The Twilight Saga 5: Midnight Sun 26. Awakening

The constant drone of the machines continued to echo through my psyche as the evening street lights casted shadows through the hospital room. Rene refused to leave Bella's side for any period of time. I let her have my seat next to Bella but continued to stay in the room, sitting in the corner quietly listening to Rene's thoughts whirl through her child like mind. She was unlike Bella in every way; she even sensed danger when it came to the Cullen's, unlike Bella. My poor baby†¦what time is it? She looked towards the clock. Eleven. Charlie should be here shortly. I'm going to have to have a talk with him. Her thoughts then became a little disjointed in anger as she thought of her daughter falling down two sets of stairs because she had run away from Forks. Forks, she scoffed internally. I knew this wasn't a good idea. I warned her. I told her she didn't have to leave. What kind of mother am I to condemn my child to a place like Forks? Ignoring her constant prattling, I continued to stare, fixated on Bella, waiting for her eyes to open, willing them to just flutter. I couldn't see the clock that was over my head, but I was counting every second as they passed. It was easy to keep track because my only focal point was Bella and how long she had been devoid of consciousness. It had now been exactly 39,982†¦83†¦84 seconds since we arrived at the hospital. Her heart thrummed evenly as her scent was beginning to slowly return to her. The sweet nectar that was her life filled the room with the delicious aroma. Craving the sweetness, I brought the scent into my lungs, letting my throat burst into flames. It was only two hours ago that she finished her second blood transfusion and I was afraid her scent would forever be a pitiful imitation of the luscious blood pulsating through her body. It felt like my body was undergoing physical suffering owing to her condition. Her blood deficient was because of me; a creature so monstrous that I preyed on this innocent creature by allowing her to become a part of my life. More than that, she was my life. My phone lightly vibrated in my jeans pocket ?Cdistracting me from my internal torment – and I pulled it out to read a message from Alice. Just picked Charlie up from the airport. Will be there in fourteen minutes. Snapping my phone shut, I got up to move to Bella's other side. With her mother here, I kept my distance, not wanting to over step my bounds with a parental authority that I so recently met†¦and especially under these circumstances. â€Å"Charlie will be here shortly. Carlisle and Alice just picked him up from the airport,† I said lightly. It's about time. â€Å"That's good,† her eyes never left Bella's face. For over an hour before now I was struggling to come over and talk with Rene. I wanted to flush out a good story to tell her about why we were here in the first place. She got the gist of the story from the doctor about her going through a window after falling down two flights of stairs, but that was all. â€Å"Mrs. Dwyer,† I began. Such a gentleman†¦Mrs. Dwyer. Her penetrating gaze moved from Bella's face to mine. Her eyes widened a little at my appearance. It always caught humans off guard, the little indications they didn't comprehend, no matter how many times they'd seen one of us before. She studied my face for only a brief second before she saw the grief that was displayed squarely on my face. Ignoring her senses she brought her thoughts to my expression. He really cares for her. He looks like he is going to cry. â€Å"Rene,† she corrected me. â€Å"Yes, of course, Rene. I wanted to apologize for this whole incident,† I used my smoothest voice to ease her stress, one I retained for not alarming humans. â€Å"This isn't your fault†¦,† she began, but her thoughts caught up to her mouth. What was he doing down here anyways? He didn't†¦follow her did he? He's not a stalker†¦is he? She tried to smile politely but even without her thoughts as a guide I could have guessed what she was currently thinking. Her thoughts weren't far off base. I was her vampire stalker, watching her sleep every night. I continued, not wanting to think that once she recovered, this would be the end†¦no more stealthily hiding in her room. â€Å"Yes, it is my fault. I really care about your daughter, so please understand that I want the best for her†¦Ã¢â‚¬  â€Å"Why are you here?† She blurted out. â€Å"When I brought her home after playing baseball with my family she became upset. She really misses Arizona and after I confessed my feelings for her she became angry.† The memory of her yelling at me flashed through my mind. Though she was acting, it burned to hear her say goodbye and slam the door in my face which is ultimately my worst fear. His feelings? Hum, I wonder how much he actually cares for her†¦I hope her actions aren't because of me†¦my past†¦because of my fear of her staying in Forks. Nope, not his fault†¦mine, all mine. She stared at me with her eyes filling with the sorrow of her thoughts, so I went on, trying to distract her from her mental images. It was entirely my fault, not hers. â€Å"When I found out she had run off to Arizona†¦from a call she made to Alice, I had to fix it. Carlisle and Alice came with me to try and convince her to come back to Forks; that we all loved and missed her.† We all love her? Their relationship is a little more intense than I realized. Rene speculated. â€Å"She agreed to meet us at our hotel room but she never made it. Carlisle was actually in the hallway getting ice when he heard a loud crash. Alice and I heard it also,† The look on my face showed pure agony at the thought, though this wasn't acting, this was how I truly felt. â€Å"It was Bella; she had tripped and gone through a window. We rushed to get Carlisle but he was already there. All three of us helped stop the bleeding and get her to the hospital.† Poor child. He must have been scared out of his mind. Rene reached over to place her hand over mine. â€Å"Thank you for saving her.† â€Å"Thank Carlisle. He's the doctor,† â€Å"Yes, but without you, he might not of been able to stop the bleeding in time,† a tear slid down her face and the white blanket covering Bella now had a wet spot from the droplet. Edward, we're here. Alice called out to me through her mind. I have to warn you, he's not happy. You might want to get out of there before†¦ The door to the room flew open as Charlie came marching in, livid. His face was so screwed up in anger that all the blood had rushed to his face, covering it purple, like a radish with a sun burn. â€Å"This is all your fault,† he pointed a finger at my chest, coming closer and closer. I backed away from him, â€Å"I'm sorry.† It was a pathetic attempt, but it was all I could think to say with him advancing on me. I nearly knocked over my tray of food; nothing more than a prop, really, but my mind was in such anguish that I wasn't paying attention. No, this is my fault, Rene thought while stepping in between us. She placed her hands on Charlie's chest and began to push him towards the door. â€Å"Mr. Swan, I†¦Ã¢â‚¬  I began. Rene interjected. â€Å"Charlie, that's enough. Let's talk outside,† she commanded sternly. â€Å"You won't ever see my daughter again. Do you understand?† Charlie continued to shout at me as Rene continued to heave against him until he was outside of the door. His threat was unnecessary because I had to leave her to let her live a peaceful life without all the peril. I backed slowly into the corner, sitting down on the chair again. Bella's breath had picked up slightly; the tempo of her heart increasing, like she could sense the tension in the room. Watching her small chest lightly rise and fall with each breath, seeing the blood flow seamlessly through her translucent skin, listening to her heart which was echoed perfectly with the monitor all just emphasized how delicate and precious she really was. I had to save her from the nightmarish creature I feared and loathed that finally made it to the surface when I tasted the rich flavor of her blood. I was afraid that I wouldn't have enough discipline left to be around her forever. Would all my efforts fail? Pushing my ever growing thoughts of leaving from my mind ?C fighting tooth and nail against what I didn't want to be – I opened my mind to the conversation that was now being shouted in the hall. Listening in on their conversation wasn't difficult in the least. They were barely standing outside the door and with their raised voices it was loud enough that even the humans could hear it. â€Å"Charlie, calm down right this instance!† Rene yelled at him. â€Å"You left him in there with our daughter. She left because of him,† he growled furiously with the protective concern, emitting a possessive edge in his thoughts. I could witness his livid expression through Rene's human eyes. Not the best vision, but it would work. He was right, though; she did leave because of me, because of the danger I placed her in. Looking at her limp form on the bed, her brown hair surrounding her glorious bruised face only brought more fear rippling and quivering through my still form. I was gasping at the air like I'd been suffocated. â€Å"No. She left because of me! If she wasn't so scared to fall in love in Forks than she wouldn't have run away in the first place. This is my fault, not his. If you want to blame someone, blame me,† she retorted. â€Å"You didn't hear the way she yelled at him.† I flinched at the memory, my nerves stretching tight ?C guitar strings, tensed to resonate at the gentlest of pressure. â€Å"She was so angry and upset,† his voice had lowered some, noticing all the attention on them. Charlie hated attention as much as Bella did. â€Å"Wait, did you say love?† Rene eyed the door automatically, picturing my tortured face in her mind. â€Å"Yes. I believe he loves her,† she murmured. â€Å"Well†¦Ã¢â‚¬  he stuttered. â€Å"That still doesn't matter!† â€Å"They were trying to help. You know our daughter, she is very clumsy. If it didn't happen now it probably would have happened in the future. It's better if it is when a qualified emergency room doctor is around,† Rene rubbed his shoulders. I could hear her impatience at her ex-husband. Dr. Jones was still on duty and over heard part of the conversation in the hall. Must be her father the way he was yelling. He walked towards them. â€Å"Hello, I'm Dr. Jones. I am the one who worked on your daughter this afternoon.† A nurse had followed behind him and entered the room. She began taking Bella's vitals, not even realizing I was sitting in the corner. Her thoughts concentrated on the information she was writing down on the chart. I continued to listen to the conversation outside the door. â€Å"Oh, hello, yes†¦I'm Charlie, her father. Dr. Cullen told me she was in a medically induced coma?† The light rhythmic movement of Bella's heart continued at a steadied beat, a little faster than when she was in a peaceful sleep. Again, I was counting the seconds. â€Å"Yes. She is healing nicely. Once her swelling goes down around her brain we will try and wake her, but it is strictly up to her body to decide when she is ready to awake from this coma,† he stated firmly, yet in a tone that would help ease his stress. â€Å"Yes. Of course. I understand,† Charlie rubbed his temples. â€Å"I'll leave you alone. Let you have some time with your daughter,† he murmured before walking away. â€Å"Thanks,† Charlie barely spoke. When the nurse swiveled around she finally saw me sitting there. Her heart jumped and began beating wildly. I didn't even see him sitting there. â€Å"Oh, I'm sorry. I'm just leaving now,† she began to walk towards the door. Now that I think about it†¦ she glanced over her shoulder. He is hot! I might have to volunteer to come back in here tonight. She finally opened the door nearly knocking over Charlie who had reached for the door at the same time. Standing, I opened my mouth to apologize again. Charlie held up a hand. â€Å"No need.