Sterile versus non-sterile gloves

Sterile versus non-sterile gloves Sterile technique is generally used for laceration repair despite a lack of scientific evidence that this is necessary (Wilson, 2003). This study addresses whether there is a difference in the infection rate of lacerations randomised to receive repair using sterile versus nonsterile gloves. This will help to increase knowledge on the evidence of infection rates when nonsterile gloves are used. If it can be proven that the use of nonsterile gloves for laceration repair poses no risk, this could save time and have considerable financial savings. This may change clinical practise in the future. Research Question: Sterile versus non-sterile gloves: A safe alternative in the management of acute simple wounds in the pre-hospital environment? Sterile technique (including the use of sterile gloves) for acute simple wound or laceration management is traditional and the practise continues to be recommended (Wilson, 2003). However, there are few studies and little evidence to support this practise. Using clean nonsterile gloves rather than individually packaged sterile gloves for uncomplicated wound repair in the community may result in cost and time savings. Study objective: This proposal is for a prospective randomised controlled trial designed to determine whether there is a difference in the rate of infection, after suture repair of uncomplicated wounds and lacerations, using clean nonsterile gloves versus sterile gloves in a community setting. Justification: The research question separates this proposed study from in-hospital studies, and addresses the small data set available specific to community and pre-hospital environments (Perelman et al, 2004; Worral, 1987; Bodiwala George). Results will add to the body of evidence, broaden the knowledge base for the healthcare community and further the cause of science (Medical Research Council, 2010). This trial aims to provide quality data for publication, enabling informed re-use by others and thereby reducing the risk of data creation duplicity. Background: The Department of Health (DoH) (2005) paper Taking healthcare to the patient states that at least one million of the people taken to AE every year could be treated at the scene, in their homes or in the community. With the advent of the Emergency Care Practitioner (ECP) role, many simple wounds / lacerations are suitable for treatment and closure in the pre-hospital setting. During the year 2008 09, the National Health Service (NHS) reports that there were 663,475 Accident and Emergency attendances in England for lacerations, accounting for 8.5% of total attendances (NHS, 2010). Figures for the Ambulance service this trial will be run at show that over a six month period from April to September 2010, their ECPs attended 1555 calls for laceration / haemorrhage, 72.5% (n= 1127) of which were dealt with at the scene, negating a visit to an Accident and Emergency department. These wounds were cleansed, treated and closed where necessary using a variety of techniques from tissue adhesiv e to paper stitches or sutures. As sterile gloves are not available, the practitioner carrying out treatment of these wounds would have been using clean, non sterile gloves. This is in stark contrast to wound closure in the Accident and Emergency department where the use of sterile gloves is universal (NHS Clinical Knowledge Summaries, 2010). The question asked by this study is whether there is a difference in the rates of infection between wounds treated by practitioners wearing sterile versus non sterile gloves in the community. To answer this it is necessary to investigate what contributing factors to wound infection there are, how they are best managed and what, if any, difference gloves make to the control of infection. Pratt et al (2007) advise that best practice (in the absence of strong evidence) must be guided by expert opinion and national and international guidance; all of which should be integrated into local practice guidelines. In the case for use of sterile versus nonsterile gloves, there has been insufficient research to provide reliable evidence, therefore clinical tradition is followed and sterile gloves are the preferred choice. This dogmatic adherence to tradition is underlined by Flores (2008) who states Although ritualistic practice needs to be questioned, with the rising incidence of multi-resistant infections, it seems prudent to err on the side of caution when in doubt. Obviously then, it is important to remove the doubt by rigorous research into the area for concern, thereby adding quality data to the body of evidence and knowledge, and allowing this to steer best practise, however this is out of the scope of this study. Literature Review. A search of Cochrane Library gave 135 results, 1 of which directly answered the question (Perelman et al, 2004 see appendix one). A search of three other databases British Nursing Index (BNI), The U.S. National Library of Medicine premier life sciences database (PubMed) and Cumulative index to nursing and health literature Nursing allied health (CINAHL) revealed the same plus 2 others: Bodiwala George (1982) and Worral (1987) using the search term Infection OR Cross Infection OR Disease Transmission OR Infection Control AND Glove* OR Protective Device* OR Surgical Glove* OR Sterile Glove* OR Non Sterile Glove* AND Acute Traumatic Wound* OR Wound*.  