HRD Essay Example | Topics and Well Written Essays - 500 words - 2

HRD - Essay Example She somehow managed to spend the meeting with her client as they asked numerous questions. As soon as she returned to her job, she contacted her director and mentioned that she is shocked to note that she was rather introduced to the company as a CQI practitioner for which she was not hired. Since there were fewer consultants at work, it came to understanding that Kindred had to take their client. It is for this reason that Kindred had to consult academic researchers at the library as well as her class mates who were specialist. Also, she had to take help from a friend who pretended to be an assistant (Cummings & Worley, 2009). Herein, it should be noted that Kindred had to face dilemma at her job. There were three types of dilemmas which were noted in the case of Kindred namely dilemma of self, competence and confidence. Firstly, the dilemma of self notes those kindred was confused about her identity which was falsified by her director in front of clients showing her as a CQI specialist for which she was not even hired. Secondly, the dilemma of competence level was that she became doubtful about as she was skilled in different area (Cummings & Worley, 2009). The question remains that whether her lack of CQI specialty was because she didn’t aspire to learn or because of her director who presented her wrongly. And finally, dilemma of confidence which marked that she was not sure for whom she was working. The question remained in her mind that whether her director is an honest person or not. She was making many assumptions in her mind that even in the future; her director would have done similar acts by sending to clients for which she would not have been competent at all (Cummings & Worley, 2009). If I was in her position, I would have done the same because ethics are to be followed. A career growth is not expected until or unless there are subjected clauses and ethics which are

Eye laser surgery Essay Example | Topics and Well Written Essays - 500 words

Eye laser surgery - Essay Example Despite the surgery being carried on people’s eyes successfully and improving their natural eyesight, it does not result to lack of use of glasses (Justesen 80). People will still be required to wear glasses to ensure they do not expose their eyes to any other kind of danger. Eye laser surgery is an effective way of correcting and reshaping your eye despite several challenges. They are several reasons as to why this form of surgery might be deemed important. This might be because someone is unable to use contact glasses and do not at any cost need them for their personal reasons such as cosmetic issues (Papel 116). Another reason is that, wearing of glasses limits what one can do especially in reference to entrainment or any other leisure activity that requires rigorous physical participation. In such a situation, the affected individual seeks the help of a surgeon to help with the eye problem through the laser surgery (Justesen 80). Others try to avoid as much as possible the cost of maintaining the contact lens because they require an extra care because of their fragility nature. People should consider several medical grounds before the laser eye surgery process is carried out for precautionary purposes. Surgeons recommend an individual to be over 20 years before they decide to use this medical procedure for their eye corrections (Justesen 80). Before the process is carried out, there is need to determine the thinness of the corneas because this kind of surgery has extra risks which can seriously impact on an individual. In case of a special condition such as diabetes or a weak immune system, doctors should be in a position to advice accordingly. There are several rare side effects associated with laser eye surgery. Most of the notable side effects include glare and the impact of seeing halos around pictures. Others negative effects that result from this kind of eye surgery are challenges while driving at night or in a mist

Comparison Italian And German Fascism

Comparison Italian And German Fascism In the 20th century there were a lot of rises and falls of many types of government. In some cases, two world wars influenced these events and multiple changes arose in power. The First World War gave way to such styles of rule as Fascism and Nazism. Very often these two ideologies are conflated as the same thing. However, while there are similarities between these concepts, a lot of differences also exist, that need to be mentioned. In order to understand these two movements, one should get to know the meaning of these terms. Such political ideology as Fascism is used in reference to the style of ruling that arose in Italy after The First World War and was represented by Benito Mussolini. And Nazism is embodied by the man who might be a true Nazist itself, Adam Hitler. Fascism could be considered as militant political movement that emphasized loyalty to the state and obedience to the leader. It based on the principles of Authoritarianism: government tried to organize and control with strong discipline as much as possible in peoples lives. The first obvious difference between these two political systems is about the intention: Hitlers Nazi wanted to avenge what the world done to them after the World War I, he wished Germany to gain the hegemony all over Europe. While Mussolinis fascism just wanted to reconstruct Roman Empire, build up the southern part from agriculture to industrial as the northern part of Italy. Other areas of differences between Germany and Italy involve their people. Hitler had peoples support till the end, while Mussolini gradually lost peoples faith. After the World War I, Germany and Italy were in the same period of difficulty. Germany was considered to be the nation that made the war breaks out. Because of this reason, they had to pay massive reparations to some countries. It harmed their economy so much, and embarrassed the German people. This pushed up Hitler to start his ideas of new political policies called Nazism. Main points of this policy was to demanded more land, expand anti-semitism, and to make Germany become a super nation. Hitler used political propaganda to fuel their cause against the enemy. One of propagandas methods was the radio. That is kind of demagogism, the people knew nothing about the truth, but lies. Hitlers Nazi were also against the Jews, use them as scapegoat. Jews were cheated extremely rude. About economic, Hitlers Nazi could