† Rene continued to stand in the hall, uncertain if she needed to enter or not, worried that Charlie might decide to release some more of his fury on me. â€Å"I'll leave you two alone,† I mumbled while walking out of the room. Rene turned to get dinner, taking deep breaths while her thoughts were grumbling in complaint at Charlie's behavior. And he's such a nice boy†¦I just don't understand. As soon as the door clicked shut Alice was at my side. I see he calmed down. He was in a white rage in the car on the way over here. I thought I was going to have to restrain him he was so angry. I nodded, not speaking. I was still burning from the pain. I know what you're planning. I ignored her. Curiosity continued to eat at her as she walked next to me down the hall which was rich with the scent of bleach and plastic. She looked at me inquisitively, wondering what I was thinking that was making the visions in her mind flash. My thoughts were burning, wishing I could know what was going through Bella's mind right now. Her mind was closed to me, and now her eyes were too, the one link I had left to her internal knowledge. Everything is going to be okay, I can see it. She tried to comfort me. Still, I continued to walk silently next to her. Bella's oddly deep brown eyes were fixated in my irises which were crimson with fresh human blood. My contacts were beginning to burn away. Before I could ask Alice, she had another box placed in her palm. Here, let's not give Charlie any reasons to hate you more. â€Å"Thanks,† I replied dully. If I thought going on a single hunting trip – leaving Bella behind, vulnerable – was excruciating, the next twelve hours were worse. The extreme and generally prolonged pain and mental suffering were the most constant of my torments. But, the most painful of my torments was Charlie's possessive nature over his daughter. With him here, I was basically kicked out of her room, Rene constantly apologizing for his poor behavior. During the afternoon hours Alice and Rene would converse about everything from style to yoga classes, even though Alice has no need for yoga. Though I sat there, listening to their conversations, they continued to become aware of how tightly wound I was, feeling the stress emanate out of me without the special gift that Jasper has. Edward, Alice called from her mind around two in the afternoon. Charlie is going back to Forks. The officers†¦well, he is the police force, they need him back. He already received that call and will be on a plane by five. This was the first decent news I had heard in days. Regardless, today would be a hard one. Harder than the day before because each second that I continued to count added to the time that her deep depths were closed, her mind locked up tighter than Fort Knox. Like Alice had predicted, Charlie came strolling around the corner to give us the news about his departure. He completely ignored me, but in his mind he was thinking daggers towards me. Daggers that would never pierce my cold, steel skin. Rene walked with Charlie out of the hospital, leaving Alice and I alone together. Let's go see Bella. Without answering her, I rose, walking quicker than human speed towards the room. Whenever Charlie wasn't taking up all of Bella's coma time, I was there, by her side. When I got the chance, I was holding her. Rene had stayed the night, and was planning on doing it again ?C something I wasn't terribly excited about. When we reached the door I opened it and was instantly hit with a spectacular scent wafting through the room. Each breath was full of fire which was also full of her life. I ignored the burning, pushed it in the back of my mind. There was a newspaper on her bedside table. I picked it up to the page that was left open. It was a story that covered the arson of a ballet studio and theft of a car that was left outside. Anger pulsed through me at the thought of James again, though I pushed it aside because another angry thought hit me. I wished that Rene hadn't known about this, because now she was too afraid to stay in her own home. My continuance of emotions ached for some kind of physical outlet, and yet the only outlet I had was now gone, dead. Not today†¦Alice murmured. She's not ready. My hopes plummeted at this news. She continued to watch the future which spun, twisted and became mangled again. I wish†¦ â€Å"This is obviously not the time to bring that up,† I barked. I was just going to say I wish she'd wake up soon, Alice's eyes were wide with innocence, and I didn't believe it for a second. Looking at her eyes, I saw the reflection of my own eyes which were an odd brown, muddy color. Momentarily it caught me off guard, forgetting I was wearing the contacts, even though they continued to obstruct my perfect vision. I stole my eyes away from her to bring them back to Bella's limp and lumpy form. Her eyes were closed lightly, as if she were very peaceful. Her hair glinted in the bright white light over her face. My remorse and the guilt burned with the thirst, and, if I had the ability to produce tears, they would have filled my eyes. Each second that I continued to count reminded me of the precious soul lying in the bed before us. She was so breakable, and I broke her, she was good and she didn't deserve my fate. My mind was bouncing around like a tennis ball, willing myself to stay away from her, to no longer let my life collide with hers†¦destroying it in the process. What have I done? As the hour passed my mind continually would titter on a line of right and wrong. First, my thoughts leaning one way, then the other. Alice was becoming irritated at my constant state of vivid flashes of the future which would crumble every time I changed my mind. Then, when I didn't think the burning could get worse, I imagined her waking up and kicking me out of her room. I had to remind myself that she had every right to hate me, to not trust me with her safety. That she should. Would you quit! Alice shouted from mind. You aren't going anywhere. I won't let you. Remember, you did save her life. Her thoughts were confusing and incomprehensible. Did I not place Bella in front of the danger that lurked around her until it struck? Wasn't this all my fault in the first place? Quickly, I decided that the best course of action was to ignore her thoughts. After an hour had passed Rene entered the room, her mind happily jumping from subject to subject. What books she liked, her favorite movies, how she painted Bella's new room in Florida. Each second, I counted†¦I angered even more†¦mostly at myself. I tried ignoring Bella once, letting her go and it didn't work. I remember thinking that there were other options besides her ultimate doom. Now that I am sitting at her bedside, where she was on the brink of death nearly twenty four hours ago, I realized that keeping her in the fragile state would inevitably destroy her. I had to leave. Not now, but after she recovered. I did this, I have to clean it up. I won't leave her here, broken, without help. I've had it! Alice stood up. â€Å"Rene, I'm sorry, I have to go. I'll see you tomorrow.† So soon? Rene stared at me. But he's not good company. â€Å"I understand, dear. See you tomorrow.† Surely it had to be miserable being around me, but if they understood my frustrations, my ever growing war that was raging inside me, then they would leave me alone. I argued with myself as the evening hours progressed, afraid my less noble side would win the argument. To add to my ever growing torments, the silence emitting from Bella was torturing me. Night after night I watched over her, and she spoke, tossed, turned, and murmured some more. Not last night†¦and not tonight. The mystery that surrounded Bella continued to make my curiosity flare. The lure of her unprotected and unconsciously spoken thoughts were making me sick with regret. I should have stayed away and then tonight would have been like any other night when I went to visit her. I missed her murmurs, her spoken dreams and fears. The only sound from Bella was her light breathing, which had a little rattle from her bruised ribs and her steady heart beat. I shook my head in disgust at what I had done to her. Though she was bruised and tubes and wiring seemed to be coming from her every orifice, she was still beautiful. Her dark hair was tangled wildly around her pale face. As the night progressed into the early morning hours, Rene never kicked me out. Instead she slept resolutely with Bella's hand in hers. Jealousy raged inside me at her touch. I wanted it to be me holding her hand, lying with her, comforting her. It was foolishness to think that we belonged together, even though I could never imagine myself without her, or with anyone else. She deserved happiness and love with whomever she chose, yet she chose me†¦the cold inhuman creature that almost brought her to her death. Could a dead frozen heart break? I felt like mine was. In an instant, a memory flooded my troubled mind, making my mind teeter in yet another direction. That first evening I became the peeping tom†¦Bella, she was dreaming of me, mumbling my name. â€Å"Stay,† she sighed. â€Å"Don't go. Please†¦don't go.† That was the night she changed me, the rare and permanent thing that you could never give back. It was love, and no matter how many years pass, hundreds, thousands, tens of thousands, I would forever love this one girl. I gazed at her unconscious face, reminding myself of the love that had settled into every portion of my stone body that night. If I loved her though, then I was strong enough to leave her because that is what would be best. Loving her would not keep me from killing her, if I let myself make mistakes, like I did this week, she could be killed. Though, it would not be intentional, only a horrible accident. Obviously, I am capable of making mistakes. In only an half hour of speaking with her for the first time I slipped up twice. Deliberately, I took in a deep breath, letting her scent rip through me like wildfire. With each breath, I let it remind myself of the monster that was living deep inside me. Though he was gone, missing right now, I knew he was still there, sending waves of fire through my throat. Rene was sleeping soundly now, dreaming about a horseback riding class she had that was a little bizarre. Still, I continued to count the seconds as the sun rose over the mountainous horizon. I closed the vertical blinds so my skin wouldn't sparkle. Again, I felt my contacts disintegrate and had to replace them. In the bathroom, my eyes still were bright red with Bella's blood. Another reminder of the damage I inflicted upon her by being with her. I felt my pocket vibrate and reached in to grab my phone. It was nine in the morning. It had now almost been two days of a still, unmoving beauty lying in this bed, comatose. I read the message. Bella will awake at 913. Thought I'd give you the heads up so you could wake Rene so she could get her breakfast. It will give you time to be alone with Bella. A great relief spread over me at this news. The seconds I would no longer have to count because she would be awake, talking to me. Purposefully, I dropped my phone, the sound vibrated off the walls in the tiny room. Rene jumped to her feet. â€Å"What's going on? Where's Grace?† she mumbled, her face bewildered. I had to suppress a laugh. â€Å"Grace?† I asked. â€Å"Dream,† she muttered. That horse scares the living fire out of me! Again, my giddy state was hard to control. My lips twitched on the edges at the thought of her waking. â€Å"They are serving breakfast,† I offered. Oh course, he wants time alone with her. â€Å"Yes, breakfast sounds nice.† Rene left with one last glance over her shoulder before shutting the door. Curling up onto Bella's bed, I held her hand while watching the clock. The seconds were going by slower. The last minute before her awakening seemed to take twice†¦no three times as long. Each second that ticked by had my thoughts scattering in every direction. Now that I knew she would be awake soon, the thought of leaving her was inconceivable. I would always love this fragile human girl for the rest of my limitless existence. I gazed at her unconscious face, feeling this love for her settle into every portion of my cold steel body. If I wasn't strong enough to leave her maybe I was strong enough to construct a new future. She moaned while her eyes fluttered. Could a dead, frozen heart beat again? It felt like mine was about to.