LIMIT set to Human AND English. This shows there is little tangible research into the hypothesis suggested in this proposal. The prospective Randomized Control Trial (RCT) by Perelman et al (2004) in Canadian Emergency Departments compared sterile versus nonà ¢Ã¢â€š ¬Ã‚ sterile gloves (both latexà ¢Ã¢â€š ¬Ã‚ free) in sutured repair of lacerations. The study enrolled 816 patients (age à ¢Ã¢â‚¬ °Ã‚ ¥ 1) with blinding of patients and outcome assessors. Infection rates by 23 days were 4.3% in the nonà ¢Ã¢â€š ¬Ã‚ sterile group and 6% in the sterile group (no statistical difference), however credence was given to the possibility of skewing results due to the Hawthorne effect (Bowling, 2009) (As blinding the clinician in this type of study is impossible, it is possible that physicians using nonsterile gloves are simply more careful). This is the only RCT study of sterile versus nonsterile gloves. It is of high quality with a reasonable sample size, let down only by the non-standardised partially blind follow up. There are two older studies with significant limitations (comparing no gloves to sterile gloves) and questionable randomisation. Bodiwala George (1982) showed through their study of 408 patients that the difference in infection rates between gloved and ungloved suturing was not statistically significant. Worral (1987) found that infection rates were higher in the sterile gloved group, although the study group was small (n=50). Both these studies lend support to the idea that sterile gloves offer little in the way of reducing infection rates in the repair of simple lacerations, however suturing without any gloves is inappropriate and unsafe for practitioner and patient. Allan (2009) supports the findings of these earlier studies and concludes that present evidence indicates simple lacerations can be repaired with clean nonsterile gloves without an increased risk of infection. Acute traumatic wounds, in comparison to surgical incisions, are by their very nature already exposed to infective agents and the time delay between injury and treatment is longer (Forsch, 2008). Meticulous cleansing and where necessary, debridement is essential in reducing infection rates (Durham Hines, 2001). Moscati et al (1998) found that irrigation of acute traumatic wounds to remove grit, foreign bodies, dressing residue, excess exudates and other potential contaminants to be vitally important in preventing later complications of infection and tattooing. Generally it is agreed that wound cleansing by irrigation is preferable to swabbing or wiping (Dealey, 2005). Trott (2005) supports the old maxim The solution to pollution is dilution, stating that the most effective method for reducing bacterial load on wound surfaces and for removing debris and contaminants from within a laceration is through irrigation. This begs the question: if in the acute traumatic laceration a high bac terial load is already present, of what benefit are sterile gloves in their treatment and closure? Theoretical framework: This is a positivist paradigm (Parahoo, 2006), collecting scientific quantitative data. The research question is based on the empirical data from previous similar trials. It is acknowledged that empirical data is vulnerable to interpretation (Rubin Rubin, 2005) and this trial seeks to limit this by means of closed questions in the data gathering tool. The proposed study hypothesises that the use of clean nonsterile gloves when suturing acute simple lacerations in a community setting has little or no effect on post procedure wound infections. To refine the research question, guidance was taken from Lewith Little (2009) to ensure it is focused, is feasible and explicit. It is also a Statement of expectation relative to the variables investigated (Polit Beck, 2004). Research Methodology: This research will be a randomised controlled trial (RCT). This is chosen as there is a direct comparison between two variables; an RCT providing robust data. The RCT is the most appropriate method of study design, especially in the setting of wound repair, as suggestibility