help their people out of the crisis, all economic activities devoted to the nation and the enlargement of the army. Role of women was not be respected, under Nazism, women ha ve only role to take care of children and support their husband to serve the state. No place for women in any important field like political or economic. About Italy, Mussolinis fascism was the only policy which have freedom, all others were extinguished. All people who against the new policy was killed or exiled. Though parliament still met, all the important decisions were done by Fascism party, all followed what the dictator Mussolini told. Local power replaced by the mandarins appointed from Rome. Local fascists always had the same power as the government officials. No freedom of press in Italy that time, all the press, radio, movies, theatre were censorship strictly. All anti-fascism editors were replaced by fascist supporters. Schooling was tightly supervised, all books were rewritten to praise the fascist system. Teachers must wear uniform, students had the right to point out any teachers who did not have the fervency to the fascism. All the economic activities also under controlled by corporate state, they tried to harmonize the employers from all class. Lockouts and strikes were not allowed. About religion, especially here is Catholic, was forced. No other religions could exist. In spite of these differences, these two fascism states share many important experiences. Since Mussolini and Hitler are allies, the way they used fascism is very similar, they have almost the same political point of view. Both of them were dictator fascists, looked for the new form of government: totalitarianism. They love to use violent, followed the doctrine of anti-democratic and anti-socialist, despised to civil rights and individual liberties. Their political ideologies formed just after the World War I. Violent propaganda was the key tool in both nations to increase social conflict everywhere in their nations, enabled the fascism government to dominate the points of view of the public to what they want to. The education systems in Germany and Italy were also very similar. The main purpose in education was to create as much well-trained and loyal soldiers as possible, because of the physical training was a major part of education. The womens role in both states was not respecte d. France is considered as the common enemy for both Germany and Italy, because France invaded territories of both two countries. All characters above may be not enough, but they are somehow representative for the similarities between Italian Fascism and Nazis Germany. Although political systems of Fascist Italy and Nazi Germany differ from each other in many areas, but they still share some common experiences. As James Brown quotes: Fascism and Nazism, although poles apart in their intellectual content, are similar in this, that both have emotional appeal to the type of personality that takes pleasure in being submerged in a mass movement and submitting to superior authority.

Free Essays - Immorality and Corruption in the Great Gatsby :: Grapes Wrath essays

Immorality and Corruption in the Great Gatsby In the novel, The Great Gatsby by F. Scott Fitzgerald many of the characters could not be classified as a truly moral, a person who exhibits goodness or correctness in their character and behavior. Nick Carraway is not moral by any means; he is responsible for an affair between two major characters, Jay Gatsby and Daisy Buchanan. Jay Gatsby does show some moral qualities when he attempts to go back and rescue Myrtle after she had been hit by Daisy. Overall Gatsby is unquestionably an immoral person. Nick Carraway and Gatsby share many immoral characteristics, but a big choice separates the two. Daisy Buchanan is an extremely immoral person; she even went to the lengths of taking someone's life. Jay and Daisy are similar but Daisy is borderline corrupt. The entire story is told through Nick Carraway's point of view and by his carelessness it is obvious the narrator possesses poor values. Throughout the entire novel it is clearly portrayed that Nick Carraway is not a moral character by any stretch of the imagination. Nick Carraway may seem to have some good values, but he is in fact immoral for many reasons. First, Nick uses Jordan Baker; he never actually became interested in a serious relationship with the golf star. Miss Baker is basically just a fling to him. Secondly, Nick Carraway always seems to be the middleman in all the trouble that is going on in the novel. The narrator knows about all the lying, deceiving, two-faced things that are going on throughout the story, and he is completely ok with it. Also Nick defends Gatsby even though he very well knows of all Gatsby's criminal activity and liquor smuggling. Finally, Nick is the character who sets up two of the main characters, Daisy Buchanan and Jay Gatsby, to have an affair. It never crosses Nick's mind that it is an immoral thing to set up an affair. During the novel there is a discussion betwee n Gatsby and Nick about when to set up the secret meeting with Daisy. During this exchange Nick actually says, "I'm going to call up Daisy tomorrow and invite her over here to tea.

Radio and Television in Mass Media Essay

A form of media that revolutionized the way humans communicate was the radio. David Sarnoff is the best candidate for the man who put radio on the map. Although it may have not been his choosing, the sinking of the Titanic in 1916 put his name in the record books. For three days straight, the young Sarnoff decoded messages from the sinking ship from his office in New York (Wells 36). The Titanic broadcast was groundbreaking, because it showed and economically profitable way by which radio could be used as a medium of mass communication for ordinary families (Wells 36). By 1930 transmitters were popping up in cities around the nation. A record 30 million households had a set, and the one set per household was becoming a reality (Wells 42). The power of radio was not really noticed until a monumental broadcast in 1939. H.G. Wells’ â€Å"War of the Worlds† broadcast brought a whole nation to its knees and caused widespread panic among millions of viewers. Hours after the broadcast, people from coast to coast were thrown into panic, believing monsters from Mars, invulnerable space ships were destroying the earth. They took to cars, ran out to warn neighbors, traffic was jammed, church services were ended. Four times during the show the listeners were