Analysis of “The Author to Her Book”

What is the most useful thing you have learned about the teaching process? What would be your ‘top tips' to others? [Responses from 70 school librarians surveyed by Netskills in 2007] To introduce an element of fun into training. Happy people are more likely to learn plan your activities be flexible – if it doesn't work ditch it try not to do too much in one session review your session and adapt it some classes respond differently to others learners need to be involved and engaged with the learning process 1. Make the skill you are trying to teach relevant to the students at their point of need. . Don't underestimate the power of â€Å"†modelling†Ã¢â‚¬  a process. keep trying – don't give up be strong be assertive stay calm be helpful and work as part of a team It's not as difficult as some teachers make it look! Manageable bites – do not attempt to serve the whole in one ‘IT'. Fairness & honesty – sounds woolly but children spot a phony immediately. Also – we are here to educate not be their next best friend. Consistency – links with the above. Sense of humour! Teaching starts with the learner – they need to be engaged and understand what they are being offered is relevant and useful.Sessions need to be clearly structured in small steps so the learner can succeed and build confidence. Don't try to pack too much into one session – it's much better to cover the information carefully and allow time to recap at the end. Be well prepared Know your subject matter inside out Be able to ad lib if necessary Look at the broader aspects of the Curriculum including assessment. Education is our market so get involved with academic staff and what they do. With young people activities always take much longer to deliver than you expect.You need to be able to make learning available in different ways – some people will respond to a hands on approach – others want everything in hando uts to be able to refer back to – and others want demonstrations. Being flexible and not making people feel unsuccessful if they take a long time to learn something new or need to repeat activities is very important in helping people to learn. – not to try to do / teach too much at any time – that children have different ways of leaning so to make any input as varied as possible.Willingness to learn, make mistakes, review and revise, collaborate well with school staff and sustain motivation and a professional image seem to be very important. That people learn in different ways, and that you need to think about this when presenting materials – sometimes you can present the most important details more than once, using approaches to suit different learning styles (eg in a presentation, in a quiz, and in a handout) Try to forget how you might be teaching and to concentrate on what they are learning. Focus on 1 thing at a time, just because you don't get them for long, don't try to cram in everything possible.Have your 2/3 learning objectives spelled out at beginning (tell them what they are going to learn, teach it and then check understanding) Make sure that the information is accurate and appropriate to the level of the learner Try to make it as multi-sensory as possible to stop them getting bored – keep it short and useful Give handouts to assist further development Always check your timing is realistic and plan the lesson well Be aware of different styles of learning. Use the same structure for planning lessons as the teaching staff. Have a plan B in case of IT failure, over/underrunning time.Make it as relevant as you can, spend as much time as possible with the students so you know exactly what they are trying to research and what their strengths and weaknesses are. Try to meet as many learning styles as you can. Observe and learn from teachers in the classroom and follow same strategies and techniques e. g Starter activiti es Main body Clear aims and objectives Plenary Take account of different learning styles Mindmapping Differentiated work Listen. Don't expect everyone to understand first time. Pace yourself Change the way you present information eg practical, etcThe different ways in which children learn and the necessity to pitch lessons across a range of abilities. To listen and respond positively, encouraging rather than demoralising. Different people learn in different ways. Include a variety of strategies in each lesson. Make the content relevant to the context. Plan what you're going to do but be flexible enough to go with the flow. You need to understand your audience. Keep it SMARTER make it fun! Develop your own style of presentation and learn behaviour management â€Å"Remember that the members of any class will have a mixture of preferred learning styles-make sure there is variety.Do not be too dominated by your own preferred style Be well prepared, lack of organisation will show Have m ore material than you need: make sure there are extension activities available Make sure your audience think you are prepared to listen to them as well as teach them I used to be very concerned not to appear to patronise HE students and at first, tended to expect too much from them-then I discovered that actually they respond well to simple presentations with graphics etc, So, my advice would be: ‘Pitch your lesson to be simple and accessible, then differentiate the assessment challenge to the level(s) of ability/student expectation'.This works in school just as it did in HE Skills that have proved most useful have been to vary pace and delivery style. I would offer these ideas as top tips: Use the three part lesson – a clear opening giving objectives, body of what you want to convey and then a plenary to ensure the main points have been absorbed. Vary your delivery method and types of support material to address the different learning styles. Encourage student question ing at higher levels to improve their learning processes. Allow peer teaching to take place between the students – great way to cascade new knowledge.Use student evaluation to improve the lessons. Ask teachers for advice on planning activities, try and get to meetings on secondary strategy, etc Be flexible – what works with one class may not work with another. It is a waste of time telling students what they don't need to know at that time. You need to consider the different ways in which people learn and structure your teaching accordingly in order to ensure that as many people as possible benefit from your session. Students need to ‘have a go' themselves to make learning more relevant. Teaching is a two way process. planning is key ind out what students know beforehand/build on prior knowledge connect the learning cater for variety of learning styles focus on process as much if not more than content develop learner attributes allow time for practice/reflection on learning teach skills in relevant context offer extension activities for G and differentiate carefully for individual learning needs look confident even if you're not! You never stop learning. More teachers should know this, but they don't. Be aware of the level of work involved in teaching, especially creating classwork and assessment. Aim low – whoever you are teaching. Keep calmBe well prepared Keep it simple Try out any worksheets yourself to make sure they can be completed in the time available. Have extension activities ready for the more able who will finish early. Keep instructions/worksheets simple – too much text is a turn-off. Be aware of different learning styles – you'll naturally write things to suit your own style but not everyone learns the way you do! † Listen. Be well prepared. Continually assess if the pupils are understanding as you deliver the lesson. Preparation of materials [sometimes differentiated] is key and the willingness to be flexible and adapt materials as necessary.Be aware of your timing Match the activity/material(s) to the ability/age of the students† Keep it informal and use their individual interests to garner enthusiasm Different presentation styles for different audiences Don't talk too much Active participation of audience Know your audience's ability – don't use jargon they can't understand, don't patronise Think about different styles of presenting information – don't overuse PowerPoint. Be prepared to repeat yourself and back up the information you give in many different formats and on many occasions.Be passionate about what you are doing – students soon pick up if you are bored with the subject yourself. Be prepared to adapt to change within your organisation. Keep an open mind and be prepared to adapt the ways you can teach library inductions, information literacy and support whole school literacy in line with your school's priorities. Creativity is key! Be we ll prepared. It'll always take longer than you think. Never show fear! I have found observing, associating and learning from teachers (and sometimes their mistakes! ) has been the key element in the growth of my own understanding of teaching.It's an ongoing learning process! Ask for help/ advice/ support from sympathetic teaching colleagues &/ or Staff Development Coordinator. Starting in a new school – ask to shadow a form for a day & ask to follow up with occasional lesson observations of teachers with different teaching styles (& different year groups). Planning and preparation are key. Ensure you know what equipment you need before the lesson starts and that it works; arrange furniture in a way that you want it. Ensure that you know what outcomes you want from your lesson and how you are going to achieve them.Make sure that all pupils are involved. Don't just talk but make sure that each lesson has variety within it – questions and answers, worksheets etc. Ensure t hat you sum-up what you have covered at the end of the lesson. Make everything that you talk about relevant to the pupils. Teaching comes in a variety of formats and styles differ enormously among teachers. It is more difficult than we think and easier than teachers make us believe. Teaching is changing constantly. Listen to and learn from the children you teach. Teachers are learners themselves and good teachers know this.With their unique set of skills, most librarians would be very able to complete an equivalent to a PGCE. Be confident, assertive and fair. Be well prepared – plan effectively. Relax – pupils smell fear. Include variety in the lesson, don't talk for too long – pupil attention spans are limited. Liaise with teaching staff. be ahead of all requests – if possible. Be concise, but pertinent. patience! I was totally thrown in at the deep end in my first job as I was expected to teach with no training what-so-ever AND my teaching was OFSTED in spected that year (although I did point out to the inspector that I wasn't a teacher. Over the last 9 years I have taught myself by reading and watching other staff. I have written my own lesson plans and schemes of work. In my current role I am teaching a lot of IT and would like to train to be an IT teacher but can't afford to have the time off work to do the teaching practice. It would be nice to have some teaching qualification for school librarians taking this into consideration. Find an ally on the teaching staff and ask for help. Be prepared to ask for and accept guidance. Have a number of areas in the curriculum where you think teaching of research skills can be integrated and explain with a lesson plan.Have to be flexible. Teachers think on their feet! Need to have various ways of explaining- not all pupils learn in the same way. Use the same methods as teachers in your school: class line up outside, take register, require silence before speaking, students seated boy-girl. Adapt to how your school does these things. Vary methods – do not expect students to be able to sit still for a long time. Use music, get students to move around, use competition between groups of students, engage children with controlled use of ICT and encourage multi-media. Act like a member of teaching staff using school behaviour policy.Have high expectations of students in terms of their learning and behaviour. Get feedback from students and teachers and use this to improve your sessions for the next time. Learn from other librarians and share things that work. To teach something pupils actually want to learn, or show them how useful it will be to know more about the topic. With regards to library skills it should be within a course that teaches information skills, as that is essential. Adapting material to individual needs. Also using a variety of methods, particularly ‘hands-on' or kinaesthetic activities.