and patient expectations are potentially significant sources of bias (Jadad Cepeda, 2000). Although double blinding is impossible in this trial, the assessing clinician (data gatherer) will be blinded as to what gloves were used. However a weakness is acknowledged in that the patient may inform the assessing clinician and by so doing inject a risk of bias. To reduce the effect of other variables, ECP practise and equipment is standardised (Health Professions Council, 2010). All wound closure by the ECPs will comply with the most recent evidence based practise (NHS Clinical Knowledge Summaries, 2010). All cleaning materials, local anaesthetics and equipment are identical county wide, ensuring equality. Only mono-filament suture material will be used (no silks). Acknowledgement is given to the following variables over which this trial has no control: Individual client hygiene, poor compliance with wound care advice, further trauma to wound site post repair. The trial will be run over a six month period and utilise cluster randomisation by geographical area. For three months, sterile gloves will be used by ECPs in the west of the county whilst the east ECPs will use clean nonsterile gloves. At the three month point this will be reversed with west ECPs using clean nonsterile gloves and east ECPs using sterile gloves. Data will be collected by RW at the end of each week. Sampling: Randomised from the population area (east / west). Randomisation is automatic due to the nature of calls; assistance only being sought when needed by the public, therefore the study has no control over and cannot affect bias of patient, place, time etc. Only those calls attended by ECPs and deemed suitable for suture closure will be included. Limits: Inclusion: Patients over 18 years of age, who have sustained an acute, simple traumatic laceration which is less than six hours old requiring primary closure with simple, interrupted sutures. Exclusion: Patients with the following Very dirty / Tetanus prone wounds, immunocompromised, immunosuppressed, concomitant antibiotic use, deep wounds requiring layered suturing to eliminate dead space, puncture wounds, bite wounds (animal or human), any wound where there is suspicion of retained foreign body or damage to underlying structures, diabetes, wounds over 6 hours old. Data Collection: Data will be collected via post in the form of two clinician completed multi choice questionnaires at 3 days and at removal of sutures (ROS). The first interval gives a reasonable healing time for wound review and early identification of infection if present (patient safety). The second time interval was chosen as patients will need to re-present for this procedure and it gives reasonable opportunity for infection, dehiscence or other problems if present, to be apparent and acted upon as necessary. RW will be the dedicated researcher for collection of questionnaires, data analysis and telephone follow-up, (thus reducing response loss and attrition of data) at no cost to the trial. Patients will be supplied with 2 copies of the questionnaire as part of their discharge advice pack to facilitate continuity should they re-present at an earlier time for any reason, or at another facility. If the forms are not returned, telephone follow up will be done. As the patient should attend for wound review regardless of this research, completion of the questionnaire will cause minimal impact on clinician time, with little interference to departmental workloads. Questionnaires are designed to be simple and rapid to complete. All questionnaires will be supplied with a self-adhesive stamped self addressed envelope for ease of return. It is recognised that a limitation of this study is non return of questionnaires for whatever reason; this will be factored into the final statistical analysis. As it is impossible to blind the clinician as to whether the gloves are sterile or nonsterile in this trial, their input into it will be limited to indicating on the ECP form (See appendix 2) which group the patient fits into; A for sterile glove use, B for clean nonsterile. Randomisation and selection bias through allocation is avoided by the unpredictable nature of the emergency and unplanned workload covered by the clinicians (ECPs). This should help increase validity of findings (Bowling, 2009). As the division of the Ambulance service utilised for this trial is already divided into east and west areas, this will be used to control the intervention by allocation of sterile or nonsterile gloves. Initially, the west ECPs will use only sterile gloves for suturing wounds, with the east ECPs using clean nonsterile gloves. At the half way point in the trial, the researcher will reverse this. This allocation of gloves