reminded that they were hearing a dramatization, but many citizens couldn’t see past. After the incident, Wells told reporters that radio is a popular democratic machine for disseminating information and entertainment (Naremore 38). The power of radio was soon known, and this incident brought light to it. Today there more than 575 million radios in America alone (Encyclopedia Britannica). The latest study from the National Broadcasting Company found that 90.5 percent of the adult population listens to some type of radio during the week. Today, Clear Channel Communications owns over 1,200 radio stations across the United States, and Cumulus, the second largest owns 266 stations. (Grant, Meadows 141). With the FCC eliminating caps on ownership, one day everyone may be listening to the same news, spun whichever way Clear Channel feels like spinning it; to the left wing, or the right. Traditional radio is facing its toughest battle these days though. Satellite radio is sweeping through the market like a wildfire; with CD-quality sound, and hundreds of channels to choose from, who wouldn’t spend the ten dollars a month to have  XM or Sirius? Although both companies reported losses in mid-2004, each service looks to become profitable by the end of 2005 (Grant 142). Radio will be hard-pressed to keep up with satellite. XM’s digital music library is among the world’s largest – 1.5 million titles and counting. Out of the 121 channels available on XM, 68 are 100% commercial free 24 hours a day, year round, with over 1500 hours of live programming every week. Although XM and Sirius only represent radio’s 4.5 million subscriptions only represents a fraction of radio’s 290 million weekly listeners, the number of satellite subscriptions is expected to double in 2005 (Bachman 4). On Christmas Day 2004, over 50,000 subscribers signed up for satellite radio service. If both companies hit their projections, there will be 7.7 million satellite radio subscribers by January 2006 (Bachman 4). Satellite radio isn’t the only next generation radio system on the market. In 2004, 10,000 HD radios were sold, with prices ranging from $500-$1,000. B the end of 2005, Strubble predicts there will be a t least 600 HD radio stations, covering 80% of the U.S. and about 100,000 HD radios sold. HD radio representative John Smulyan believes, â€Å"WE think this is one of those opportunities for game-changing radio business† (Bachman 5). Television began with three companies that still dominate the airwaves, ABC, NBC, and CBS. In a world of subscription, these companies till offer free TV, but the ratings are going more towards cable. The clean cut programming that was once aired is being replaced with a plethora of violence and political propaganda that may ruin television. Television ranks just behind radio in penetration in the U.S. With over 106 million home, or 98% of the U.S. population having televisions, there is a plethora of sets ready to catch signals for people to view. Network TV has emerged over the last two decades as the dominant vehicle for interpreting national politics. TV has become the major source of news for the population, and the only news source for others. The problem is that politicians and journalists feed off each other like leeches. The politician needs the journalist for their messages to reach the intended audience, and journalists need the politicians to have something to write about. The coverage politicians seek gives them an outlet from which to speak. Those  who look good in the media can make a good image for themselves. The real problem comes when the news turns out to be propaganda, causing action from an opposing side that leads to deception. More than propaganda, violence seems to be the hot topic debated daily by politician and parent alike. Can what you child sees on television affect how he lives his/her life? E.B. White once said that â€Å"television is going to be the test of the modern world† (Simons 151). There is no doubt that television has become the central activity in homes today. Its ability to entertain, teach and persuade has huge impact on viewers. In the United States 98% of households have at least one set (Simons 149). What is astonishing is that children are watching an average of 7.5 hours a day (Simmons 149). One of the main concerns with television programming is the violence viewed by children that cannot understand the differences between fantasy and reality. Davidson, in a issue of Rolling Stones, agreed that â€Å"children are vulnerable to television between the ages of 2 to 8 years because of their maturational inability to separate what they view from reality† (qtd. in Simmons 152). Violence was such an issue that is came under consideration in the 50s and 60’s in Congress. The findings supported the idea that a casual relationship existed between television violence and aggressive behavior. The National Coalition on Television Violence has classified the Mighty Morphin Power Rangers as the most violent program ever studied, with almost 200 violent acts per hour (Simmons 150). In an experimental study involving 5 to 11 year olds, children who watch Power Rangers committed seven times more aggressive acts than those who did not. Shows such as these caused a large number of accidents and quarrels due to the children imitating the characters actions. There is no doubt that the television programming has engulfed the U.S. population. As of 2003, 71.3% of U.S. households received cable programming (Grant, Meadows 29). This fact is amazing, because cable had only been around for fifty years. Not only programming is changing, but how we receive it as well. In May 2002, the FCC set a deadline by which all U.S. commercial television broadcasters were required to be broadcasting digital television signals. This date was a little early though, but by September 2003, 38 of 40 stations in the 10 largest markets in the United  States began broadcasting digital television signals (Grant, Meadows 28). By early 2004, 1.5 million household were watching HDTV, and that number is going to rise sharply. This means clearer sound and displays, recordable content, and crisp, clear reception of the same channels that have always been around. What if new 16Ãâ€"9 television sets make news broadcasts look weird or maybe cartoons might not look good on a widescreen set? There is no telling where the television market will go, hopefully bigger and better; but will content become more subtle, or so radical that new laws must be made to subdue? â€Å"Radios.†Encyclopaedia Britannica Online. 1999. Encyclopedia Britannica. 13 February 2005 Grant, August and Jennifer Meadows. Communication Technology Update. Oxford: Focal Press, 2004. Naremore, James. The Man who caused the Mars Panic†. Humanities, Vol 24 (2003) 38-40 Simmons, Betty Jo, Stalsworth, Kelly, Wentzel, Heather. â€Å"Television Violence and Its Effects on Young Children.† Early Childhood Education journal Vol 26 (1999): 149-153 Wells, Alan. Mass Media and Society. Palo Alto, National Press Books. 1972