Biography of Pancho Villa Essay Example | Topics and Well Written Essays - 250 words

Biography of Pancho Villa - Essay Example Villa was notorious for his short temper and cruelty, particularly towards women.   His Indian heritage gave him a deep knowledge of the land, making him a excellent guerilla fighter. He was drafted into the 14th  Calvary Regiment in 1903. He deserted and joined the revolutionary forces of Francisco Madero in 1910. (Becker). After Madero’s ouster, Villa escaped to the United States in 1912.   By the end of 1914, he returned to Mexico, formed the Division del Norte and joined the revolution against Victoriano Huerta, along with other revolutionaries such as  Venustiano Carranza  and  Emiliano Zapata. He also served as provisional governor of Chihuahua in 1913-1914. Villa was often in conflict with other military groups and even fought with U.S. troops from 1916 to 1917. In 1920, Villa was given a pardon in return for stopping his independent military activities.   (Biography.com). On July 20, 1923, Villa was driving past the intersection of Benito Juà ¡rez and Gabino Barreda in Maturana, when he was assassinated and killed instantly. Villa is remembered for fighting for the causes of the poor and his opposition to foreign exploitation of his country.

Critical Analysis Essay Example | Topics and Well Written Essays - 750 words - 6

Critical Analysis - Essay Example In this paper, the authors report on the effects of PDNF on tyrosine hydroxylase (TH) activity, a rate-limiting enzyme during the synthesis of dopamine and other catecholamine neurotransmitters. TH is important because it is involved in increasing the production of neurotransmitters. The study came up with the following additional actions of PDNF: Strengths. The paper has many strengths. First, it presented data that was based on solid experimentation that covered a wide range of immunological, molecular, and imaging techniques. The data was clearly presented using graphs and images. The discussion was straightforward and concise. The strongest point of the study is the methodology followed to arrive at the results. The authors arrived at their results through a series of experiments that each showed the action of PDNF on TH. To show that PDNF increased the TH expression in PC12 cells and primary mesencephalic neurons, the authors grew the cells in media that was treated several times with PDNF. Results obtained with immunostains were confirmed using immunoblots. Western blots and SDS-PAGE were also utilized. The study also used a luciferase gene assay to check the effect of PDNF on the promoter of TH. The method used to confirm the mechanism of action of PDNF on TH was done in a simple manner, where a construct of a mutation for the cAMP response element (CRE) labelled with luciferase transfected to PC12 cells. This step was able to show the effect of CRE on the action of PDNF on TH promoter activity. The discussion portion was able to summarize in a clear manner the results of the experiments, and related these to previous work done in the field of TH activation. The paper points to the mechanisms that could explain the action of PDNF. As an example, it was pointed out that PDNF mediated the phosphorylation of serine residues in the catalytic sites of TH. The phosphorylation activity of PDNF was

Demand for Bonds Essay Example | Topics and Well Written Essays - 1000 words

Demand for Bonds - Essay Example Thus there will be a windfall loss if bonds are purchased. Thus, bond demand will be low. This also implies that if expected future bond prices are high, then the demand for bonds will rise and vice-versa. iv) Expected inflation: Expected inflation has an adverse impact on bond demand. If there is an increase in expected inflation, bond demand will fall and vice versa. v) Relative risk: If the risk associated with a bond increases relative to other assets the demand for that bond will fall. Analogously if there is a decline in the relative riskiness of a bond, its demand will increase. vi) Relative liquidity: If there is an increase in the relative liquidity of a bond, i.e., if converting the bond into cash becomes relatively easier, the demand for it shall rise if other things remain the same and vice versa. vi) Business-cycle movements: If the economy is undergoing a boom, there will be an increase in the demand for bonds. Similarly, the demand for bonds will fall if the economy is suffering a recessionary period. b) Analyse the following statement:   â€Å"This week, the yield on the US Treasury note closed below 3%, a level not seen in 50 years. In the UK, the 10-year Gilt yield sits below 4% for the first time since 1961, according to UBS. Germany’s Bund yield is closing in on 3%. ... This time, the threat of delfation is being taken more seriously. Should policymakers again avert that fate, bond yiels may be primed for an explosive rise as fiscal spending plans and the expansion in money supply suggest inflation is the likely outcome†. [Source: Financial times 28-Nov-2008] Before commenting on the report it will be useful to note that as mentioned above bond demands (and thus investment) are induced by business cycle booms and dissuaded during recessions. However, during booms since the threat of inflation looms large, it is a natural counteracting force to the possibility of overinvestment. Similarly, during recessions, the adverse effect on the demand for bonds can be countered by the threat of deflation. Now, let's turn to the report. The first and foremost point to note in this context is the date of the report. It is dated November, 2008. Thus the US, UK and the German economies were in recession, arguably the worst one since the great depression (This was during the heart of the global financial crisis). Thus, one should expect expansionary monetary policies during this time. Lower interest rates ideally stimulated investment demand and thus increase the effective demand which leads to an expansion in real aggregate output with a multiplier effect and thus employment as well. What is reported seems to be along the same lines of intention. The current yields on US Treasury note fell to a level that was a precedent in 50 years. Similarly there was a decline in long term yields in the UK economy (gilt) and Germany (bund yields). However, in order for this policy to work, the falling bond yields

Video Observation and Reflection Movie Review Example | Topics and Well Written Essays - 1000 words

Video Observation and Reflection - Movie Review Example She explains that it is vital they work in that manner because the girls may not participate well when they partner with the boys. Completing the task required that the students partner so that they share and discuss how the connections worked. They also managed to walk around and ask the other students how they managed to work on their experiments successfully (Completing the Circuit: A Conversation About Teaching, 1999). Engagement Questionnaires were given to the students by Ms. Block to allow her know about the encounters of students with electricity. Posters about various uses of electricity and the applications were made by the students. Engagement can spring from two different conditions: experience and dialogue (Bilica, 2007). Experience has been used by Ms. Block through the classroom experiments she has administered. The students in the learning have been assigned the duty of carrying out experiments using the materials they have been given and making precise observations a bout the circuits. Through dialogue, the students purposefully discuss the unit content with their experiences in relation. They write down the class notes and the discussion details. The students thus become the creators and users of knowledge and not passively the recipients of it. Communication Ms. Block herself allowed the students to talk about their observations. This she does by first taking them through the step-by-step process of discussing with them the things she will look for during the learning session. She asks the students questions regarding what their thoughts about sharing and working in groups. It is a process of question asking and letting the students give out their thoughts on the topic (Bilica, 2007). Ms. Block explains that she will be interested in the way the students will be sharing the materials she will give out. Additionally, she will be interested in how the students themselves will share with others the observations and ideas as the experiments contin ues. While giving out the instructions on how the discussions and experiments should be carried out, Ms. Block was standing in front of the class. The students communicated with each other by: 1. Discussing with their individual partners about the connection details and the observations. 2. Moving from their individual groups to other tables to check, ask and help others on their experiments. 3. Giving out their observations to the whole class as they answered the questions asked by the instructor later on when they had finished different phases of the experiment. Direct instruction Ms. Block directly instructed the students about what she looked for during the lesson. She explained-before she gave out the materials for the experiment-that the students will work in groups. The atmosphere in the classroom The groups had different encounters and views during the experiments. This helped to bring out seriousness and involvement in the learning environment (Barton & Haydn, 2006). Studen ts could reveal their excitements when their connections were a success. Others, however, could be seen to be a bit nervous considering that they had difficulties completing their circuits. Ms. Block did her best by also engaging in the experiment process by checking on the groups that were not working out their connections properly. The classroom atmosphere was fun, and the students mood was jovial. We could finally say that the classroom

Case Analysis on Ryan Air Essay Example | Topics and Well Written Essays - 2500 words

Case Analysis on Ryan Air - Essay Example The Ireland-UK market was Ryanair’s initial target market, which it successfully managed to capture. By 2003, however, its route system had expanded to serve 86 destinations on 133 routes across 16 different countries. The heart of Ryanair’s current strategy is based on providing no frills service with low fares designed to stimulate demand, particularly from budget conscious leisure and business travelers who might otherwise have used alternative forms of transportation or who might not have travelled at all. Another strategic position adopted is Ryanair’s point-to-point short haul flights. Ryanair chooses to fly to regional airports rather than the larger national airports due to the favorable cost terms received. This facilitates the passing of low fares and has the added bonus of being less congested therefore aiding in flight punctuality. This offers convenience to clients, especially those constantly undertaking business trips, in terms of time and cost. The possession of both Regional and secondary airports is another current strategy. Airport charges include: Landing fees, loading fees, aircraft parking fees and noise charges. By acquiring regional and secondary airports, Ryanair is able to reduce these fees. This is because these airports are less congested and are anxious to increase their passenger output. The external environment refers to the factors that are out of control of the firm. These are factors tat the firm cannot be able to control could be because of market forces among other reasons. The external environment within which a business operates has a great influence on its mode and extent of its operations. The PESTEL framework (Appendix A) categorizes environmental influence into six main types: Political, Economic, Social and Technological, Environmental and Legal (Johnson and Scholes, 2002). Focusing on the Political environment, there has been

