai, J., Petrella, R. and Speechley, M. (2009) Systematic review of hip fracture rehabilitation practices in the elderly, Archives of physical medicine and rehabilitation., 90(2), pp. 246-62. Colais, P., Di Martino, M., Fusco, D., Perucci, C.A. and Davoli, M. (2015) The effect of early surgery after hip fracture on 1-year mortality, BMC Geriatrics, 15(1). doi: 10.1186/s12877-015-0140-y. Compston, J. (2009) Guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK, Maturitas., 62(2), pp. 105-8. Coruhlu, O. and Pehlivan, S. (2016) Worst pills. Available at: http://www.worstpills.org/includes/page.cfm?op_id=459 (Accessed: 5 December 2016). Edwards, P., Huang, D., Metcalfe, L. and Sainfort, F. (2008) Maximizing your investment in EHR. Utilizing EHRs to inform continuous quality improvement., JHIM, 22(1), pp. 7-12. Hanna, L., Gulati, A., Graham, A. and Corporation, H.P. (2014) The role of Fascia Iliaca blocks in hip fractures: A prospective case-control study and feasibility assessment of a junior-doctor-delivered service, International Scholarly Research Notices, 2014. doi: 10.1155/2014/191306. Heyburn, J., Holloway, G., Leaper, E., Parker, M., Ridegway, S., White, S., Wiese, M. and Wilson, i (2012) Management of proximal femoral fractures 2011, Association of Anaesthetists of Great Britain and Ireland, 67(1), pp. 85-98. Jones, D. and Mitchell, A. (2006) Lean thinking for the NHS. Available at: http://www.nhsconfed.org/~/media/Confederation/Files/Publications/Documents/Lean%20thinking%20for%20the%20NHS.pdf (Accessed: 11 December 2016). Kalmet, P.S.H., Koc, B.B., Hemmes, B. and ten Broeke, R.H.M. (2016) Effectiveness of a Multidisciplinary Clinical Pathway for Elderly Patients With Hip Fracture: A Multicenter Comparative Cohort Study, Geriatric Orthopaedic Surgery Rehabilitation, 7(2), pp. 81-85. Levin, D. 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Sir Gawain and the Green Knight :: English Literature Essays

Sir Gawain and the Green Knight Sir Gawain and the Green Knight, a fourteenth-century tale written by an anonymous poet, chronicles how Sir Gawain of King Arthur’s Round Table finds his virtue compromised. A noble and truthful knight, Gawain accepts the Green Knight’s challenge at Arthur’s New Years feast. On his way to the Green Chapel, Gawain takes shelter from the cold winter at Lord Bercilak’s castle. The lord makes an agreement with Gawain to exchange what they have one at the end of the day. During the three days that the lord is out hunting, his wife attempts to seduce Gawain. At the end of the story, it is revealed that Morgan le Faye has orchestrated the entire situation to disgrace the Knights of the Round Table by revealing that one of their best, Sir Gawain, is not perfect. The passage begins with Lord Bercilak returning from his first hunting trip. As has been agreed, he hands over the wild boar he has killed to Gawain. In turn, Gawain gives the lord a kiss. The lord gives Gawain a chance to admit that he has been intimate with Lady Bercilak when he says, â€Å"it might be [the kiss] all the better, would you but say where you won this same award† (Norton 187. Gawain is a gentleman, who would never kiss and tell, so the two reaffirm their pact for the next day. The lord’s determination in â€Å"pursuing the wild swine till the sunlight slanted† is paralleled by his wife’s determination in seducing Gawain as â€Å"she was at him with all her art to turn his mind her way† (188). Lady Bercilak attempts to exploit Gawain’s reputation as she tries to seduce him. She greets him in the bedroom and coyly asks how â€Å"a man so well-meaning, and mannerly disposed†¦cannot act in company as courtesy bids† (189). Lady Bercilak is not subtle (she points out that the door is locked and the two are alone in the castle) as she offers herself to Gawain, saying, â€Å"I am yours to command, to kiss when you please† (189). She tries to make Gawain feel guilty by implying that he is insulting her by not succumbing to her seductions and proclaiming his love to her.