Qualified nurse during a clinical placement Essay

Decision making essay Decision making is important to nurses in today’s society, ( Thompson et al 2002) as a number of policy and professional imperatives mean that nurses have to worry about the decisions they make and the way in which they make them. The government has produced several policy initiatives (DOH 1989, 1993a, 1993b 1913c,1994, 1995, 1996a, 1996b,1997, 2000, 2000) which have led to the creation of an evidence based health care culture ( Mulhall & Le May 1999). Thompson et al (2002) believe that poor decision making will no longer be acceptable, the government aim to examine professional performances and the outcome of clinical decision making for the first time. Evidence based practice will no longer be an optional extra but a requirement of all health care professionals. The aim of this essay is to analyse and evaluate a decision made by a nurse in a community practice. The author will highlight why she chooses the particular issue and how it is important to nursing. The author will provide an overview of two general approaches to decision making, rational and phenomenological, by evaluating and analyzing them. The author will consider decision making theories, and try to apply them to the decision making process witnessed in her community placement. She then aims to show, how they should or could have been used as an aid in effective decision making. She will also consider influencing factors that effected the decision making process. A pseudonym is used throughout the essay to protect the patient’s identity, as stated in NMC (2002) code of professional conduct section 5. The patient chosen for the purpose of this essay will be referred to as Jo. Jo is 53 year old women who suffer with rheumatoid arthritis. This also resulted in Jo having bilateral hip replacements. Jo is on steroid treatment, which leads to thinning of the skin and susceptibility to trauma (Mallet and Dougherty 2001). Jo lives with her husband and two grown up  sons. Jo was refereed to the district nurse on her discharge from hospital following her second hip replacement. The initial referral was to check the surgical wound. However on arrival it was pointed out by Jo that she had a skin tear on her left shin that wasn’t healing. The district nurse performed an assessment and concluded the wound was a venous leg ulcer as it had been present for 6 weeks. The district nurses used Sorbisan and Telfa to dress the wound. Twice weekly visits were carried out to Joe for a further 4 weeks, and it became obvious that the ulcer was not improving. The district nurse had to make a decis ion on what care to provide. The decision was to try another dressing Aticoat which is impregnated with silver, and not to refer the patient to the leg ulcer clinic at the local hospital. The district nurse involved with Jo’s care was a G grade nurse and in charge of a community practice that had 3 other nurses working in it. The author decided to focus on this particular decision, as she was influenced by the amount of evidence based research available on the issue, and how the district nurse chose to ignore the evidence, and made a decision on the basis of personal knowledge. The author visited a leg ulcer clinic while on her community placement, and asked the expert nurses running the clinical at what stage they would like to see patients referred to them. She was told if a wound wasn’t healing after 4 weeks the patient should be referred, this information was passed on to the district nurse and ignored. The district nurses felt that if he referred all his patients after 4 weeks the leg ulcer clinic at the hospital wouldn’t be able to cope. In doing this he chooses to ignore the expert advice. I found this very frustrating and interesting, and as Scott (2004) said we ought to promote good and not cause harm, in Jo’s case, the action of not referring her to the appropriate expert nurse could be seen as prolonging healing thus causing her harm. I decided to investigate further what issues led to him making his decision. To achieve excellence in care nurses need to base there decision on evidence based care (Parahoo 2002). There is no shortage of research on wound care  and the management of venous leg ulcers. However because research is based mostly on opinions or experience, hence the development of guidelines and protocols that have practical use is difficult (Leaper et al 2004). There are many sources of evidence, Journal; the Cochran Library database relevant to wound care, however there is so much information it would be difficult for nurses to know where to start. Evidence suggest the management of patients with venous leg ulcers is fragmented and poorly managed ( Carrington 1999). Vowden (1997) agrees and suggests healing rates are poor and treatment costs are high, this could be as a result of nurses not referring patients to appropriate experts for assessment and using expensive, inappropriate dressings such as aticoat, which is impregnated with silver. Although there is evidence to suggest that dressing impregnated in silver and sorbisan are highly effective in heavily exudating wound (Leaper et al 2003& BNF (2004) Jo’s ulcer was shallow and not heavily exudating. The evidence for the care of venous leg ulcers strongly points to the uses of 4 layer bandaging. This is demonstrated in Allen and Nelson (1996) work, they found that healing rates improved for patients who  attended a leg ulcer clinic and had 4 layer bandaging applied. This is also backed up by evidence printed by the RCN(`1998), and Research carried out by Nelson (1996), which suggests that between 40 and 80% of leg ulcers heal with the application of compression bandaging. Jo had suffered with her leg ulcer for 10 weeks before a decision was made by the District nurse to change the dressing from Sorbisan to Aticaoat. The use evidence based care, provides the foundation for evidence based practice ( Harding et al 2002), the ulcer healing rate and outcome for Jo could