gives a reasonable control group from both sides of the county and acknowledges differences in individual ECP procedure, geography, demographics etc. Ethics: The four point biomedical ethics framework suggested by Beauchamp Childress (2001) has been considered in the design of this trial. This trial recognises autonomy for both patient and practitioner by seeking informed consent from participants. It promotes beneficence through its attempt to treat patients expeditiously, to high standards, without prejudice; and non-maleficence by reassuring participants that their data with be kept confidential. Justice is assured by equality of treatment for each participant. Ethical approval for the research will need to be sought from both the Ambulance service Clinical Review Group and University Ethics Committees prior to starting the research process. The researcher will be responsible for ensuring that the participants welfare is maintained. Consent will be sought by the attending ECP. Kimmel (2007) acknowledges that participants should come to no harm psychologically, physically or socially. By strict adherence to wound care guidelines (cleansing, dressing etc) in the acute assessment and treatment phase, and due regard for the patient during follow-up, this should be addressed. Consent: Prior to the study, education of ECPs through a micro-teach session (a 5 minute presentation) and poster campaign for those who cannot attend will be carried out. The ECPs will be asked if they will partake in the trial; there will be no expectation on them to do so and their inclusion will be purely voluntary. Informed consent will be sought from all patients although acknowledgement is given to the fact that the patient will be presenting in a post injury phase; they may be distressed, in pain and anxious. All patients participating in the trial will have a clear explanation given to them prior to discharge to ensure they fully understand their role and right to leave the trial at any point. Confidentiality: All data for publication, dissemination or public review will be purely statistical and numerical, having no personal details of the participants; there will be no breach of confidentiality. Participant safety: All prior research has concluded that there is statistically no difference in rate of infection when comparing glove use, adding support to the argument that there is little risk to the patient (Bodiwala, Worral, and Perelman). All gloves used will be latex free, reducing any risks of latex allergy / sensitivity to patient and clinician alike. All participants will have the opportunity to withdraw at any phase of the trial. Data Analysis and discussion: Data will be presented in a 22 contingency table (See appendix 4). As the research question is looking for a possible relationship between two variables, a bivariate statistical analysis will be used (See appendix 4). Specialist advice will be sought for the analysis of the statistical data. It is hoped that response rates will be very high as the respondent will be a medical professional (not the patient), the questionnaire is very short and straightforward, and is supplied with a self adhesive, stamped self addressed envelope. This scenario is similar to Perelamans experiment which achieved a 98% response. The patient, by the very nature of their injury, will need to attend for follow up / ROS. Calnan et al (2005) suggest a response rate of approximately 56% when reliant on the patient. Timeline: Year 2011 Initiate experiment 1st April Data collection Continuous and ongoing (RW) Complete fieldwork by 1st September Complete analysis by 1st October Give presentation on 8th October Complete final report by 1st November Conclusion: Sterile technique is generally used for laceration repair despite a lack of scientific evidence that this is necessary (Wilson, 2003). This study addresses whether there is a difference in the infection rate of lacerations randomised to receive repair using sterile versus nonsterile gloves. This will help to increase knowledge on the evidence of infection rates when nonsterile gloves are used. It is apparent that could it be proven that there is little evidence to support the continued use of sterile gloves; this could reflect a significant cost saving for the NHS (see appendix 5). This may change clinical practise in the future. References / Bibliography: Allan, M.G. (2009) Lacerations: Sterile Gloves Water? Tools for Practice. June 1, 2009. Beauchamp, T.L. Childress, J.F. ( 2001) Principles of Biomedical Ethics. New York: Oxford University Press. Bodiwala, G.G., George, T.K. (1982) Surgical Gloves During Wound Repair In The Accident And Emergency Department. The Lancet: July 10, 1982. pp 91-92. Bowling, A. (2009) Research Methods in Health (3rd ed), Maidenhead: Open University Press. Calnan, M., Wainwright, D., ONeill, C., Winterbottom, A. Watkins, A. (2005) Lay evaluation of health care: the case of upper limb pain. Health Expectations. 