Oil in Determining the Social, Political and Economic History of the Essay

Oil in Determining the Social, Political and Economic History of the U.S - Essay Example The sole dependence on oil for political, social and economic history is a dangerous trend that the United States of America should endeavor to address, since it has relied on it in the past, continues to do so in the present, and does not seem to address it for its future needs. Economically, oil has continued to play a very key role in the United States of America in the twentieth and twenty first centuries since it has become a very integral input in almost all forms of production processes that are undertaken in the Nation. In the areas of agriculture, mining and manufacturing in all areas have become very dependent on the input of petroleum and as such, the price of the final products in this sectors and the growth of the United States economy has depended at a very large scale on the global price of petroleum. This implies that in the case of an energy crisis, the impact on the United States economy would be very significantly negative (O’Rourke and Connolly 590). Though to a large extent the price of petroleum has remained significantly low for many years, there have been exemptions to this in the 1973 to 1990 in what historians have called the energy crisis where prices became subsequently high in the world and affected the prices of the production in the United States, the price of products and ultimately the economy as a whole (Parra 35). Unlike in the past when the United States was an oil exporter, its domestic consumption has made it the largest importer of oil in the world. There was a crisis in 1979 to 1981 during the Iranian revolution which made the United States to employ many rationing measures to counter the negative effect on the economy, for example the manufacture of cars that used less fuel per kilometer. There was a crisis too in 1990 during the Iraq attack of Kuwait which was resulted in a great increase in the price of oil (Parra 43). Though the crisis was not as severe as the earlier ones it was only because, the American Gove rnment has increased domestic reserves to forestall the eventualities of crises. The stockpiling of reserves has been done in anticipation of depletion of the world’s resources whereby the stored oil is preserved for emergency purposes and, it came in handy to absorb the impact that the 1990energy crisis would have brought to the nation. Though this reserve has exceeded 500millon barrels, the current consumption rate is such that in the case of any type of crisis, this reserve would last for a very short time (Parra 56). On the political front, oil has shaped the politics of the United States and especially in its policy concerning the Middle East the world’s major oil hub. The war in Iraq in 2001 for example has for example been seen by many as not as a war to protect Kuwait, but as an American plan to protect its oil interests in the middle East (Parra 73). It is on record that former President Bush’s cabinet said that Iraq remained a stabilizer to the smooth transportation of oil to global

Paintings of Paul klee Essay Example | Topics and Well Written Essays - 1000 words

Paintings of Paul klee - Essay Example There are two major conspicuous colours used in this painting; to begin with, there is the use of red colour and grey colour. In addition, it is evident that there is a picture of a lady who is probably surrounded by some birds and some flying images, which can be interpreted as spirits. On the other hand, there is a red colour at the bottom of the painting indicating direction. It is quite challenging to have a conclusive idea of the information expressed by other red colours in the painting. This is another great piece of art work painted by Paul Glee in 1921; it is quite obvious that the information expressed in this painting. In relation to the spatial analysis of the painting, the images appear to occupy the central part of the frame which measures 305mm by 454mm. There is also two major colours that are conspicuous in the painting; white and grey. Moreover, there seem to be only one painting of a man surrounded by what appears to be animals. Additionally, there is no conflict o f colours, they properly match the intentions of the artist and expresses a scenario that attempts to depict a man on a theatrical stage. That is, there is proper use of colours hence indicating a proper colour harmony. In relation to the intention of the painter of the information expressed by the painter, there seem to a series of comic actions occurring in the scenario expressed; to begin with, the man in the painting is surrounded by what appears to be birds, dressed in skirts. Moreover, the man is the painting does not have arms.

Prepare a two-page paper discussing Dr. Charans insights and how Essay

Prepare a two-page paper discussing Dr. Charans insights and how present-day executive leadership should plan and operate - Essay Example It is also important for the leaders to get full details of their operations so as to be better positioned to defend their core business in the event of economic crisis striking. Short term strategies are advocated so as to be able to deal with the situation. Essentially, there are six leadership traits for hard time which include the following In most cases, revenues for businesses are generated through sales hence the need for the sales people to be as realistic as much as possible. They should scan the current environment and see if they can get an opportunity through evaluating the customers’ potential to buy. These communicate the financial position of the business both internally and externally. Their main role is to communicate clearly and honestly so as to keep the investors and lenders abreast about the situation obtaining on the ground. Another role is to allocate resources according to the current state of economic affairs. There is need to identify the projects that matter as well as set new priorities. To those CEOs who presided over thriving organisations, there is a tendency to believe that they know everything. This over optimism is at time dangerous since they can engage in other risky activities such as debt which can sink the organisation into oblivion. Against this background, CEOs should remember that they are leaders and should inspire their workers even during trying times. They should remind the workers that there is light at the end of the tunnel hence should not despair. There is need to establish respectful relationships with the stakeholders in order to contribute to the firm’s credibility. Information about the situation obtaining on the ground is very important and it should always be truthful. Capable leaders will often have a vision and emerge stronger from a financial crisis.

Gaggaet Essay Example for Free

Gaggaet Essay Kuma Maka Msenge wewe Unafirwa wewe Kuma wewe Your mum’s pussy Your gay Sexual intercourse of gay Your pussy What kinds of swear words do you use in your own language? Korean English Sexual intercourse Reproductive Organs Idiotic Animalize Malay Babi Pig One of the rudest word in Malaysia Malaysia is a Muslim country and Islam is restricted to pork. The religion has food restrictions according to their own dietary laws, which is â€Å"Halaal† Swahili Msenge Wewe Gay One of the rudest word in Tanzania Homosexuality is not forgived in Tanzania. It’s new to their culture. It is also defined as man is using you. Have you ever spotted some differences between the swear language women and men use? Men tend to use the rudest one. Men use swear words more than women do. -? To establish a masculine identity or to express group solidarity. Men tend to use more swear words related to sexual intercourse and reproductive organs than women do. Men (1) You’re a pussy, dick, jerk, cunt (2) What/Why/How/When the fuck Women (1) You’re a bitch, ass, shit (2) What/Why/How/When the hell Men (1) Unafirwa (2) Pumbaru (silly) Women (1) Malaya wewe (your bitch) (2) Mshenzi (nasty attitude and behavior) Men often use swear words to show or express friendliness ; Women don’t. Hey what the fuck?! How the fuck did you get here? Come and have a bite you dickhead. Why do language learners often find it easy to remember swear words in English? The brain treats swear words differently than other words. From a scientific research, swearing is a motor activity with a strong emotional content. This is one reason that most people remember swear words four times better than they do other words. Swear words trigger emotion. Effects from Mass media Books Society Trend Slang Thank You