have been improved by a quick referral to the leg ulcer clinic, as this is seen as the most effective way to treat leg ulcers ( Musgrove and Woodham 1995). One of the reasons the district nurse was hesitant about referring Jo to the ulcer clinic, was that he felt compression banging is uncomfortable and requires a strict regime (House 1996), and his experience patients didn’t often comply. However Jo was not offered the choice. Taylor (1996) believes that communication with patients is crucial to compliance, he suggest by educating patients it will enable them to understand the importance of the compression and assist patient to comply to treatment. Patients need to be given the option of whether they are involved in the decision making process. In Jo’s case the district nurse made the decisions, he didn’t explain alternative treatments to Jo, or explain the 4 layer bandaging to her. In the authors opinion the patient was not given an informed choice. There is a professional responsibility to obtain informed consent from patients before a nursing care procedure is carried out (Cable 2003, Averyard 2000, NMC 2002). The ethical issue of informed consent came essentially from the Nuremberg Code (1947)  as a result of human experimentation in world war two. This was aimed specifically at humans involved in medical research, however consent is now applied to nursing clinical procedures (General Medical Council 1988). There is increasing evidence to suggest that well-informed patients manage their health and treatment better, this enables them to feel in control of there illness (Ogden 2001) and have better psychological outcomes (Gibson 2001). Although Gibson (2001) argues that knowledge alone does not change health outcomes for patients, to allow Jo to give informed consent she would need information that was relevant to her condition and treatment. Jo is an intelligent women and giving her a choice of treatment would have protected her autonomy (Edwards 1996) and individual rights (Caress 2003), however Jo was not offered a choice in treatment, and alternatives were not discussed. The district nurse made a decision and applied the treatment. In doing this the district nurse used his power to manipulate Jo into accepting the treatment the he wanted to give. Giving restricted information the nurse restricted the patient’s choices to secure her compliance (Lukes 1974). The district nurses actions went against advocating the government Expert Patient Policy (DOH 2000), which highlights the need for changes in society that mean individuals expect to have choices, and be involved in decision  making (Kenney 2003). Although Jo gave consent for the treatment given, she did not, in the author’s opinion, give informed consent. Decision making can be divided into two groups, decision making from a rationalist perspective and from a phenomenological perspective ( Tanner 1987). Rational  decision making is a step by step approach that follows a logical course, and clearly definable stages (Harbison 1991), taking into account obvious starting points and objectives, assessment tools, policies and protocols. It gives clear predictable outcomes and is process driven. Rational decision making works, on the basis that when a problem arises, the decision maker agrees a definition of the problem and  discovers all the possible solutions, matches the problem with the recourses and chooses a solution that best matches the problem, and then implement solution  ( Harbison 1991).This approach fits in well with the current trend towards research and evidence based care (Harbison 1991). Using the rational approach to decision making, makes assumptions that all decision makers will take into consideration all possible options and consequences, in light of a thorough understanding of a situation. However in practice this approach would be influenced by time constraints, habit and routine, and Harbison (1991) argues that sensitivity could be lost when following a rational approach. Using Phenomenological process in decision making can be seen as a subjective individual approach (Easen et al 1996). This approach takes into account nurses opinions and views, for this reason as discussed by Thompson (1999) it can create bias, as it is based on experienced expert knowledge. Using expert clinical reasoning the nurses draws on a deep understanding of the patient situation and holistic care needs. Intuition is a quality that  nurses have traditionally valued (Trueman 2003), however with the development of evidence based care it is now seen be some to be unreliable, unscientific and unsuitable for nursing practice (Trueman 2003). Intuition has been criticised for not being able to provide a rational for the decision made,  however Benner (1984) believes intuition is understands without a rational. Benner (1984) argues that during a long nursing career, nurses can gain a great deal of knowledge and skill practice, this leads to them being intuitive about the decisions they make. Intuition is not something that is measurable according to Benner (1984), it is developed through experience, expertise and knowledge, along with personal awareness and personality. McCutcheon and Pincombe (2001) also believe that there are benefits derived from intuition in practice, such as enhanced clinical judgment and effective decision making. Although Cioffi (1997) argues that holistic patient assessment and improving nurse-patient relationships are being undermined by a drive for evidence based care. Intuition has been identified as a useful tool as nurses can analysis the situation as a whole rather that a series of tasks (McCutcheon and Pinchcombe 2001). Both the phenomenological and rational decision making theories have a number of strengths and limitations. McKenna (1997) argues that knowledge can only become known by others if it is shared knowledge and communicated to others. McKenna (1997) suggests this causes a problem for the phenomenological model it is almost impossible to communicate something which is intangible, and which the practitioner is unable to express. Using a mixture of both theories can create a holistic and well documented procedure. Lauri and Saklantera (1995) using a factor analytical approach found evidence that both Benners (1984) intuitive model, and the hypothico- deductive approach of information processing, had a degree of analytical usefulness in explains the decision making of nurses. The implications were that both had something to offer and neither is often a single