Monday, September 30, 2019

New Surgical Technology: Adoption or Diffusion? Essay

This article raised an interesting subject: surgeons and patients seeking improved treatment often forget that a new technique is not necessarily a better one. Human body with its health problems remains the same but the surgical technology is always moving towards progress. People develop new surgical tools and new surgical procedures constantly. However, do we carefully test all these new tools and procedures before using them on people? And how? On humans? On animals first perhaps? Is it ethical? How do we know that new tools and procedures are better than the existing ones? Too many questions†¦ New surgical technology promises improved patient care and, therefore, surgeons may hurry to adopt it despite little evidence or their advantage over existing procedures. Surgical procedures that are later found to be ineffective waste resources and endanger lives. Anything new must be carefully tested and proved in fact to be better. Therefore, the key to this problem is a cautious and total understanding from the surgeons and the patients of why such new procedures come to be offered as treatment. Let’s look in detail how this new medical technology gets adopted in the US. It may come in the form of: * a drug * a device * a procedure * a technique * a process of care For the surgical technology in particular, new things come in the form of a new procedure that uses existing devices or drugs, or an existing procedure that uses new devices. Before adopting any new technology, people should seriously consider the following factors: * Will this new technology improve the quality of clinical care? * If found successful, will the inventor promote its rapid adoption? * How widely this new technology will be distributed? * Will it pass all known and potential barriers for adoption, (financing, marketing, etc.)? * Is it compatible with the existing technologies and operating rooms? From all of these questions the main factor is always the same: the new technology MUST improve the quality of clinical care for patients. If this precondition is not satisfied, the technology should be abandoned: even a logical and scientifically positive attitude is no substitute for proof in practice. There were cases where surgical technology that was quickly adopted without evidence of its relative benefit, was abandoned after careful examination. For example: In 1964, Dr. Smith reported that injecting the enzyme chymopapain into an intervertebral disc relieved pain caused by herniation of the lumbar disc. In 1989, the American Medical Association’s diagnostic and therapeutic technology assessment group questioned the effectiveness of the procedure and raised concerns about its safety. Their evaluation showed that, compared with placebo or no treatment, chymopapain was effective in only selected patients. In addition, when it was used by less experienced surgeons some patients had serious complications, including allergic reaction and even damage to the spinal cord. I feel positive about innovation in all fields especially when people can improve the quality of life by repairing and healing the human body. However, before adopting any new technology in the operating room, it should be offered to patients for a trial period. Also surgeons shall carefully watch and study this procedure being done numerous times, and if it can be supported by the already existing equipment and the existing operating rooms. Do we ask the patient about the convenience or improvement by the new procedure or equipment? Of course! He is the one on the operating table putting his life in the hands of the surgeon. Surgeons always like the new technology if it can be easily and quickly understood, and added to their existing practice without waste of time. If the input to their practice is great, surgeons will invest more time and effort and disregard disruption of their routine day to expand the competitive advantage that a new technology offers. What I learned from this article is the use of new surgical technology has the potential to provide patients with the best possible care. On the other hand, if the new procedure or instrument were not carefully tested and approved, it ruined surgeon’s reputation, wasted resources, and caused harm to patients. Surgeons and institutions must not adopt a new technology without solid evidence of its efficiency and superiority over existing ones. In reality, quite a few innovations in medical technology were often adopted without enough evidence and testing and this was wrong. No matter how good the surgeon’s skill and ability to perform a procedure, it is wrong, if the procedure should not be done in the first place and may potentially harm the patient. Source: Article from BMJ : British Medical Journal 2006 January 14; 332(7533): 112-114. Editorial by Gabbay and Walley and pp 107, 109. Contributors and sources: CBW is senior adviser for the Health Technology Center and senior fellow at the Institute for the Future in California. ————————————————- References: McCulloch P, Taylor I, Sasako M, Lovett B Griffin D. Randomised trials in surgery: problems and possible solutions. BMJ 2002; 324: 1448-51. [PMC free article] [PubMed].