8(2):149-160. Dealey, C. (2005) The Care of Wounds (3rd ed). Oxford: Blackwell. Department of Health (2005) Taking Healthcare to the Patient: Transforming NHS Ambulance Services [online] Available at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4114269 Accessed 24/10/10. Durham C. Hines, S.E. (2001) Laceration assessment and management. Patient Care for the Nurse Practitioner. Jun; 4 (6): 17-20, 23. Flores, A. (2008) Sterile versus non-sterile glove use and aseptic technique. Nursing Standard. 23 (6) 35-39. Forsch,  R..  (2008). Essentials of Skin Laceration Repair.  American Family Physician.  78(8),  945-51.   Grava-Gubins, I., Scott, S. (2008) Effects of various methodologic strategies: survey response rates among Canadian physicians and physicians-in-training. Canadian Family Physician. Oct;54(10):1424-30. Hampton, S. (2003) Nurses inappropriate use of gloves in caring for patients. British Journal of Nursing 12(17):1024-7. Health Professions Council (2010) Standards of Proficiency. [Online] Available at http://www.hpc-uk.org/assets/documents/1000051CStandards_of_Proficiency_Paramedics.pdf Accessed 13/11/10 Jadad, A.R., Cepeda, M. (2000) Ten challenges at the intersection of clinical research, evidence-based medicine and pain relief. Annals of Emergency Medicine 2000;36:247-52. Kimmel A.J. (2007) Ethical Issues in Behavioural Research: Basic and applied Perspectives (2nd ed). Oxford: Blackwell. Lewith, G. Little, P. (2009) Randomised Controlled Trials in Saks, M. Allsop, J. (2009) Researching Health: Qualitative, Quanatitative and Mixed Methods. London: Sage. p 225. Medical Research Council (2010) Data Sharing Initiative: Aims. [Online] Available at www.mrc.ac.uk Accessed 09/11/10. Moscati, R.M., Reardon, R.F., Lerner, E.B., Mayrose, J. (1998) Wound irrigation with tap water. American Academy of Emergency Medicine. 1998; 5(11): 1076-80. National Health Service: Accident and Emergency Attendances in England (Experimental Statistics) 2008-09. Hospital Episode Statistics [online] Available at http://www.ic.nhs.uk/webfiles/publications/AandE/AandE0809/AE_Attendances_in_England%20_experimental_statistics_%202008_09_v2.pdf Accessed 24/10/10. National Health Service (2010) Clinical Knowledge Summaries: Lacerations Management. [Online] Available at http://www.cks.nhs.uk/lacerations/management Accessed 11/11/10. Parahoo, K. (2006) Nursing Research: Principles, Process and Issues. (2nd ed.) London: Palgrave-Macmillan. Perelman, V., Francis, G.J., Rutledge, T., Foote, J., Martino, F., Dranitsaris, G. (2004) Sterile versus Nonsterile Gloves for Repair of Uncomplicated Lacerations on the Emergency Department: A Randomized Controlled Trial. Annals of Emergency Medicine. 2004; 43(3): 362-370. Polit, D.F. Beck, C.T. (2004) Nursing research: Principles and methods. (7th ed.). Philadelphia: Lippincott, Williams Wilkins. Pratt, R.J., Pellowe, C.M., Wilson, J.A., Loveday, H.P., Harper, P.J., Jones, S.R.L.J., McDougall, C., Wilcox, M.H. (2007) epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infections 65(Supplement): S1S64. Royal Mail [Online] available at http://www.royalmail.com Accessed 11/11/10. Rubin, H. Rubin, I. (2005) Qualitative Interviewing: The Art of Hearing Data (2nd ed.) London: Sage. Trott, A.T.(2005) Wounds and Lacerations: Emergency Care and Closure (3rd ed.) USA: Mosby. Wilson, J. (2003) Infection Control in Clinical Practice. (2nd edn.) London: Balliere-Tindall. Worral, G.J. (1987) Repairing Skin Lacerations: Does Sterile Technique Matter? Canadian Family Physician 1987; 33:1185-1187. Appendix 1 Relevant Paper Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses Perelman et al 2004 Canada 816 patients over the age of 1yr old with simple lacerations prospective randomised controlled trial Infection post repair Infection rate for sterile vs non-sterile gloves was 6.1% and 4.4% respectively with no significant statistical difference partially blind follow up looking for signs of infection was not standardised Appendix 2 ECP information form Questionnaire 1 ECP No: Group A / B Incident No. Name: Age M / F Contact Tel. No: Site of laceration: Number and size of sutures: Appendix 3 Follow up Questionnaire Name: Age M / F Contact Tel. No: Is there any erythema extending à ¢Ã¢â‚¬ °Ã‚ ¥ 1cm from the wound? Y / N Is the wound hot to touch? Y / N Is the wound inflamed or swollen? Y / N Is there any purulent discharge? Y / N Does the patient report any increase in pain? Y / N If yes to any/all of above, is the patient systemically well? If no, refer immediately.