solution to explain decision making in  practice. Using a decision making model such as Carroll and Johnston (1990) would have enabled the district nurse to reflect and evaluate the effectiveness of the care delivered. Carroll and Johnston (1990) outline seven stages of temporal decision making, and acknowledged that these stages may not simply be followed through there sequence, but the nurse can backtrack at any stage. The first two stages of recognition and formulation involves the examination and classification of the situation by the district nurse. During a home visit the community nurse may be confronted with a range of patient problems (Bryans and McIntosh 1996). Some of these are discrete and easily recognised, while others are likely to dependent upon various circumstances in the patients life, which are likely to remain hidden unless they are explored by the nurse (Bryans and McIntosh 1996). In view of the fact that patient and nurses are strangers to each other, Thompson et al (2002) believe this exploration must be skillfully negotiated by the community nurses, if nurses appropriately identify needs, and thus begin the process of addressing these needs and planning suitable care. If this part of the assessment had been undertaken effectively by the district nurse, the patient may not have suffered for a long period with the leg ulcer. Bryans and McIntosh (1996) suggest this phase of decision making is generally less conscious and deliberate, and more difficult to articulate, than subsequent phases. Although Elstein et al (1978) suggest this a very important part of decision making it often gets neglected. Many decision making models start with an assessment phase such as Walsh (1998)  nursing process, which has four stages of decision making, assessment, planning, implementation and evaluation. If the assessment carried out by the District nurse is poor then the rest of the planning and care delivered will be poor. It has been highlighted in many publications Lait & Smith (1998), Lawrence (1998), Thompson (1999) that a holistic assessment is needed in the care of patients with leg ulcers. Holistic assessments help to identify underlying pathology, and ensure correct diagnosis (Moffat & O’Hara 1995). However the way each individual nurse views the wound will depend on there experience and whether they have come across a similar situation before (Thompson et al 2002). Walsh (1998) highlights the need for a goal to measure against in the assessment phase. In Jo’s case the tool used, could have been a wound chart. A wound chart was however was not used, so on subsequent visits the nurse’s used there own judgment on whether the wound had changed. It was however difficult to clearly classify the wound, a point highlighted by Flanagan (1997) who warns wound classification can lead to inconsistencies in care. Different nurses visited each time making it difficult to provide continuity of care. The district nurse had defined the objective, which was to treat the leg ulcer. However the planning phase of Walsh (1998) model was not implemented, the nurse did not consider an alternative as identified as important in Schaefer (1974) theory. The best outcome, in the district nurses view, was considered although not in an evidence based way. Carroll and Johnson (1990) refer to the common sense view of decision making, in  stages 3,4, and 5, alternative generation, information search and judgment or choice. These three stages can be associated with problem solving approaches and with hypothetic deductive models such as Dowie & Elstien (1988). Hypothetic deductive  method could have been used to identified what was going on with the wound e.g. blood test could have been taken to test for clotting factors, a Doppler could have been used to test for circulation. However nurses can’t always wait for a lab test to give a hypothesis so the district nurse then drew on his experience. However using reflection in action (Schon 1983) and taking into consideration of the added problem of Jo being on steroids, he could have put these things into action to help create an evidence based care plan. Carroll and Johnston (1990) usefully includes decision making and subsequent (stages 6, 7) action and feedback. The inclusion of action and feedback in models of decision making has particle relevance to Jo’s community nursing assessment, because her assessment was continuous in nature ( Cowley et al (1994). If the district nurses had utilized the information properly the outcome for Jo may have been more successful. The best outcome for the patient depends on the patient’s response to treatment the nurse’s intervention and appropriate use of information gained from the evaluation (Luker and Kenrick 1992). District nurses need to be flexible in providing care in patients own homes, because of the sheer diversity of home environments and lifestyles of there patients. Luker & Kenrick (1992) believe that community nurses have there own personally owned knowledge that they find difficult to describe. Benner (1984) would describe this as intuition. However many influencing factors are involved with the nurses decision making, the district nurse that treated Jo had 20 years experience, but in the authors opinion had not used reflective and evidence based practice. The use of reflection enables nurses to learn from there experience and build up an expert knowledge base. However if you don’t learn from your mistakes it doesn’t make you an expert. 02971588 11 Experience doesn’t always equal expertise. If you are a ineffective nurse to start with you may always be a ineffective nurse. The district nurse involved with Jo’s case didn’t seem to reflect upon his actions and learn from practice but just performed a task. As long as the patient was being visited twice a week it didn’t seem to matter how long the wound took to heal, as Thompson et al (2002) suggest 20 years experience may be no more than one years experience repeated 20 times. According to Walsh and ford (1990) there is a need for assertiveness and this  was sadly lacking. Walsh & Ford (1990) argues the lack in assertiveness may be generated from being a mainly female profession, and Corbetta (2003) suggests women that work tend to be judged as inferior. However the district nurse involved in this decision making essay was a man, so I would question whether social conditioning had rubbed of on him. The district nurse seemed to resist altering his practice as directed by the ulcer clinic, it was almost as if he had ownership of