Sunday, September 29, 2019

Constructing On Constructivism The Role Of Technology Education Essay

AbstractionA complementary relationship exists between engineering and constructivism, the execution of each one profiting the other. Constructivism is a philosophy saying that larning takes topographic point in contexts, while engineering refers to the designs and environments that engage scholars. Recent efforts to incorporate engineering in the schoolroom have been within the context of a constructivist model ( e.g. , Richards, 1998 ) . The intent of this paper is to analyze the interrelatedness between constructivism and engineering as revealed by empirical research. The instances include a assortment of surveies in a assortment of scenes – instructor instruction, on-line acquisition, and K-12 instruction ; constructivist schemes include collaborative and concerted acquisition methods, prosecuting in critical and brooding thought, rating through electronic portfolios, and a critical expression at emerging instructor functions within constructivist paradigms. Success has be en reported in the development of constructivist class faculties utilizing engineering as cognitive tools, profiting both pupils and module. However, many instructors do non utilize constructivist patterns, and those who do are non wise in their choice of engineering usage ( Rakes, Flowers, Casey, & A ; Santana, 1999 ) . Technology needs to be viewed in a 3-dimensional position: semiotic, epistemological, and matter-of-fact, enabling the â€Å" building of cognition † by scholars through a procedure of socialization.Introductionâ€Å" Once cognizing is no longer understood as the hunt for an iconic representation of ontological world, but, alternatively, as a hunt for suiting ways of behaving and thought, the traditional job disappears. Knowledge can now be seen as something that the being builds up in the effort to order the as such formless flow of experienceaˆÂ ¦ † von Glasersfeld ( 1984, p. 39 ) The usage of computing machine engineering to back up acquisition has been hard to document and quantify ( Clark, 1994 ; Russell, 1999 ) , go forthing the function of computing machines in the schoolroom unstable. In the past decennary, a sudden revival of involvement was markedly observed in the schoolroom usage of technological inventions, along with the increased usage of the Internet and other digital engineerings ( Reiser, 2002 ) . The field of Instructional Design and Technology, excessively, saw the development and outgrowth of alternate attacks, such as cognitive and constructivist theories, that deviated aggressively from traditional patterns, such as behavioural theoretical accounts. New accents, like electronic public presentation support systems, web-based direction, and knowledge direction systems, non merely agitate the cognition base of the field, but besides widened its skyline across concern and industry, the military, wellness attention and instruction, worldwide ( Reiser, 2002 ) . Enterprises, such as located larning theory and constructivism presented fresh attacks to convey about reforms in the spheres of public instruction and higher instruction ( Anderson, Reder & A ; Simon, 1996 ; Brown, Collins & A ; Duguid, 1989 ; Jonassen, 1999 ; Reiser, 2002 ) . To understand the potency of engineering execution in heightening the teaching-learning procedure, the impact of constructivism on schoolroom patterns has been studied by many research workers ( e.g. , Black & A ; McClintock, 1995 ; Richards, 1998 ; Brush & A ; Saye, 2000 ) . Other research workers have suggested that constructivist schemes exploit engineerings for greatest impact in larning ( e.g. , Duffy & A ; Cunningham, 1996 ) . A complementary relationship appears to be between computing machine engineerings and constructivism, the execution of each one profiting the other. Constructivism, derived chiefly from the plants of Piaget ( 1970 ) , Bruner ( 1962, 1979 ) , Vygotsky ( 1962, 1978 ) , and Papert ( 1980, 1983 ) , is both a philosophical and psychological attack based on societal cognitivism that assumes that individuals, behaviours and environments interact in mutual manner ( Schunk, 2000 ) . Constructivism is a philosophy saying that larning takes topographic point in contexts, and that scholars form or construct much of what they learn and understand as a map of their experiences in state of affairs ( Schunk, 2000 ) . More late, research workers ( e.g. , Lave, 1990 ; Saxe, Guberman & A ; Gearheart, 1987 ) have presented more qualitative certification of larning in context. Technology, harmonizing to Jonassen, Peck, and Wilson ( 1999 ) refers to â€Å" the designs and environments that engage scholars † ( p. 12 ) . The focal point of both constructivism and engineering are so on the creative activity of larning environments. Likewise, Hannfin and Hill ( 2002 ) depict these larning environments as contexts: in which knowledge-building tools ( affordances ) and the agencies to make and pull strings artefacts of understanding are provided, non one in which constructs are explicitly taughtaˆÂ ¦ a topographic point where scholars work together and back up each other as they use a assortment of tools and larning resources in their chase of larning ends and problem-solving activities ( p.77 ) . The intent of this paper is to reexamine the research on the integrating of engineering in the schoolroom, foregrounding the connexion between constructivism and engineering. The focal point is on the constructivist position of larning as an active procedure of building instead than geting cognition, and direction as a procedure that supports building instead than pass oning cognition. The reappraisal is followed by a series of instance surveies, stressing constructivism and engineering ‘s relationship. Finally, deductions for instructors and instructor pedagogues are presented.Review of Related LiteratureIn order to understand larning within a constructivist model, as an activity in context, the whole acquisition environment must be examined. However, the broad diverseness of constructivist positions makes the task really complex and beyond the range of this paper. These positions normally emphasize the function of the instructor, the pupil, and the cultural embeddedness of ac quisition ( see for example, Duffy & A ; Cunningham, 1996 ; Honebein, Duffy, & A ; Fishman, 1993 ; Simons, 1993 ) . Using these commonalties as guidelines, this reappraisal outlines the relationship of constructivism with engineering by looking at ( a ) engineering as cognitive tools, ( B ) constructive position of the thought procedure, and ( degree Celsius ) the function of the instructor in engineering enhanced environments. Technology as Cognitive Tools A cardinal premise of constructivism is that larning is mediated by tools and marks ( Duffy & A ; Cunningham, 1996 ; Ezell & A ; O'Keeffe, 1994 ) . â€Å" Culture creates the tool, but the tool changes the civilization. Participants in the civilization appropriate these tools from their civilization to run into their ends, and thereby transform their engagement in the civilization † ( Duffy & A ; Cunningham, 1996, p. 180 ) . The computing machine is an example of mediational agencies that has facets of both tool and mark. The computing machine ‘s function in instruction has been mostly viewed as an instructional tool and for supplying a richer and more exciting acquisition environment ( Duffy & A ; Cunningham, 1996 ; Jonassen & A ; Reeves, 1996 ; Taylor, 1980 ) . However, by concentrating on the scholar, the function of engineering can back up new apprehensions and capablenesss, therefore, offering a cognitive tool to back up cognitive and metacognitive procedures. For i llustration, an electronic exchange plan between pupils of a category in the U.S. with a similar schoolroom in Northern Ireland shared multiple cultural positions through images, narratives, letters and multimedia plans ( Duffy & A ; Cunningham, 1996 ) . The experience was enriching, increasing their apprehension. Further, clear uping the function of engineering in acquisition, Duffy and Cunningham ( 1996 ) province: Technology is seen as an built-in portion of the cognitive activityaˆÂ ¦.This position of distributed knowledge significantly impacts how we think of the function of engineering in instruction and preparation, the focal point is non on the person in isolation and what he or she knows, but on the activity in the environment. It is the activity – focused and contextualized- that is cardinal†¦ The procedure of building is directed towards making a universe that makes sense to us, that is equal for our mundane operation ( pp. 187-188 ) . Therefore, the undertaking of the scholar is seen as dynamic, and the computing machine makes available new larning chances. The position of engineering as cognitive tools is besides shared by other research workers ( e.g. , Jonassen, 1994 ; Jonassen & A ; Reeves, 1996 ; Lajoie, 2000 ) . The traditional position of instructional engineerings of direction as conveyers of information and communicators of cognition is supplanted with active function the scholar plays in larning with engineering. Technologies, chiefly computing machines, help construct cognition bases, which will â€Å" prosecute the scholars more and ensue in more meaningful and movable knowledgeaˆÂ ¦ Learners map as interior decorators