Essay --

Petrini was enraged by all of this, and rallied his friends and the local community to protest against this worldwide industrialization of food by arming themselves with simple bowls of locally cooked, traditional pasta. They chanted, â€Å"We don’t want fast food †¦ we want slow food!† This initial idea developed gradually and three years later, in 1989, delegates from fifteen countries met in Paris to approve and endorse The Slow Food Manifesto, co-founded by Folco Portinari (Italian literary historian and University professor), and accordingly the Slow Food movement was officially established. It is a non-profit, grassroots movement, which now has thousands of members across the globe, that seeks to promote the desire for good, healthy, local food through a better understanding of it’s taste, quality and production, and thus counter the speed of the fast life. Figure 8: The Slow Food logo With an understanding of the psychological use of colour in design, it was interesting to discover that Slow Food have utilised red into their logo as well as McDonalds, displayed in figure 8. There appears to be a contradiction of the snail as an icon symbolising slowness, and red as a colour representing excitement and speed. Its original objectives were to re-evaluate and celebrate local cooking traditions, inform citizens on the negatives of fast food, educate them on where their food originates from and also promote the use of local food products in cooking. Figure 9 shows an example of a local market stall with Slow Food values, . Founder Carlo Petrini, believes that: "Everyone has the right to good, clean and fair food." By ‘good’ he means that the food is fresh, ‘clean’ is part of the natural food cycle, posing no threat to the ... ...ess, much like the methodologies and founding principles used in the Slow Food movement, there can be many benefits from slowing down. Carl Honorà © declares that the greatest thinkers throughout history were those that favoured the slow approach, asserting â€Å"Charles Darwin described himself as a slow thinker. Einstein was famous for spending ages staring into space in his office at Princeton University.† These extremely successful individuals demonstrate the significance of decelerating the mind into a lower gear in order to engage in more deep, holistic considerations. Abraham Lincoln, apparently proclaimed, â€Å"Give me six hours to chop down a tree and I will spend the first four sharpening the axe.† This famous quote refers to the importance of preparation in a task, and that an intelligent person does not start a job straight away, they plan and prepare it first.

P3 U2 Essay

P3: Describe the potential effects of discriminatory practice on those who use health or social care services. Discrimination has the potential to affect individuals in wide-ranging ways. In health and social care, the effects of discrimination can be catastrophic and even end in the death of a service user. Anyone planning a career in health and social care should be aware of the potential negative effects caused by discrimination. We will explore them here. Marginalisation As you might expect, marginalisation means being pushed to the margins of society. In other words, you are unable to participate fully in the health and social care services that are available. Marginalisation can occur at both micro and macro levels. Governments have been accused of marginalising groups of the population in terms of their health and social care needs. Disempowerment People who are discriminated against (especially by powerful groups in society such as health care professionals) are often totally disempowered. This means they are not able to take action Individuals can be disempowered through another form of discrimination – ‘the health worker knows best’ syndrome. Low self-esteem and self-identity If we have high self-esteem and self-worth, it means that we appreciate our own worth and value ourselves highly. Conversely then, having low self-esteem means that we feel helpless and powerless to cope and can even feel depressed. People who are discriminated against are in real danger of developing low self-esteem, which can lead to them being unable to cope with life’s challenges and changes. This is particularly important for those individuals who have to cope with illness or changes in their social condition. If they are to cope well, they need to believe in themselves and their ability to manage, whatever situation they are in. Health care workers need to pay attention to an individual’s self-esteem and constantly work at improving this – this is a good method for helping individuals to cope positively with their situation. Restricted opportunities Discrimination, as we have already seen, has the potential to prevent access to health and social care services. This could be through the attitudes and beliefs of the health care workers who fail to value all individuals or it could be through the effects of low self-esteem. Negative behaviours  including aggression and criminality Another effect of discrimination can be seen in the