the patient’s problem and care, and he saw it as a failure if he had to refer the patient on to a specialist service. It is the resistance to change practice that is cited by several authors (Gould 1986, O’Conner 1993, Koh 1993) as major influence inhibiting the introduction of research into practice. However Parahoo (2002) suggests to change the way nurses work, using evidence based practice, nurses need to think about what they do, how they relate to the people they care for and generally stimulate a more reflecting and questioning attitude. Reading research articles can generate a reflective approach (Parahoo 2002) although the author is aware that changing practices based on one research article is unsafe. Nurse managers have an important role in coordinated efforts, aimed at providing effective evidence based care. Although not all nurses are inclined towards academic work (Jootun 2003), the district nurse was the manager so without him being aware and appreciative of nursing research his team of community nurses provided an inadequate service. However as Sleep (1992) states it is unfair and unrealistic for educational programmes to place upon practitioners the burden of introducing research into the workplace, unless the climate prevailing in both service and management spheres is receptive to change. The organisation needs to facilitate changes in nursing to allow the professional as a whole to practice evidence based care (Parahoo 2002). The district nurse worked in a small isolated practice and his priority seemed to be the setting up of new PCT policies. Patients with leg ulcers were almost in the way. If the district nurse had a positive attitude towards research and regularly read research articles on wound care, which as Gould (2001) suggest are available in digestible form, the  care provided would have been evidence based effective care. Recommendations Joint education and clinical career pathways are needed to close the theory practice gap. Many nurses working in small practices are not getting the education they need to prove the government with a highly effective and trained workforce. Many organizations within the NHS are busy and overworked. The time is not available for them to update their knowledge and training. To help nurses who work in isolated community practices the setting up of groups or research meetings could enable them to keep up to date with relevant research, and would enable the effective utilisation of research findings. Nurses can also be encouraged to use expert nurses that are available at many hospitals and PCT. The use of computer networks and interactive software and research newsletters could also aid in the implementation of research practice. Evaluation Carroll & Johnston (1990) provide a framework for decision making, the author feels if the district nurse had used such a framework the care delivered to Jo could have been more effective and evidence based. The District Nurse didn’t evaluate or reflect on the care he delivered. Using decision making model such as Carroll and Johnston (1990) and Walsh (1998) nursing process, the nurse could have delivered evidence based reflective care. Models such as these are used as a guideline to nursing procedures, if they are followed it ensures that patients get best care and that nurses don’t become complacent in the care they deliver, but use a systematic approach alongside there  experiences and expertise Conclusion Intuition has been identified as a useful tool that needs to be recognised within nursing, however a need for a ration approach along side it is necessary. This will enable nurses to provide evidence based care with clear rationales. There are many aspects of nursing that cannot be subjected to measurement, and intuition is one of them, and so is caring. To ignore intuition as a nursing skill would be to deny the patient of truly holistic care. However I would say that the nurse involved with Jo’s care was not an expert in the care of leg ulcers, and was baseing his care on limited research. The effect this had on the patient was a poor standard of care. Reference list Aveyard, H. (2000) Is there a concept of autonomy that can usefully inform nursing practice? Journal of Advanced Nursing 32, 352-358 (BNF). (2004) British National Formulary British Medical Council. London Benner, P. (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley, Workingham. Bryans, A. McIntosh, J. (1996) Decision making in community nursing: an analysis of the stages of decision making as they relate to community nursing assessment practice. Journal of Advanced Nursing 24, 24-30. Cable S et al (2002) Informed consent. Nursing Standard. 18, 12, 47-53. Caress, A. L. (2003) giving information to patients. Nursing Standard. 17, 43, 47-54. Carrington, C. (1999) A nurse led clinic for treatment of venous leg ulcers. Nursing Standard. 13, 20, 42-46. Carroll, J. S. Johnston, E. J. (1990) Decision Research: A Field Guide. Sage, Newbury Park California. Cioffi, J.(1997) Heuristics, servants to intuition in clinical decision-making. Journal of Advanced Nursing 26, 203-208 Corbetta, P. (2003) Social research: Theory, Methods, and Techniques. London, Sage. Cowley, S. Bergen, A. Young, K. Kavanagh, A. (1994) The changing nature of needs assessment in primary health care. Paper presented at the Fourth International Primary Health Care Conference, Kensington Town Hall, London, June. Department of Health. (1993a) Research for health Her Majestys Stationary Office, London Department Of Health. (1993b) Report of the task force on the strategy fro research in nursing, midwifery and health visiting. Her Majesty’s Stationary Office, London. Department Of Health. (1993c) A vision for the future. Her Majesty’s Stationary Office London. Department Of Health. (1994) Supporting research and development in the NHS ( the Culyer Report) Her Majesty’s Stationary Office. London. Department Of Health. (1995) Methods to promote the implementation of research findings in the NHS Her Majesty’s Stationary Office. London. Department of Health. (1996a) Promoting clinical effectiveness. Her Majesty’s Stationary Office. London. Department of Health. (1996b) Research and development: Towards an evidence based health service. Her Majesty’s Stationary Office. London. Department of Health. (1997) The new NHS: modern, dependable. Her Majesty’s Stationary Office. London. Department of Heath. (2000) Towards a strategy for nursing research and development. Her Majesty Stationary Office. London. Department of Health. (2000) The