utilizing the engineering as tools for analysing the universe, accessing information, interpretation and forming their personal cognition, and stand foring what they know to others † ( Jonassen, 1994, p. 2 ) . Technological tools such as spreadsheets, databases, adept systems, picture conferencing and others can be used by pupils to analyse capable affair, develop representative mental theoretical accounts, and so transcribe them into cognition bases ( Jonassen, 1994 ; Jonassen & A ; Carr, 2000 ; Jonassen & A ; Reeves, 1996 ) . An illustration is the development of fake microworlds and games by kids utilizing Logo scheduling. Logo scheduling has evolved since the early text-based medium conceived by Seymour Papert and his squad at MIT in the 1970 ‘s, to a well easy, digitized format. Kafai, Ching, and Marshall ( 1997 ) gave an introductory preparation plan to fifth and sixth grade pupils one hebdomad before the design undertakings. The Logo version included support for modern computing machine characteristics like multimedia, sprite life, sounds, films, and pigment tools. Harmonizing to Kafai and her co-workers ( 1997 ) , the multimedia package proved to be a good context for pupils to larn through coaction and undertaking direction. The interaction between squad members, the flow of thoughts and loud thought encouraged the kids to experiment and happen alternate ways for planing and work outing jobs. For illustration, the pupils worked on different characters separately, but so worked together to inc orporate all the characters, and in debugging ( Kafai et al. , 1997 ) . Cognitive tools do non prevent the usage of computing machines to increase productiveness for larning. Off-loading insistent undertakings and lower order undertakings to cognitive tools frees cognitive resources for deeper thought ( Duffy & A ; Cunningham, 1996 ; Jonassen, 1999 ) and reduces mistakes. Harmonizing to Swain and Pearson ( 2001 ) , instructors and pupils must be educated to utilize the computing machine as a productiveness tool, every bit good as a tool for acquisition, research, networking, coaction, telecommunications, and problem-solving. Using computing machines as a productiveness tool is one of the six National Educational Technological Standards ( NETS ) ( hypertext transfer protocol: //cnets.iste.org/ ) for instructors which states that instructors will â€Å" utilize engineering to heighten their productiveness and professional patterns † ( Morrison, Lowther, & A ; DeMeulle, 1999 ) . Constructive position of â€Å" Thinking † The procedure of thought in constructivist paradigms requires higher-order accomplishments, diging deeper and harder into content and context ( Black & A ; McClintock, 1995 ; Jonassen, n.d. ; Manzo, 1998 ; Swain & A ; Pearson, 2001 ) . Traditional schooling, harmonizing to Manzo ( 1998 ) , really discourages constructive believing with ends of conveying bing cognition that conflicts with any existent effort to bring forth new apprehension. â€Å" Constructivist thought combines both the critical and originative rational procedures. It can be practiced by promoting critical analysis in activities. Schools, instructors and pupils can be conditioned to swerve away from traditional schooling regimen to promote constructive thought † ( Manzo, 1998, p. 287 ) . Cognitive tools, along with constructivist larning environments, usher and activate cognitive acquisition schemes and critical thought ( Jonassen, 1994 ) . Cognitive tools help in cognition building and non knowledge reproduct ion. The cognition constructed by the scholars reflects their comprehension and construct of the information. To exemplify, when pupils build cognition bases with databases, they need to analyse the content sphere and engage in critical thought. Black and McClintok ( 1999 ) emphasis the importance of reading as being cardinal to knowledge and acquisition. Their design of Study Supported Environments ( SSEs ) based on constructivist design rules called Interpretation Construction Design ( ICON ) focused chiefly on the interpretative building of reliable artefacts in the context of rich background stuffs, and crossing across different Fieldss of survey. Their survey showed that in add-on to larning specific content, pupils were able to get generalizable reading and debate accomplishments. For illustration, in learning 6th grade antediluvian history, a plan called Archaeotype A © was used that presented pupils with a in writing simulation of an archeological site. Students who worked collaboratively in groups, had to delve up artefacts through simulation, observe and mensurate them in fake research labs, and eventually through a procedure of reading and debate, arrived at the apprehension of general rules behind what they were making. In a follow-up rating survey, it was found that there were important additions in the interpretive and debate accomplishments of pupils who had participated in the survey against a control group ( Black & A ; McClintock, 1999 ) . Brooding thought, that requires careful deliberation, is besides encouraged by constructivists ( e.g. , Kafai et al. , 1997 ; Swain & A ; Pearson, 2001 ; Walker, 2000 ) . Metacognition, or the self-monitoring and self-denial of the acquisition procedure, is emphasized. New cognition which is composed is added to old representations, modifying them in the procedure. This normally requires external staging in the signifier of people, books, or engineerings such as computing machines. Swain and Pearson ( 2001 ) recommend the pattern of brooding thought by instructors to measure their engineering usage. They stress the importance of certification of brooding ideas to find the extent and quality of personal versus instructional utilizations of engineering, organisation and execution of environments and activities. Jonassen ( 1994 ) describes technological tools as â€Å" rational spouses † and â€Å" powerful accelerators † in the procedure of acquisition, â€Å" scaffoldin g the all important procedures of articulation and contemplation, which are the foundations of cognition building † ( p. 5 ) . The Role of the Teacher in Technology Enhanced Environments The function of the instructor as a facilitator is seen as most of import in a constructivist context ( Witfelt, 2000 ; Richards, 1998 ) . Within a constructivist schoolroom, the instructor engenders societal and rational climes, where collaborative and concerted acquisition methods are supported. In parallel, technology-enhanced schoolrooms tap constructivist schemes ( Jonassen, 1999 ) , set uping problem-based undertakings where pupils actively construct cognition, associating knew cognition with old cognition. In non-traditional schoolrooms such as the open/global schoolroom ( Walker, 2000 ; Witfelt, 2000 ) , the function and duties of the instructor have changed. The instructor, as an agent, has to invariably update information and engineering for doing learning reliable and relevant. For illustration, while developing a class faculty for instructors and taxonomy for instructor competences in the usage of educational multimedia, Witfelt ( 2000 ) observed that it was of import to unite several theories such as constructivism, postmodernism, situated intelligence and multiple intelligences. However, the theoretical model would be constructivist in nature with the instructor presuming the function of the facilitator, supplying an environment for self-generated research, understanding the societal and collaborative nature of acquisition, assisting kids concept cognition and initiate problem-based, project-oriented work. With this passage in functions and duties, Witfelt ( 2000 ) listed new in structor competences in constructivist contexts that include supervisor makings, protagonist and facilitator of pupils ‘ work, adviser and subject-matter expert, galvanizer and encourager, supreme authority at group treatments, critic in mobilising greater attempt when aims are non being met, and judge to better general larning capacities of pupils.Case StudiesAfter analyzing the literature on engineering integrating and constructivist rules, a complementary relationship between engineering and acquisition within a constructivist model seems sound and advantageous to instructors and scholars. To exemplify these rules discretely, model instances are presented that reflect the doctrine established above. Teacher-trainees at Winthrop University in South Carolina undertook a meaningful technology-based activity to carry through literacy ends ( Richards, 1998 ) . They developed an electronic portfolio around a literacy-related subject, including informations, contemplations and critical responses, which they shared with their equals and other pedagogues. The extract of engineering was helped by implementing constructivist-based activities, such as coaction and cooperation in a group, prosecuting in job resolution and building possible solutions to social quandary, and pass oning the deeper processing of content and the critical development of literacy accomplishments and schemes ( Richards, 1998 ) . Student perceptual experiences were determined through formative and summational appraisal methods. Students responded positively toward achievement of concerted and collaborative acquisition, the engineering constituent maps and the relevancy of the activities to future callings in schools. However, they