Effective Teaching Strategies for Deaf Students

Effective Teaching Strategies for Deaf Students What protocol would you put in place to ensure that pupils hearing aids and other amplification equipment are working optimally and used appropriately and that other aspects of your role in relation to audiology are met? Give the rationale for the procedures that you have specified. How would you evaluate the effectiveness of procedures that you have established? Rationale From the outset it is essential to determine what a ‘protocol is? As stated in the online Ask Oxford Dictionary protocol has many definitions, the one I believe provides a clear definition in this instance is â€Å"The accepted code of behaviour in a particular situation†. (Ask Oxford, Nov 2009) An educational establishment where children are using hearing aids and other amplification equipment would benefit from a protocol being in place. This would ensure that children using amplification equipment are accessing the curriculum at an optimal level. Teachers of the Deaf have a duty to ensure that each childs equipment is working and allowing them to learn and thrive within their educational environment by carrying out the protocol that is in place. It is therefore the duty of the teachers of the Deaf to carry out checks on the equipment. A protocol is therefore required to ensure that all Teachers of the Deaf are carrying out the same procedures and there is consistency through out the school. â€Å"Teachers should aim to give every pupil the opportunity to experience success in learning and to achieve as high a standard as possible.† (NCDS, 2005, p.5) By carrying out the checks, Teachers of the Deaf establish good practice and in turn aim to allow pupils to succeed. The children benefit when the protocol, which the school employs, is shared with parents and carers. Listening and learning take place in both the home and school environment. This would extend the â€Å"accepted code of behaviour† to the home life optimising the childs access to everyday learning experiences. With the need for a protocol established it is also necessary for that protocol to become a routine as to how, when and why Teachers of the Deaf should apply the specialised knowledge they have within their specific educational establishment. â€Å"Teachers of the deaf are specialist teachers, whose firm base in audiological knowledge is a fundamental part of their specialism† (Malthy and Knight, 2000, p.vii) Putting into practice a clear set of guidelines allows for each individual, working with children using these devices, to know who is responsible for each area and who to report faults to. This is the case, especially when multi-agency teams are involved in an individuals learning. To answer the question outlined I intend to: Describe the setting to which the protocol applies to Discuss the aims of the protocol and whom it applies to Review and evaluate the effectiveness of the protocol in relation to practice and research Protocol Setting The setting to which this protocol applies to is unique, in Scotland, in the sense that it is a mainstream school where hearing-impaired children are fully integrated into mainstream classes. Children have access to a full curriculum, which enhances their educational experience. (See Appendix 1 for a full policy statement) Teachers of the Deaf are also used in a unique way they are class committed in a mainstream environment with no more than four hearing impaired children in their class. It is important now to emphasise that the teachers have a responsibility and a duty of care to hearing and hearing impaired pupils in class. It is recognised in Watson. L and Parsons.J (1998) that the majority of Teachers of the Deaf are working in mainstream schools either as part of a unit or in peripatetic work but in this setting children are fully integrated into mainstream classes. This setting provides a real life setting for the children as hearing and hearing-impaired peers work together as they would in everyday life. This allows an inclusive ethos to develop educating respectful and open-minded individuals. It allows for the development of a safe and secure environment where all children feel valued and equal. Aims The aims of the protocol are clearly set out in the Aims of the Audiology Programme (Appendix 1). They are in bold and easily identified on the page. This is of great benefit to Teachers of the Deaf and other individuals that encounter the document. The mix of visual diagrams and the clear print allows this section to be user friendly and less intimidating to the user. The initial statement presents a positive and motivating aim for everyone involved. I will look at each aim individually and discuss how effectively the protocol (Appendix 2) achieves those aims. All pupils with a hearing impairment will be assessed regularly through a range of tests. Included in the protocol are the schools own testing strategies, which are of great importance as they make the protocol more meaning full to the individual establishment as these tests will differ depending on establishment. In Appendix 2, the protocol outlines the different checks that would take place to ensure that pupils hearing is assessed regularly. The G.A.P assessments are included in each child record and include a variety of linguistic and speech tests that are outlined in Appendix 2 and are carried out by the in house Speech Therapists. The Ling Speech Sound Test could be included in this however; it is outlined in the actual protocol. It will be used to gather information on how well a pupil is able to identify frequency elements in sounds. Ideally, this should be carried out before teaching and listening takes place to ensure that the amplification equipment is working optimally. If the test highlights any frequency issues, the stetoclip can be used to investigate further. In the event of everything, appearing to be working properly the issue can be raised with the educational audiologist on their visit to the school. They can then investigate and adjust amplification equipment to ensure opt imal teaching and learning conditions are maintained. Tympanometry tests are carried out and a record kept in each pupils file. This provides information on the middle ear. It looks like an audiogram, which can be difficult to interpret. If the information from this was translated into a report that was more understandable Teachers of the Deaf could use this information and translate it positively into their teaching environment so that it makes learning more accessible to the child and in turn meets the needs of the pupil. Other tests included in the protocol are Pure Tone Audiograms aided and unaided. These tests are usually used to determine the degree of deafness. The tests are carried out using different frequencies and intensities. The tests can be conducted through air conduction, using headphones or bone conduction using a bone conduction headband. Air conduction: this is where the individual wears headphones, the tester then selects pure tones from different frequencies and intensities. This test relies on the person being tested to be honest. Once the test is completed the range of deafness is apparent however the cause is not. Bone conduction: this is conducted in a similar way to air conduction. Maltby and Knight (2000) explain that it determines the nature of deafness. The signals are passed through the skull bone and travels to the cochlea. â€Å"The difference between the air conduction result and the bone conduction result is known as the air-bone gap and this indicates the extent of any conductive hearing loss.† (Maltby and Knight, 2000, p.34) The results produced are displayed on an audiogram. It is important to emphasise that these tests are not carried out by Teachers of the Deaf but by audiologists. However, it is important that Teachers of the Deaf are aware of them and how results can be used to improve a pupils residual hearing. This brings me to the point I made earlier on how the audiogram can be difficult to interpret. It would be of great advantage to teachers, parents, and other professionals if the information were transposed into a report, which can be used to benefit the child. The use of pupils residual hearing will be maximised Many factors can contribute to ensuring that a childs residual hearing is maximised. In Appendix 2 it outlines the documentation and assessments, each individual will undertake during their time in school. This part of the protocol needs to be looked at as Record of Needs is being replaced with Additional Support Plans and Co-ordinated Support Plans. This highlights the need for the protocol being a working document and not something that is just produced to meet audiology requirements. In completing these assessment such as Pure Tone Audiograms aided and unaided and Tympanometry Records all agencies involved will be able to contribute to the action that should be taken within the educational environment to maximise the pupils residual hearing. In addition to this it is of great importance to consider the acoustic setting as this contributes to how well residual hearing is maximised. This leads on to the next aim. The acoustical settings for learning will be monitored and acted upon where necessary. In every classroom, there is background noise and this contributes to how effective a hearing aid can be. â€Å"Hearing aids work well when there is little or no background noise† (Maltby and Knight, 2000, p.61) However, this is unrealistic to attain within an educational environment. Children are often working in groups and teaching can take place in whole class settings where they can be further away than what would be desired for optimal hearing. The hearing aid volume can be increased however this will amplify the background noise that is present also. A quiet learning environment is one, which would provide optimal learning conditions however in a mainstream school this is unlikely. The increased class effects noise. Areas, which contribute to background noise within a mainstream class are, movement, chairs being pushed and pulled, bags being accessed and the rustling this produces, increased amounts of talking, group activities going on independently when other direct teaching is taking place. All of these can lead to a poor acoustic setting. It would therefore be beneficial for the protocol to include measures for the Teachers of the Deaf to assess this before teaching in this environ ment. They could use a sound level meter, which encourages the teacher to put his or herself in the position of the deaf child and try to remove any pieces of furniture, which are not essential which sounds can reflect off. The teachers are also able to position themselves around the class identifying where the best place for a deaf child to sit within the class is. This allows for greater access to teaching and learning and ultimately reducing some of the background noise. As the background noise does not only come from the people inside the class, it is important for the teacher to do this so that outside noises are reduced. Traffic, toilets, general outside activity, weather can all be heard in the classroom. (Maltby and Knight 2000) It would therefore be of great value for the protocol to offer ways of minimising background noises within the classroom setting however it doesnt provide ways of making the classroom acoustically sympathetic. Reducing background and reverberation could be set out in guidelines and could provide suggestions. â€Å"An acoustically good environment is crucial for effective classroom listening †¦ schools provide an acoustically hostile environment that particularly disadvantages hearing aid wearers.