expert Patient: A new Approach to Chronic Disease Management for the 21st Century. HSMO Dowie, J. Elstien, A. (1988) Professional Judgment, A Reader in clinical decision making, Cambridge, Cambridge University Press. Easen, P. Wilcockson, J. (1996) Intuition and Rational Decision making in professional thinking: a false Dichotomy, Journal of Advanced Nursing, 24 (4) 666-673 Edwards, S. D. (1996) Nursing Ethics; A Principle-Based Approach. Macmillan Basingstoke Elstein, A. Shulman, L. Sprafka, S. (1978) Medical Problem Solving: An analysis of clinical reasoning. Harvard University Press, Cambridge. Flanagan, M. (1997) Guidelines and protocols in Clinical decision making Journal of Wound care 6 (5) 207. General Medical Council (GMC). (1988) Seeking Patients Consent: The Ethical Consideration. General Medical Council, London. Gibson,P. (2001) Self-Management education and regular practitioner review for adults with asthma ( Cochran Review). The Cochran Library. Issue 3. Oxford, Update Software. Gould, D. (1986) Pressure sore prevention and treatment and example of nurses failure to implement research findings. Journal of Advanced Nursing, 11, 389-394 Gould, D. (2001) Pressure ulcer risk assessment. Nursing Standard 11 (5) 43-49. Harbison, J. (1991) Clinical Decision making in Nursing Journal of Advanced nursing Practice (16) 404-407 Harding, K. G. et al. (2002) Healing chronic wounds. British Medical journal Vol 324, 106-161 House, E. (1996) Patient compliance with leg ulcers treatment, Professional Nurse. 12, 1, 33-36. Jootun, D. (2003) Creating a research culture in a nursing school. Nursing Standard. 18, 3, 33-36. Kenny, I. (2003) Patient are experts in their own field. British Medical Journal. 326, 7402, 1276-1277 Koh, S. (1993) Dressing practices. Nursing Times, 89 (42) 223-230. Lait, M. Smith, L. (1998) Wound Management: a literature review. Journal of Clinical Nursing 7, 11-17. Lauri, J. Salantera, S (1995) Decision making models of Finnish nurses and public health Journal of Advanced Nursing 21 (3) 520-527 Lawrence, S. (1998) Tailor-made treatment. Nursing Times 94, 77-78. Leaper, D. Scott, E. Melling, A (2004). The evidence base in wound healing. Nursing Standard. 18, 24, 73-77. Luker, K. A. & Kenrick M. (1992) An expiratory study of the sources of influence on the clinical decision of community nurses. Journal of Advanced Nursing 17, 682-691 Lukes, S. (1974) Power: A Radical View. London: Macmillan. Mallet, J. Dougherty, L. (2001) Manual of Clinical Nursing Procedures fifth edition Blackwell Science. London. McCutcheon, H. Pinchombe, J. (2001) Intuition: an important tool in the practice of nursing, Journal of Advanced Nursing 35 (3) 342-348. McKenna, H. (1997) Nursing Theories and Models. Routledge, London. Moffat, C. OHara, L. (1995) Fundamentals in clinical practice. Journal of Community Nursing 9, 9, 10-16. Mulhall, A. Le May, A. (1999) Nursing research: Dissemination and implementation. London: Churchill Livingstone. Musgrove, E. Woodham , C. (1995) Fundamentals in clinical practice. Journal of Community Nursing 9(9), 10-15. Nelson, E. A. (1996) Compression Bandaging in the treatment of venous leg ulcers. Journal of Wound Care. 5, 9, 415-417. Nursing Midwifery Council. (2002) Code of Professional conduct London. Nuremberg Code, (1947) (1949) Trials of War Criminals before the Nuremberg Military Tribunals under Control Council Law. US Government Printing Offices, Washington D.C. no. 10, vol 2. O’Conner, H (1993) Bridging the gap? Nursing Times, 89 (32) 63-66 Ogden, J. (2001) Health psychology 2nd edition. Great Britain. Biddles LTD. Parahoo, A. K. (2002) Nursing Research Principles, Process and Issues. Palgrave Macmillan. London. Phillips, P (2000) Tissue viability: information for the 21st century. Journal of Tissue Viability. 10, 2, 46-52. RCN Institute, (1998) Clinical Practice Guidelines. The management of Patients with Venous Leg Ulcers. Manchester: University of Manchester. Schaefer. (1974) Decision making theory. Sited in Decision making handouts Angela Hudson. University of West of England. Schon, D. A. (1983) The reflective practitioner: How professionals think in action. Temple Smith, London Scott, E. (2004) Managing risk in the perioperative environment. Nursing Standard. 18, 30, 47-52. Sleep, J. (1992) Research and the practice of midwifery. Journal of Advanced Nursing, 1: 1465-1471 Tanner, C. A. (1987) Theoretical perspectives for research on clinical judgment. In Clinical Judgment and Decision Making: The Future with Nursing Diagnosis. Hannah K.J. Reimer M. Mills W.C. and Letourneau S. eds) John Wiley, New York, P21. Taylor, P. (1996) Assisting patients to comply with leg ulcer treatment. British Journal of Nursing, 5, 22, 1355-1358. Thompson, A. (1998) Working the system. Nursing Times 94, 71-72. Thompson, C. (1999) A conceptual treadmill: the need for middle ground in clinical decision making theory, Journal of Advanced Nursing 30 (5) 1222-1229 Thompson, C. Dowding, D. Mullally, S. (2002) Clinical Decision Making and Judgement in Nursing London Churchill Livingstone. Trueman, P.(2003) Intuition and practice. Nursing Standard, 18, 7, 42-44 Vowden, K. R. (1997) Leg ulcer management in a nurse led hospital based clinic. Journal of Wound care. 6, 5, 23-236. Walsh, M. (1998) Models and critical pathways in clinical nursing: conceptual frameworks for care planning 2nd edn London Bailliere. Walsh, M. Ford, P. (1990) Nursing Rituals: Research and Rational Actions. Oxford: Heinemann Nursing. Bibliography Allen, M. Hourston, R. (1989) Running an ulcer clinic. Journal of District Nursing, 7, 508. Brazier, M. (1992) Medicine, Patients and the Law, 2nd edition. Penguin, London Benner, P, Tanner, C. (1987) How experts nurses use intuition. American Journal of Nursing 87 (1), 23-31. Champion, V. L. Leach, A. (1989) Variables related to research utilization in nursing: an empirical investigation. Journal of Advanced Nursing, 14:705-710 Effken, J. (2001) Information basis for expert intuition Journal of Advanced Nursing 34, (2) 246-255. Hewitt-Taylor, J. (2004) Challenging the balance of power: patients empowerment. Nursing Standard. 18, 22, 33-37. Lawton, S..(2003) Continuing Professional Development: a review. Nursing Standard. 17, 24, 41044. Newton, H. (2003) Telemedicine in educational settings. Nursing Standard. 17, 44, 75-80. Norton, S. et al (1997) Teledermatology and underserved population’s. Archives of Dermatology. 133, 2, 197-200 Williams , D. (1988) Leg Ulcers. Taking your time with leg ulcers. Mims Mag, 1 May, 105-108