recommended that more clip be provided for treating thoughts and synthesising them in the portfolio. Research conducted at the Open University, U.K. besides demonstrated a positive relationship between constructivism and engineering integrating ( Walker, 2000 ) . A distance-learning class was developed maintaining in head the experiential and constructivist positions of larning. The intent was to assist pupils in a distance-learning class learn in better and more effectual ways, to be active scholars, building their ain apprehension. Assignments and appraisals were besides oriented towards constructivist ends. Their attempts culminated in a new paradigm of class development. A study of all the pupils who completed the class and took the scrutiny revealed that the bulk felt that they had improved their acquisition accomplishments to a considerable extent. A follow-up study was undertaken the undermentioned twelvemonth. These findings revealed a high proportion of positive responses to inquiries sing the continued usage of contemplation to better assignments, based on teachers ‘ feedback and rating standards. However, pupils were less positive about their usage of contemplation in general. These pupils like those described above ( Richards, 1998 ) struggled with maintaining and utilizing contemplation efficaciously. Students were non the lone donees of the mixture of constructivist schemes with engineering tools. Harmonizing to Richards ( 1998 ) and Walker ( 2000 ) , the development of class faculties based on constructivist patterns and the integrating of engineering were besides good to the module, as they had to be after and revise to incorporate engineering so that pupils could be helped to go more capable and mature scholars.Deductions for PracticeThese instances have important deductions for instructor pedagogues and instructors. In the country of instructor instruction, Kim and Sharp ( 2000 ) observed that the planning of instructors consistent with constructivist patterns was extremely variable with most preservice instructors cognizing really small about the effectual integrating of engineering in instruction. Since instructors tend to learn as they were taught, it is indispensable that both preservice and inservice instructors must be exposed to constructivist-based direction, which wo uld so ease the development of learning schemes consistent with recent reform motions ( Kim & A ; Sharp, 2000 ) . An exposure to constructivist learning methods and coincident multimedia acquisition experiences influenced the planning of constructivist behaviours and extract of engineering ( Kim & A ; Sharp, 2000 ) . Technology may besides act upon teacher pattern to integrate constructivist rules. Rakes, Flowers, Casey and Santana ( 1999 ) study that as the sum of engineering available, the degree of engineering accomplishments of the instructors, and the usage of engineering increased, the usage of constructivist schemes in the schoolroom besides appeared to increase. â€Å" Technology can supply the vehicle for carry throughing constructivist instruction patterns † ( Rakes et al. , 1999, p. 3 ) . So, increasing the accomplishment degrees of instructors with respect to computing machines and supplying extra chances for instructors to incorporate engineering into lessons may promote the usage of constructivist behaviours. Availability, skill degree and usage may non, nevertheless, warrant purposeful usage of engineering nor constructivist rules. Rakes et Al. ( 1999 ) reported many instructors concentrated on the drill and pattern type of package, pretermiting basic computing machine accomplishments development, or dealt merely with presentation accomplishments and Internet resources. These research workers recommended concentrating on staff development and preparation in engineering usage and constructivist patterns that moved beyond literacy accomplishments to turn to more thoroughly application and curriculum integrating issues. When turn toing the function of the instructor in constructivist paradigms, there should be no misconstruing sing the importance of the instructor. Yet, many instructors feel uncomfortable with the deficiency of a chiseled content and the displacement of venue of control to the scholars ( Brush & A ; Saye, 2000 ; Duffy & A ; Cunningham, 1996 ) . Making suited contexts is non simply supplying scholars with resources and allowing them discover things for themselves, but forming resources in such a manner to breed cognitive disagreements in the heads of the scholars, animating them to larn how to larn through a procedure of coaction and defendable apprehensions ( Duffy & A ; Cunningham, 1996 ) . As a facilitator of acquisition, the instructor is non ineffective and on the out of boundss. On the contrary, the instructor is free to utilize a assortment of constructivist schemes, such as coaching, mold, and scaffolding, to help each scholar ( Collins, Brown & A ; Newman, 1990 ) . Scaffolding may include support from other persons and artefacts, every bit good as the cultural context and history that the scholars bring to the environment. Scaffolding, nevertheless, does non intend guiding and learning a scholar toward some chiseled end but back uping the growing of the scholar through cognitive and metacognitive activities ( Hannafin, Hill & A ; Land, 1997 ) . Therefore, the instructor assumes the function of a manager and ensures common apprehension of the positions of the scholar. In utilizing collaborative and concerted groups, the instructor must be careful in guaranting that they are non merely schemes for acquisition, but means to advance dialogical interchange and reflexi veness ( Duffy & A ; Cunningham, 1996 ) . As Morrison, Lowther, and DeMeulle ( 1999 ) competently suggest, â€Å" Technology and a constructivist attack need non be at odds with each other. If we change our position of computing machines from simply a agencies to present direction to one of a tool to work out jobs, so the reform motion can act upon the usage of engineering, and engineering can act upon the reform of instruction † ( p. 5 ) .DecisionConstructivist positions assert that acquisition is the active procedure of building instead than passively geting cognition, and direction is the procedure of back uping the cognition constructed by the scholars instead than the mere communicating of cognition ( Duffy & A ; Cunningham, 1996 ; Honebein, Duffy & A ; Fishman, 1993 ; Jonassen, 1999 ; ) . Truth is determined by the viability of the scholars ‘ apprehension in the existent universe, where viability is culturally determined. The constructivist model seeks to understand multiple positions, and challenges the s cholars ‘ thought ( Duffy & A ; Cunningham, 1996 ; Jonassen, Mayes & A ; McAleese, 1993 ) . It examines the societal beginnings of buildings, whereby it acknowledges larning as a procedure of socialization. Therefore, the survey of societal and cultural procedures and artefacts becomes a cardinal issue. Context is a dynamic whole including the person and sociohistorical facets ( Duffy & A ; Cunningham, 1996 ; Ezell & A ; O'Keefe, 1994 ) . Thinking is ever dialogic, linking heads, either straight or indirectly. The indirect or semiotic agencies are the marks and tools appropriated from the sociocultural context ( Duffy & A ; Cunningham, 1996 ) . Within this displacement in focal point from the objectivist to the constructivist context sphere, engineering can play an built-in portion in the acquisition environment ( Duffy & A ; Cunningham, 1996 ) . â€Å" The profusion of the engineering permits us to supply a richer and more exciting ( entertaining ) larning environmentaˆÂ ¦ our concern is the new apprehensions and new capablenesss that are possible through the usage of engineering † ( Duffy & A ; Cunningham, 1996, p. 187 ) . By incorporating engineering with constructivist methods, such as problem-based acquisition and project-based acquisition, scholars are more responsible for and active in the acquisition procedure ( Grant, 2002 ) . Additionally, mundane applications, such as word processors and spreadsheets, become powerful instruments for reliable acquisition. Constructivism offers flexibleness to instructors to individualise larning for each pupil while utilizing engineering tools to augment cognitive and metacognitive procedures.SubscribersAloka Nanjappa is presently a doctorial campaigner, Instructional Design and Technology, Department of Instructional Curriculum and Leadership, University of Memphis, Tennessee. She was Assistant Professor in a college of instruction, affiliated to the University of Bombay, India, learning Experimental Psychology, Educational Technology, and Methodology of learning Mathematicss. She has besides taught in the K-10 and undergraduate degree ( Zoology ) in India. Aloka was late awarded the Outstanding ID & A ; T Graduate Student Award by the University of Memphis, Tennessee. Her research involvements lie in teacher instruction with a focal point on engineering integrating in the schoolroom. Michael M. Grant is an Assistant Professor at the University of Memphis in the Instructional Design and Technology plan within the teacher instruction section. His most recent research has focused on suiting single differences and constructionism. He has worked with both preservice and inservice instructors on incorporating engineering.