† (Maltby and Knight, 2000, p.54) Therefore, guidelines within the protocol should encourage the use of carpets, curtains blinds, acoustic ceiling tiles and soft materials, which can in turn absorb and reduce the amount of background noise. (BATOD, 2001) This will help promote the fruitful learning environment outlined in Appendix 1. As classrooms are, in general, noisy places to be it would also be of great value that the protocol takes into account classroom management strategies, laying out rules for talking and listening. Establishing a whole school approach would provide consistency for not only the children but also the Teachers of the Deaf who undoubtedly have varied teaching styles and approaches. â€Å"†¦It is the teachers responsibility to maintain discipline and cooperation and thus reduce noise levels. Ensuring only one person talks at a time. (Maltby and Knight, 2000, p.58) Fm and Sound Field systems help reduce the amount of background noise as this amplifies one source of sound benefiting the hearing aid or cochlear implant user. This will allow for enhanced teaching and learning taking place and allow the learner to become more focused and interactive with the lesson in hand. It is therefore of great importance that they are utilised effectively. Sound Field systems not only benefit hearing-impaired children in the class but those of hearing children as well. This is due to the teachers voice being amplified and making it clear for all present in the room. Brett and McCraken (1998) have referred that some authorities are not using the system successfully and in turn not providing children with the heightened sensory provision. The system not only increases the volume of the person using it but also helps eliminate noises in the classroom, which can be controlled such as movement, chairs moving, quiet discussions. This has outlined the importance of monitoring the acoustic setting for the children it has also highlighted areas in which the protocol could be improved to optimise the service provided to the children. Including these areas would make Teachers of the Deaf and Teachers of the Deaf in training more aware of areas which can be detrimental to the learning environment and moreover have a negative impact on the childs learning. The amplification needs of each pupil will be assessed and addressed. Each child is an individual and in turn, each child has individual needs. So it is of the utmost importance that Teachers of the Deaf regularly assess the equipment each child uses. This will ensure that faults are highlighted quickly and fixed without any real issues arising for the child and their learning. Brett and McCracken (1998) outline the particular needs of a Hearing Aid wearer and provide outline for assessing the equipment. These include making sure that hearing aids are well fitted and that the individual is able to hear in a range of environments. These are of great importance in a school as children are moving from area to area rather than being stationary in the one environment. This is where the acoustic setting assessments are monitored and acted on if necessary. Tests are carried out, which were discussed in the first aim, to gather information. This information can then be used to make decisions regarding amplification equipment of each individual making sure that Teachers of the Deaf are meeting the needs of each child. The amplification equipment and technology will be working to optimum effect and will be used effectively. It is essential that this aim is addressed in the protocol as teachers and parents should be checking the childs amplification equipment on a daily basis. This will allow problems to be detected quickly and rectified. In turn, this will maximise the potential learning that, the child has access to and allow the child to engage fully in their learning and the social interactions, which can take place within the classroom. This is concurred by Maltby and Knight; they believe that auditory equipment if working properly will enhance the learners experiences and the overall progress which a child can make. This setting is one, which uses oral communication, and not signing so any problems with amplification equipment is extremely detrimental to the childs development. â€Å" †¦ without effective exposure to the sounds of the environment and particularly of speech the opportunity to develop spoken language will be diminished.† (Maltby and Knight, 2000, p.38) The mainstream protocol for this setting outlines how to check all different kinds of amplification equipment. However it may need updated as, no child now wears the Sprint (the body worn processor) as this just adds to the bulk of the protocol and the amount of paper which you have to go through especially if you are new to the school. In addition to this upon evaluating the protocol, I also feel that there should be a checklist record for each child, keeping track of any issues with equipment. This could be a simple tick list to ensure that time constraints do not impose an issue for the teachers. This would provide useful information for the educational audiologists when they visit asking if there have been any problems. This is of greater use in the lower end of the school where the children are less able to vocalise any issues, which they may be having. As it is just now, there is no such method of recording and Teachers of the Deaf are making notes on an informal basis with no consistency being formed throughout the establishment. Parents should be considered also; they could be consulted on what would be easily managed for them at home, so that the protocol can be continued there, as it is of great importance that the equipment is at an optimal level there also. Appendix 2 outlines the checks, which should be carried out on a daily basis. Daily checks begin with a visual check. By looking closely at the casing of a hearing aid or cochlear implant cracks can be identified. Moulds and tubing can be looked at and the build up of wax or condensation can be apparent. It has been argued that it is not the role of the Teacher of the Deaf to clear wax obstructions from tubing and ear moulds (NCDS, 2005) in the case of children there might not be anyone else. In meeting the overall aim of the protocol â€Å" †¦ to provide a fruitful learning environment†¦Ã¢â‚¬  it is essential that we do what we can to meet each childs individual needs. In the setting which this protocol applies, as stated before it is an oral one, it is important that the older children become responsible for checking their equipment and that the Teachers of the deaf promote each individuals independence and provide support for these checks only when needed. In this setting, other equipment is used also Radio aids and Sound Field systems are in place to provide further amplification. These have been included in the protocol along with whose responsibility it is to check these and how often the checks should be carried out. â€Å"Deaf pupils who are being educated orally without any sign support will be highly dependent on amplification, both in the form of personal hearing aids and other equipment, for example radio aids.† (Gregory, Knight, McCracken, Powers and Watson, 1998, p.138) This quote highlights the greater importance placed on amplification equipment in a mainstream school and the necessity for it to work optimally. This equipment is what the children solely rely on to communicate effectively with. Radio aids should be checked monthly using a test box. This can highlight any problems with equipment and it will ensure that the hearing aid is producing sound at a high intensity this should also be carried out across a number of frequencies. It is also important that hearing aids and processors also be checked monthly to ensure that they are in line with the manufacturers specifications. Teachers of the Deaf are not responsible for these tests and are not fully trained in the technologies used to carry out these tests however they should be aware that they take place and of their importance in ensuring that amplification equipment works at its optimal level. In this setting and as stated in the protocol (Appendix 2) the Depute Head is responsible for ensu ring these tests are completed. I am of the opinion it would be beneficial for the protocol to outline what a Teacher of the Deaf should do when the equipment is not working properly. For example if shoes or links are faulty are there temporary replacements, or are there contacts in place with manufacturers to highlight faults. It would not be the responsibility for the Teacher of the Deaf to contact manufacturers directly but that of the Depute Head however there needs to be a record or pro-forma included in the protocol for passing this information on the Depute Head to guarantee that any problems are rectified quickly. Evaluation The technology surrounding audiology and amplification equipment is evolving so the first point is that the protocol should be regularly evaluated and adapted to ensure that it fits the requirements of the equipment being used. As I stated previously there are steps and procedures included in the document that no longer apply to children in the school, I am not saying this should be discarded completely however it can be removed from the working document until required, if ever required again. The steps are clear and it is identify who is responsible for each job; however some equipment is checked annually. I feel that as there is a heavy daily reliance on these pieces of equipment and there is a strong argument that these checks should be more frequent. This would allow for problems and issues to be identified and rectified more quickly. Especially when these equipments help achieve the aims outlined in the protocol (Appendix 1) In addition to more frequent checks it would beneficial to have a check list and record sheet this would benefit, not only Teachers of the Deaf but parents, audiologists and other professionals that work with the children. It would allow for quick reference for any issues children are having with their hearing aids or cochlear implants and would highlight any recurring problems. This information would be recorded in a consistent format providing continuity throughout the school. It would also be provided to parents to allow them to keep checks on their childs equipment. With everyone using the same format, the child can be encouraged to become more responsible for maintaining and checking their own equipment. Not only does audiology evolve but also education and the way we approach teaching and education is continually evolving so the protocol should be updated with these changes. That is in Appendix 1 the policy statement outlines that the establishment follows the 5-14 guidelines. This is still the case however the Curriculum for Excellence is becoming the more dominant tool in the planning and implementing of lessons and therefore should now be included also. The greatest indication of how successful the protocol has been is whether it is still meeting the needs of the children it poses to serve. It would therefore be good sense to establish a working party within the establishment to evaluate how well it is doing this, and adapt it to be more successful or it could be added for discussion to the agenda of the Hearing Impairment meetings, which are held regularly. This would incorporate views of everyone working with the document and not just a selected few on the working party. Conclusion The protocol, which appears in Appendix 2, is one, which is already in place, and I have broken it down and looked at the aims that it says it achieves. As a Teacher of the Deaf, this protocol is established and has to be adhered to. It is an important agreement, which has to be followed by all Teachers of the Deaf, to ensure that the needs of each child within a class are being met. â€Å"One way to ensure the teacher of the deaf and other professionals working with deaf children are meeting their obligations is to devise an audiology protocol.† (Course Team University of Birmingham, 2009, Unit 4 p.80) I feel that this protocol has plus points and negative ones. It achieves all of the aims outlined however it has not been updated in some time. With new equipment, needing to be included i.e. our new FM system and older amplification equipment, which is not currently in use needing to be removed. It would also benefit from additions, some parts being condensed into a daily check sheet, which would be more time efficient as it operates within a mainstream school. This would allow for even younger children becoming more familiar with the checks they should carry out. Moreover, I feel there should also be a place for a parental part of the protocol as they are a vital part of their childs life. Even though it is heavy on wordage, it does include pictures of the equipment in question allowing for quick finding of the part of the protocol, which relates to children in your class. The protocol does establish the roles of individuals and the duties and responsibilities that they have. It also states timelines for different checks whether they are daily, weekly or annually. It outlines what should be present in each class for carrying out checks, e.g. First Aid Kit. To conclude I do feel that this protocol does suffice but would benefit from regular updates as needs change and children within educational establishments continually move on. As a teacher and particularly for Teachers of the Deaf it is important to meet the needs of every child. As a profession we endeavour to do this and having a protocol allows for consistency and continuity throughout the stages. We have ambition for all our young people and we want them to have ambition for themselves and to be confident individuals, effective contributors, successful learners and responsible citizens. All Scotlands children and young people need to be nurtured, safe, active, healthy, engaged in learning, achieving, included, respected and responsible if we are to achieve our ambition for them.† (December 2009, Scottish Government) In managing the protocol more successfully, we will achieve the above aim as set by our Government and all the aims outlined within the document of the establishment. In doing this the needs of all children that are taught, within the setting, are met.