Saturday, September 28, 2019

Business Proposal Coursework Example | Topics and Well Written Essays - 1000 words

Business Proposal - Coursework Example For this reason, there is always the need for a business to derive strategies by which it can rely on to adapt to the external environment. The factors in the external business environment play a big role in determining the operations of the internal functions. This is because; the business is expected to keep continually realigning its internal operations in order to remain relevant and effective. The external business environment is very dynamic; every day, new economic conditions always arise, legislations, competition strategies among other factors. This paper discusses the economic factors that affect the business in various ways; it focus on mobile phones, as the product that is traded most in many places for economic and social reasons. In addition, it examines the pricing approaches that are used in an imperfect market structure and the factors guiding the pricing in relation to demand patterns The economic factors in the business external business are hard to predict, for instance, the global recession has affected many businesses, making them look for various cost-saving and waste reduction approaches. While some businesses focus on ways to reduce their expenses and increase their, efficiencies, there are those that resolve to outsource functions in order to cut down on their costs. Businesses that effectively manage their external environment effectively end up becoming market leaders, with increased rates of turnover and profitability. There are different types of market structures that exist in an economy, these structures are determined by the types of products being sold, the number of buyers and sellers and their knowledge of the market among other factors. Monopolistic market structures are those characterized by a high competition between many large firms and individuals (Maurya 2008). This market structure is almost similar to a perfect competition only that here; there

Friday, September 27, 2019

Math 107 Coursework Example | Topics and Well Written Essays - 750 words

Math 107 - Coursework Example Thus, this design helps control for some lurking variables and avoids problems with confounding. 10) The actual adults satisfied with their jobs= 54% * 1581 =854 adults. From this, the 95% confidence interval is 44% to 86%. This confidence interval in consistent with the national poll result of the significance test indicated, but is more informative since it gives a range of values for the true proportion of adults 12) Double-blind is a stringent way of conducting an experiment on human subjects in order to eliminate subjective bias on both experimental group and the experimenters. More than not, double-blind experiments are employed to achieve a higher standard of scientific rigor. In this method,  neither the subjects nor the researcher knows who belongs to a control group and who belongs to an experimental group. Thus, performing the experiment in a double-blind way is used to lessen the influence of individual prejudices and unintentional physical cues on the results of the experiment. In medical studies, double-blind methods applied since there is always the possibility that the study results would be affected by conscious and unconscious bias by the experimenter. 16) In trying to make a weighted voting system that works, one first notices that the chair and vice chair actually have the same power (given the rule), so they are given the same weight (say, 5). The other three members also have the same weight, say 3 (two members must weigh more than of the chairs). Then the quota would have to be smaller than or equal to 13 (for the two chairs plus one other member to win), smaller than or equal to 11 (for one of the chairs plus two members to win), and larger than 10 and 9 (so that the two chairs alone, or the three members alone, cannot win). Thus it looks like 11 works here; indeed, the weighted voting system [11:5, 5, 3, 3, 3] is equivalent to the

Thursday, September 26, 2019

Explain the significance of Hamlet hecuba speech Essay

Explain the significance of Hamlet hecuba speech - Essay Example The significance of this monologue is in expressing the thought of Shakespeare, that the world is theatre, and all people are actors in it. 'World-theater' metaphor is the core of the whole Shakespeare's work. This monologue does not separate him with the First actor, but only makes them closer. It is based on the plot, which is far from being familiar to the English audience of XVII century, and can be supposed the most emotional of all tragedy. By asking 'What's Hecuba to him' Hamlet implies the whole story, taking place in the Danish kingdom, and this question makes Hamlet stand further away from the reader and from himself, making him the commentator of his own story. This monologue is the means of discovering the deep sense of tragedy - the metaphor 'theater-world' and to trace, how sophisticated is the transition from one reality into another. The significance of Hamlet Hecuba speech is in being the principal Shakespeare's means of showing the implications and thoughts of the tragedy. The work is abundant in parallels and comparisons of the reality with the theater. Thus, the significance of the described speech in making this plot line evident can be subjected to no argument.

Wednesday, September 25, 2019

Stragtegic Business Plan Term Paper Example | Topics and Well Written Essays - 2500 words

Stragtegic Business Plan - Term Paper Example Focus has been given to thinking about the process of developing e-commerce, as well as the benefits and challenges of e-business. From these, some insights into appropriate strategizing for the business are offered. Furthermore, there is a comparison of the online store in this context with other similar stores in the United States. The identified online stores are considered the top competitors of the online store in the market. Nonetheless, in order to overcome some of the challenges and ensure growth, a SWOT analysis of the store is explored in order to understand important aspects in the internal and external environment of the online store. In the conclusion, focus is given to the attribute of a leader. These are discussed as part of the strategy to ensure the growth and survival of the online store. Nonetheless, this paper bases on different e-business issues to develop a strategic business plan for the online store. Table of Contents Introduction 4 Background 5 Current Thinki ng Relating to the Topic 6 Relationship to current/other organizations 10 Conclusion 11 Appendices 13 References 14 Introduction One of the fastest growing business fields in the world today is e-business. Internet usage has experienced an overwhelming growth. It is estimated that the number of internet users in the world has grown by 400% between the years 2000 and 2010. For this reason, different companies have looked for ways through which they can interact with customers online. One of the ways is through setting up websites. Here, companies offer different services to their online customers, who might not be able to reach the physical stores. In addition, some businesses have become internet-based, with no physical stores. Nonetheless, the number of businesses that are online-based continues to grow today (Torabi, 2011). In order for any business to be successful, it must have a strategic plan. This maps the strategy that the business will adopt in order to attain its goals (Ba si, 2000). I have special interest in entrepreneurship, and this study program has made me knowledgeable in matters of entrepreneurship. Therefore, using the knowledge acquired in this program, this strategic business plan is meant for an online store, which deals with cell phones, iPads, and other electronic devices. Since this is a new online store, this strategic business plan should help the store to establish itself in the online market. According to Basi (2000), when developing a new business, an entrepreneur is faced with various business-related issues. This paper will therefore, focus on some of those issues. Furthermore, this paper will explore the current thinking relating to e-business. This is important, as it will offer insights in major areas the strategic business plan should base. In addition, the paper will include a comparison of the store in the context, with similar online stores. Since this paper also discusses with marketing in e-business, there will be a SWOT analysis of the online store. This will help to identify major factors in its internal and external environment, which is important in the development of strategy. Background The online business store was developed mainly to sell cell phones, iPads, and other electronic devices directly to customers. The prices of the electronics in the store are made affordable in order to attract more customers (May, 2010). The products sold in the store are ordered directly from manufacturers and importers. The

Tuesday, September 24, 2019

Read article A Pilot Program on Youth Engagement by Rachel Swaner and Research Paper

Read article A Pilot Program on Youth Engagement by Rachel Swaner and Elise White and describe 5 ethical, political or procedural challenges addressed in the report - Research Paper Example A Pilot Program on Youth Engagement by Rachel Swaner and Elise White gives some good examples ethical, political or procedural challenges that need to be addressed by researchers. One of the ethical challenges is that a program may fail to have the desired impact. This mainly arises if the target population is not given a chance to actively participate in designing the program or campaign messages. In order to address this, the programming of the youth ECHO was done in a way that it not only focused on serving the youths but also, it incorporated them as essential partners in its creation. For example, they helped to design semi-structured questionnaires for interviewing fellow youths and friends. The developers took time to listen to and learn from the community, especially the youth. They used findings from youth group to identify the issues that the Youth ECHO campaign should address. In this way, the program reflected on the experiences of the youths while providing a sense of connection between the youths and the community and, between the youths and adults. The program made the speaker an insider, speaking from their cultural context and the context of youth disconnected from the mainstream culture. Through a series of discussions, the youths had the chance to select the strongest elements of the message that would be used in the final campaign, â€Å"Dealing Drugs: It’s Not Worth It.† In this way, the messages were not perceived as suspect. This idea also helped to address the ethical issue of source credibility. By focusing on youths that are disconnected from the mainstream society, the program results are bound to be more reliable and valid. An example of a political challenge in research is that the research program or resultant campaigns could result to some unintended effects. For example, a research campaign on crime could increase crime prevention awareness but also, it could lead to a state of unwanted

Monday, September 23, 2019

Multiple choices questions Assignment Example | Topics and Well Written Essays - 250 words

Multiple choices questions - Assignment Example inners of World War II, in which the United States therefore bore the burden of leadership in the free world and was obligated to defend both democracy and freedom. It was a reality in which the US was threatened -- psychologically, politically and militarily -- by the expansion of and aggression from, among others, a totalitarian Soviet Union and the international Communist movement it sponsored (Weldes 1996: 283). 4. Crucial to the following analysis is that the institutional feature which distinguishes democracies from autocracies is the existence of a popularly elected legislature with the capacity to constrain a countrys chief executive. We assume that legislatures are more protectionist than executives in democracies and show that, even so, pairs of democracies are more likely than mixed pairs to liberalize commerce. We claim that this institutional difference contributes to a greater tendency for pairs of democratic countries to agree upon lower trade barriers than pairs comprised of a democracy and an autocracy (i.e., mixed pairs) (Mansfield, et al. 2000: 304-305). 5. ... Economic polarization is related to the alientation that groups of people feel against each other, and this alienation is enforced by notion of within-group cohesion and identity. ... What matters for conflict ... is rather economic polarization. ... [A] society that is split into two well-defined groups with [differences] in incomes is particularly likely to experience social unrest (Ostby 2008: 146). 6. A fundamental assertion of balance-of-power thought is that large-scale conflict between nations will be avoided when their power is approximately equal, and, conversely, will be more likely between nations that diverge in their power. This assertion is based on the assumption, frequently hidden, that in a conflict between any two nations there is a direct relationship between power and victory, and, other considerations aside, the more powerful nation will prevail (Siverson and