Elderly Care: Proposal on Hospital Admittance and Discharge

Elderly Care: Proposal on Hospital Admittance and Discharge A proposal of change to improve the quality of care for vulnerable older people who after being admitted into hospital and on discharge do not have a lot of choice in services that they receive. They are either sent home with a care package which does not meet all needs of the older person or moved to a residential home. It has been said that independence and mobility are the two most precious commodities that the elderly, as a group, need to nurture as a significant decline in either will significantly increase their dependence and reliance on others, either in the family or in the community. (Whitely, S. et al 1996) In general terms, the plight of the elderly in hospital is probably the most precarious of all of the age ranges, irrespective of the illness for which they were admitted. Any form of debilitating pathology, even if it only puts them in bed for a few days, may very well weaken their already tenuous grip on independence. The result may be either a prolonged stay in a hospital bed, home discharge with a care package which may not be totally satisfactory and all too often dependent on the ministrations of a group of overstretched healthcare professionals, or discharge to some form of residential care – which, although possibly seen by some as being the best option for the debilitated or infirm elderly, has an enormous impact on both the independence and the lifestyle of the elderly person. Let us briefly consider this last option which is not as straight forward an option as may appear at first sight. Let us personalise the discussion by referring to a hypothetically representative Mrs J., a 78 yr. old lady who has lived alone since her husband died some ten years previously. She is fiercely independent but has been getting progressively more frail as the years have gone by to the extent that it is a struggle to get her shopping. As a result her diet is becoming progressively more inadequate. Her personal hygiene, which was meticulous a few years ago, is now also failing, and she spends a great deal of her time alone and in bed. She has developed a low grade chest infection which required her to spend three days in hospital. When it came time to discharge her, her daughter could not look after her and took the decision that she would be better in a residential home. Mrs.J. had virtually no choice in the matter and on the fourth day she found herself in a residential home, surrounded by people with an average age rather greater than hers, many of whom were suffering from varying degrees of dementia. The home had a completely imposed and inflexible regime which was a major imposition on her as she had previously been able to do what she wanted when she wanted. There was virtually no privacy and never a time, day or night, when there was silence or quiet. Her house had to be sold to pay the fees, so she knew that there was no possibility that she would ever go home again and any money that she had, she was not able to spend as her savings were also taken to pay the fees. In the space of four days her life had been overturned and although she was warm, fed and cared for, by any rationalisation her quality of life had changed for ever. Mrs.J. is quoted as being fairly typical of many and her case used to illustrate the enormity of the life changing impact of admission to a residential home. Critically examination the need for the proposed change The particular change that we shall highlight in this particular essay is the need for multidisciplinary discharge planning, a move which is highlighted in the National Service Framework for the elderly (Standard Two). As we shall discuss later in this essay, the National Service Frameworks have been conceived and drafted in response to the perceived need for change. It therefore follows that it is a self-serving argument that it is a recognition of a need for change in this area that has prompted its inclusion in the National Service Framework .This rather tautological argument is given credence by a number of studies that have both looked at, and demonstrated the need for change in this area. The paper by Richards (et al 1998) was a first rate examination of the problem. It covered a number of areas, but, with specific relevance to our considerations here it highlighted how the patient outcome could be improved by a timely multidisciplinary pre-discharge assessment by a team which included social workers. This paper, if nothing else, underlines the need for change and provides a model for how improvements in the multidisciplinary discharge function can produce potential benefits for patients Evidence to support this view can be found in anyone of a number of recently published papers (such as Ham C 2004) which has specifically surveyed patient and carer satisfaction levels in the area of welfare and associated services after hospital discharge for the elderly. An outline and critical discussion of how change can be implemented Change can be a trophic factor in any organisation but no matter how good the intentions and aspirations, if it is badly managed, then the end result can be a catastrophic mess. One only has to consider the debacle of the implementation of the Griffiths Report (Griffiths Report 1983) in the NHS in the 80s to appreciate how a major management change could be badly implemented. The Government even set up its own commission to see what lessons could be learned from the episode. (Davidmann 1988) If we consider the overall implications of the report in terms of change management, the innovations failed because they were imposed rather than managed. (Davidmann 1988) Another fundamental concept in the field of change management is expressed by Marinker (1997) who points to the rather subtle difference between compliance and concordance. He suggests that human beings generally respond better to suggestion, reason and coercion rather than direct imposition of arbitrary change. The management of change is perhaps the most critical of the elements in this discussion. There is little point in having vision or ideas if you cannot successfully implement them into reality (Bennis et al 1999). The whole study of the Management of Change is built upon a set of constructs known as the General Systems Theory (GST). (Newell et al 1992). The process is both general and adaptable and can be summarised in the phrase â€Å"Unfreezing, Changing and Refreezing† or in simple terms, assessing a situation changing it, and then making the changes stick. (Thompson 1992). All changes, but particularly health and welfare related ones, should only really be made after careful consideration of the evidence base underpinning that change (Berwick D 2005). In specific terms one should evaluate the need for implementation of a multidisciplinary discharge procedure by considering the evidence that the current situation could be improved, make managers aware of the findings of need and than be proactive in encouragement in terms of support of any decisions that are made to implement such moves. The Political context If one considers the pre-2000 structure and organisation of the NHS, one could come to the conclusion that there were three major problems which, some observers stated were not consistent with what was required of a 21st century care provider, namely: 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) There have been a number of reforms in the NHS which potentially impinge on the cases of the dependent elderly. Arguably the most important was the NHS Plan (DOH 2000). This is a lengthy document which calls for some fundamental changes in the working practices, and in some cases the actual roles of a number of healthcare professionals. An analytical assessment would have to conclude that, although there is a lot of detail in some areas of the plan, there is actually comparatively little detail in just how these changes should be actioned and arguably even less detail in what it expected the changes to be (Krogstad et al 2002). In the context of our discussion here, we should also note the natural ideological successor to the NHS Plan, was the Agenda for Change (2004). The National Service Frameworks were then introduced after seminal guidance from the National Institute for Clinical Excellence (NICE 2004) The other reforms that have a bearing on our considerations are Choosing Health: making healthier choices easier (2004) and Building on the Best (2003). Both of these have considerable implications for the care of the elderly. The Choosing Health paper outlines the Government proposals for giving patients greater choice in the implementation of their health care and Building on the Best examines ways of improving and modifying current practices. There are specific references to the discharge procedures which are relevant to our discussions here. The Health context In the context of this essay the NHS Plan called for a number of reforms including: Increase funding and reform Aim to redress geographical inequalities, Improve service standards, Extend patient choice. Each of these areas has a bearing our Mrs.J. The geographical inequalities were primarily due to the historical context in which each area had implemented their own services together with the balance between funding and demand in each area. The improvement in service standards is mainly driven by the National Service Frameworks and he extension of patient choice clearly has a bearing on Mrs.J. although the choices available may well be less in practical terms than the complete spectrum of what is actually available and may well be constrained by factors such as available funding and the patient’s own physical state. (Wierzbicki et al 2001) The National Service Frameworks (amongst other things) sets out to reduce inequalities in service provision between providers and also to set standards of excellence, together with goals and targets that are nationally based rather than locality based. (Rouse et al 2001). National Service Framework Standard Two has as its stated aim to: 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. It is formulated within the concept of â€Å"Person Centred Care†. This is intended to allow the elderly (and their carers) to feel entitled to be treated as individuals, and to allow them to be responsible for their own choices about their own care. The Social Care context If we accept that a patient’s discharge from hospital is dependent on many disparate and variable factors including (apart from their obvious health considerations), for example, their financial, dependence and support network status. It therefore follows that before a considered decision can be made to discharge the patient, a full and careful assessment of these various aspects should ideally be made. (Gould et al. 1995). The input of the social worker to the multidisciplinary pre-discharge team is therefore vital in this respect as it is unlikely that other healthcare professionals will be in a position to make an assessment of all of these factors. If one reads contemporary peer reviewed literature on the subject, the term â€Å"seamless interface† is a concept that frequently appears. (Dixon et al 2003). This reflects the moves towards the dismantling of the â€Å"Empire† concept of each health and welfare related subspecialty. (Lee et al 2004). And the positive integration of each, for the overall benefit of the patient. Central to this process is the advent of the Single Assessment Process (SAP) which is arguably the most important new work practice to facilitate good multidisciplinary working practices. This reduces the duplication of work, derivation of facts and paperwork that hitherto was commonplace (Fatchett A. 1998). In specific consideration of our Mrs.J. we could find that she was visited by one member of the discharge team (typically the social worker), and an assessment of all of the factors that we have discussed could be made and recorded in a single central document or reference point (computer). It is the stated aim of the SAP that the needs and wishes of the elderly patient will remain at the heart of the whole process. (Mannion R et al 2005) To consider the requirements of the National Service Frameworks and in the context of social work we should also mention the concept of the carer’s or patient’s â€Å"Champion† that has been specifically encouraged. (Bartley M. 2004). These are designated workers (often specially trained or experienced social workers), who would stand up for the need of the patient or their carers. In Mrs.J.’s case we could postulate that such a champion could assess her needs as being more appropriately dealt with by an intensive course of both physiotherapy and an occupational therapy input rather than necessarily being arbitrarily placed in a residential home. The social worker is ideally placed to assess and indeed to action interventions such as that of the occupational therapist, who can be shown to produce considerable impact on the ability of the infirm elderly to remain at home. (Gilbertson et al 2000). We should not leave this area without a demonstration that the evidence base in this area of social worker input as being both positive and beneficial by quoting the Logan paper (et al 1997) References Agenda for Change, 23 November 2004,  Government White Paper:  HMSO 2004 Bartley M. (2004),  Health Inequality. An Introduction to Theories, Concepts and Methods.  Cambridge: University Press 2004 Bennis, Benne Chin (Eds.) 1999,  The Planning of Change (2nd Edition).. Holt, Rinehart and Winston, New York: 1999. Berwick D 2005 Broadening the view of evidence-based medicine Qual. Saf. Health Care, Oct 2005; 14: 315 316. 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Griffiths Report 1983 NHS Management Inquiry Report DHSS, 1983 Oct 25 Ham C. (2004),  Health Policy in Britain [5th ed.]  Basingstoke: Palgrave Macmillan Krogstad, Dag Hofoss, and Per Hjortdahl 2002 Continuity of hospital care: beyond the question of personal contact BMJ, Jan 2002; 324: 36 38. Lee, Wong, Yeung Wong, and Tsang 2004 Interfacing between primary and secondary care is needed BMJ, Aug 2004; 329: 403. Logan PA, Gladman JRF, Lincoln NB. 1997,  A randomised controlled trial of enhanced social service occupational therapy for stroke patients.  Clin Rehab 1997; 11: 107-113 Mannion R, Davies H, Marshall M (2005) Cultures for Performance in Health Care. Maidenhead: Open University Press Marinker M.1997,  From compliance to concordance: achieving shared goals,  BMJ 1997;314:747–8. Newell Simon. 1992,  Human Problem Solving.  Prentice-Hall, Englewood Cliffs: 1992. NICE 2004,  Management guidelines : NHS Directive;  HMSO, Tuesday 7 December 2004 Nickols F 2004,  Change Management 101: A Primer,  London : Macmillian 2004 Richards, Joanna Coast, David J Gunnell, Tim J Peters, John Pounsford, and Mary-Anne Darlow 1998 Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care BMJ, Jun 1998; 316: 1796 – 1801 Rouse, Jolley, and Read 2001 National service frameworks BMJ, Dec 2001; 323: 1429. Thompson 1992,  Organisations in Action.  McGraw-Hill, New York: 1992. Whitely,S. et al (1996)  Health and Social Care Management,  Basingstoke: Macmillan. Wierzbicki and Reynolds 2001 National service frameworks financial implications are huge BMJ, Sep 2001; 321: 705. ############################################################# PDG