Sunday, September 22, 2019

Enterprise Architecture as Strategy Essay Example for Free

Enterprise Architecture as Strategy Essay Technology is shifting at a faster rate resulting in development of new methods that assist in completion of certain technological demand. This has given birth to different enterprise architecture frameworks that fulfill the requirements of day-to-day activities. Architecture is a framework of guidelines, principles, models, standards and strategies that directs, construction and development of business process, design and information and resources through enterprise. Hence, enterprise architecture is a blueprint, which defines the structure and operation of a given organization (Fowler Rice 2003). Thus, a foundation in which an organization can determine how to achieve current and future aims. There are many types of EA frameworks with specified capabilities. Some of these frameworks include ToGAF, Zachman, FEAF, DoDAF and EAP. The aim of this paper is to analyze ToGAF, and analyze how it compares with other EA frameworks. The Open Group Architecture Framework (TOGAF) is an enterprise architecture framework, which approaches the development of enterprise information architecture through design, planning, governance and implementation. This EA framework employs four pillars to achieve its goals: Application, Business, Technology and Data. Before the architect plans for current and future aims of the organization, they are provided with foundation architectures that form the basis that they will use for the new development. The four pillars play a crucial role in ensuring that the process is successful. Business architecture allows the definition of governance, business strategy, the organization and any other important processes of the given organization. Applications architecture allows the provision of the blueprint for the specific application to enable the interaction, deployment and create relationships between the important business processes of a given organization. Data architecture describes the structure of the given organization and defines physical and logical data assets that are in the given organization. Technical architecture defines the software, hardware and network infrastructure that is in place and the required technical resources to accomplish the mission in question. The original aim of the TOGAF was to design and develop technology architecture for a given business entity. However, the framework has evolved becoming a methodology that is used to analyze overall business architecture. This resulted into splitting of the enterprise methodology into two parts: Architecture Development Method (ADM) and Enterprise continuum. The ADM ensures that the enterprise architecture meets the requirements of the organization in terms of business needs and information technology needs. Its ability to be tailored ensures that organizational needs are factored in each of the different execution steps of the architecture planning process. The process is usually cyclic and iterative because the entire process is split into phases. The ADM supports nine phases; the first is the preliminary and the second to the ninth ranges from Phase A to Phase H. Each phase requirements are checked and ensured that it fulfills its basic needs. For example, Phase C combines Application and Data architecture and phase B and C ensure that the clarity of the information architecture is achieved (Lankhorst 2005). For the ADM to be successful, Enterprise Continuum comes handy. Generally, the Enterprise Continuum can be seen as a ‘virtual repository’ of all the assets of the architecture that is in an organization. These assets may include architectural patterns, architectural models, architecture descriptions and other important artifacts. Enterprise Continuum brings together Solutions and Architecture Continuum. The Architecture Continuum structures the re-usable architecture assets, which brings together representations, rules, relationships of information systems that are available to the enterprise. The Solutions Continuum defines the blocks that are used by the Architecture Continuum. This then allows the architectural building models and blocks that assists building the architecture design and eliminates ambiguity during analysis and implementation of the process. Usually there is a relationship between the different EA frameworks in terms of how it operates and ways that enables it to accomplish its duties. Zachman Framework and TOGAF ADM part share some common features. ADM mapping in relation to the Zachman Framework supports a correlation. The Zachman Framework has a well established and comprehensive taxonomy that supports various models, viewpoints and other important artifacts, which an enterprise may consider developing as a phase of the EA (White 2007). The Zachman Framework covers the 30 cells, but the TOGAF does not cover all the cells. However, it is possible for the TOGAF to develop viewpoints to accomplish aspects of Zachman Framework. Nevertheless, there are some viewpoints that are supported by TOGAF, which are not included in the Zachman Framework. For example, the missing viewpoints include manageability and security. The purpose of the architecture is to define viewpoints, an aspect that is supported by the TOGAF ADM but lacks in Zachman Framework. Zachman Framework vertical axis provides a source of potential viewpoints while the horizontal may provide generic taxonomy concerns. Thus, the Zachman Framework does not have means for processes for conformant views or developing viewpoints. Hence, it does not employ a perspective that is shown by TOGAF’s ADM. FEAF structure resembles with TOGAF because it is portioned into Data, Business, Technology and Applications Architectures. Thus, it contains guidance that is analogous to TOGAF architecture and its architectural viewpoints and perspectives. However, the rows that are in the FEAF matrix do not directly map to TOGAF structure. However, the mapping of ADM to Zachman Framework has some correlation between TOGAF and FEAF. Hence, the columns that are in the FEAF matrix correspond to the three architecture domains that are supported by TOGAF; the fourth TOGAF domain covers business architecture that lacks in the FEAF structure. Enterprise Architecture Planning (EAP) is a framework that brings together Applications, Information and Technology Architectures in fulfilling the requirements of architecture. Thus, it shares many concepts with TOGAF because the aim of EAP is to form blueprints for architectures to solve business problems. Moreover, EAP supports the nine phases that are supported by the TOGAF (White 2007). The first three phases in the EAP (Business Architecture) maps to the Phase B of TOGAF ADM. Baseline Description, which is the step 4 in EAP maps to Phases C and D of TOGAF ADM. These are some of the basic features that both frameworks share. However, EAP does not support taxonomy of various views and viewpoints when compared to the TOGAF architecture. Department of Defense Architecture Framework (DoDAF) defines the architecture systems into consistent and complementary views. It defines a structure and mechanisms that help in understanding, visualizing and assimilating the complexities and broad scope of a given architecture design through tabular, graphic and textual means. Thus, it shares minimal aspect with TOGAF. In fact, TOGAF focus on the methodology of architecture in terms of â€Å"how to† without bringing into consideration architecture description constructs. This perspective is different when it comes to the DODAF architecture. DoDAF main functionality focus on the architecture through a given set of views without any specified methodology, a perspective that is different from TOGAF, which has a specific methodology (Bernus Fox 2005). ADM guides the way that TOGAF operates, an aspect that is less exhibited in the DoDAF. This is because the purpose of architecture determines description of use and supports a well tailored process to fulfill the requirements of the EA (McGovern Ambler 2003). DODAF requires that all information, analysis and products to build should be put forefront before building the architecture. However, TOGAF specify certain requirements that should be in place and grouped into the four pillars. DoDAF supports three â€Å"views† System, Operational and Technical while the TOGAF support four views. However, â€Å"views† in DoDAF differs from the view that is seen in the TOGAF. Deliverables and artifacts that are defined in the DoDAF have no corresponding parts in the TOGAF ADM. This is because DoDAF goes deeper in determining details of the specific architecture. Thus, DoDAF are at the system design level rather than in TOGAF, which is in the architecture level. Nevertheless, the level of detail can be included in the ADM especially at Phase B, C and D of the TOGAF. Enterprise Architecture plays an important role in ensuring that the business strategy and the requirements of a certain process are achieved. TOGAF approach is useful in achieving a business-oriented process through a well defined methodology. TOGAF have common features and minor differences with other EA such as the Zachman, FEAF, DoDAF and EAP. The view and viewpoint that is incorporated by the TOGAF ensures that the requirements of the organization are achieved. Thus, TOGAF plays an important role, which is envisaged by other Enterprise Architecture Framework. It fulfills the requirements that it is assigned, however, fulfills it different from the other EA frameworks. References Bernus, P. Fox, M. (2005). Knowledge Sharing in the Integrated Enterprise: Interoperability Strategies for the Enterprise Architect. London: Birkhauser. The book addresses Enterprise Architectures and Enterprise Integration in a way that makes it easy to utilize Enterprise Models and other Modeling Tools. It brings together the different models and forms of a framework into fulfilling a requirement. Thus, it develops interchange models between the given modeling tools, maintain its interdependencies and knowledge on the re-use of enterprise models. The authors also provide means towards the achievement of the ISO9001:2000. The book brings into consideration Design of Information Infrastructure Systems for Manufacturing (DIISM’04) and International Conference on Enterprise Integration and Modeling Technology (ICEIMT’04). Fowler, M. Rice, D. (2003). Patterns of Enterprise Application Architecture. New York: Addison-Wesley Publishers. The book provides proven solutions to the problems that are experienced by information system developers. The book utilizes code example in terms of C+ and Java. The book turns the problems that are associated with enterprise applications developers into a new strategy that eliminates these problems and ensures that the developers are in an environment that they can easily embrace. The authors’ helps professionals to understand complex issues associated with architecture. The book shows that architecture is crucial in completion of application development and multi-user environment. In addition, the book provides patterns and context in EA that enables the reader to have proper means to make the right decisions. Lankhorst, M. (2005). Enterprise Architecture at Work: Modeling, Communication, and Analysis. New York: Springer. The authors bring clearly the complexities that are associated with architectural domains. It brings into consideration description of the enterprise architecture and fulfillment into an organization in terms of processes, structure, systems, applications and techniques. The book brings into consideration description of components and unambiguous specification to allow for a logical modeling language. They utilize their skills in ensuring that the architects have concrete skills that fulfill the architectural practice. It also gives means that allows communication between stakeholders that are involved in these architectures. The authors also provide means to assess both qualitative impact and quantitative aspects of the given architectures. Modeling language that is utilized has been used in real-life cases. McGovern, J. Ambler, S. (2003). A practical Guide to Enterprise Architecture. New York: Prentice Hall PTR. The authors of the book have hands-on experience in solving real-world problems for major corporations. The book contains guidelines that assist the architects to make sense of the systems, data, services, software, methodologies, and product lines. The book also provides explanation of the theory and its application to the real world business needs. Perks, C. Beveridge, T. (2003). Guide to Enterprise IT Architecture. New York: Springer Publishers. The book brings into consideration different Enterprise Architecture frameworks. The authors’ clearly explains development of a modeling concept through various technical architecture, e-business and gap analysis. Moreover, the book brings into consideration operating systems and software engineering principles. Moreover, the book relates EA with service instances, distributed computing, application software and enterprise application integration. Ross, J. Weill, P. (2006). Enterprise Architecture as Strategy: Creating a Foundation for Business Execution. Chicago: Harvard Business Press. The aim of EA is to define the requirements of an organization in terms of job roles, standardized tasks, infrastructure, system and data. Moreover, the book also gives guidelines in the way that organizations will compete in a digitalized world providing managers with means to make decisions and realize visions that they had planned. Thus, the book explains EA vital role in fulfilling the execution of a given business strategy. The book provides thoughtful case examples, clear frameworks, and a proven and effective way of achieving EA. Scheer, A. Kruppke, H. (2006). Agility by ARIS Business Process Management. New York: Springer Publishers. The authors’ brings into consideration the benefits that are associated with utilizing of varies EA frameworks. It brings into consideration the various differences that are seen in each EA framework. Moreover, the authors explores the benefits that will result if a given framework is utilized in a given business strategy. Thus, the book is business oriented with EA playing an important role. Schekkerman, J. (2003). How to Survive in the Jungle of Enterprise Architecture Frameworks, 2nd Ed. New York: Trafford Publishers. This book defines the role that is played by enterprise Architecture Frameworks bringing clearly the main difference between the common Enterprise Architecture Frameworks. This book provides the right procedures and means that can allow selection of the right Enterprise Architecture Framework. The book further gives the history and overview of various Enterprise Architecture Frameworks and the capabilities that the specified Enterprise Architecture. Some common features of EA that the book explores are principles, purpose, scope, structure, and compliance and guidance to ensure that the right EA is chosen. Wagter, R. Steenbergen, M. (2005). Dynamic Enterprise Architecture: How to Make it work. New York: John Wiley and Sons Publications. The authors of the book present a way towards EA that enables organizations to achieve the objectives of their business. The book focuses on governance of the IT organization, advice and strategies provide tangible tools that assist in the achievement of the goals of the organization. If all the directives are followed the organization will achieve its goals at a faster speed. White, J. (2007). Managing Information in the Public Sector. New York: M. E. Sharpe. The book covers the basis of information technology, political and managerial issues that revolve the EA. This book is specifically written for the public and it covers all problems that are related to IT and the public.

Saturday, September 21, 2019

Educational Assistance Essay Example for Free

Educational Assistance Essay I am currently employed as a bagger at H-E-B and would very much like to be considered for the educational assistance program you offer to employees. I want to go to college to be a pharmacist when I complete high school and am already taking a pharmacy technician class along with my other classes. I know H-E-B is a wonderful place to work, not just because I already work there but because my father has worked as a truck driver there for 15 years. H-E-B is very steady, has good benefits and most importantly, treats their employees like family. I can’t think of any other workplace that can keep their employees loyalty like that. I know there is a growing need for pharmacists and with the way H-E-B has added deli’s, floral dept and pharmacies to keep up with today’s markets, I can get my degree and become a part of all that. Pharmacists are in need more and more and cannot think of anywhere I would rather put my degree to work than H-E-B. All I ask for is the chance to become a registered pharmacist and join the pharmacy staff at H-E-B. This company has been around for 100 years and with the loyalty of people like myself and my father, will be around for many more. This is my chance to fulfill my dream of becoming a pharmacist and advance my career within a company I care about. I sincerely hope you will grant my request for educational assistance and help me make continue the H-E-B tradition of quality service and a family atmosphere. If you approve my request, I will work hard to make you glad you gave this opportunity and when I become a pharmacist, I will able to help the people who work and shop H-E-B on a regular basis.

Friday, September 20, 2019

Role Expansion of Support Staff in the NHS

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