behaviour of individuals. This is particularly noticeable in children, who often display negative behaviours in order to gain a ttention, even when that attention is negative! Adults and young people as a result of discrimination and low self-esteem can also display negative behavioural traits. However, in these cases the behaviour can take on a much more ‘sinister’ appearance. It may manifest itself as aggression towards those holding power (including health care professionals or those working in the employment and judicial services) and through criminal activity such as drug taking, burglary and physical violence. Loss of rights There have been cases in the national media of care homes, secure or forensic units (places of security for people with dangerous psychiatric behaviours) and individual carers being accused of systematically discriminating against the people in their care and overriding their individual rights by the use of power or force. Older, vulnerable people in residential or nursing care homes are at particular risk of abusive situations because of the high power base of those caring for them. There are occasions when statutory powers are used legitimately to override individual rights. In these cases, doctors and judges can take decisions together to place people in places of safety for their ‘own good’. Another example of the use of statutory powers in operation is when social workers need to work with others such as the police or medical service to take children from unsafe homes and place them in centres of safety. Bibliography Books Stretch, Beryl (Editor); Whitehouse, Mary (Editor). BTEC National Health and Social Care Book 1. Harlow, Essex, GBR: Pearson Education Limited, 2007. p 80. http://site.ebrary.com/lib/croydon/Doc?id=10299110&ppg=89 Copyright  © 2007. Pearson Education Limited. All rights reserved. 25/07/13 15:25 Stretch, Beryl (Editor); Whitehouse, Mary (Editor). BTEC National Health and Social Care Book 1. Harlow, Essex, GBR: Pearson Education Limited, 2007. p 81. http://site.ebrary.com/lib/croydon/Doc?id=10299110&ppg=90 Copyright  © 2007. Pearson Education Limited. All rights reserved. 15:26 Stretch, Beryl (Editor); Whitehouse, Mary (Editor). BTEC National Health and Social Care Book 1. Harlow, Essex, GBR: Pearson Education Limited, 2007. p 82. http://site.ebrary.com/lib/croydon/Doc?id=10299110&ppg=91 Copyright  © 2007. Pearson Education Limited. All rights reserved.15:36

Tahiti essays

Tahiti essays Maeva... or as the friendly locals would say, welcome. For those of you honeymooners who seek an exotic paradise, there can be nowhere on Earth that compares with the islands of French Polynesia. French Polynesia is a Garden of Eden with a blend of rainforests, waterfalls, colorful flora that mixes magically with soft volcanic beaches and turquoise sea, a spectacular blend of nature. With stunning sunsets, colourful reefs, tranquil lagoons and volcanic beaches fringed with coconut palm trees, Tahiti spells magic and romance. Its as if this secret pocket of the world is one perpetual honeymoon, with its relaxed days, starry nights and soothing ocean waves. Often called "The Island of Love," Tahiti is the largest of the 118 islands. Born in a series of volcanic upheavals nearly three million years ago, the island of Tahiti is a range of lushly forested peaks plunging deep into the sea. The island's interior is astounding; waterfalls cascade over sheer cliffs into rainforests below and rivers cut through dense valleys of giant ferns, wild fruit trees, and shimmering flowers. Most hotels are on the northwest coast of the island on a 6-mile stretch between Punaauia and Papeete. While a visit to the town itself doesn't constitute a true visit to the island, there are interesting things to do there - - shop at numerous boutiques or the open-air marketplace, visit one of several waterfront cafes and restaurants, or tour the Museum of Tahiti and Her Islands nearby. I recommend staying at Bora Bora for at least a couple of nights, only 45 minutes flight from Papeete. If this doesnt impress your partner then I dont know what will. Bora Bora lies 240km northwest of Tahiti in the leeward Society Islands. The main island is in the centre of a multi-coloured lagoon inside a protective necklace of coral. Be prepared the first glimpse of Bora Bora is love at first sight. Sailors, poets, adventurers, ...

Star Trek Essays - Star Trek, Bajoran, Pavel Chekov, Free Essays

Star Trek Essays - Star Trek, Bajoran, Pavel Chekov, Free Essays Star Trek INTRODUCTION: Television programs provide one of the most popular forms of entertainment today. From The Simpsons to The X-Files, television shows amuse, shock, sadden, and excite us by turns. Television does more, however, than simply entertain. Television shows are cultural products, and as such, they reflect, reinforce, and challenge cultural ideas. It acts as a mirror and a model for society. In examining and understanding those cultural messages and popular appeal of certain television shows, we should understand something about the society that has created and sustained them. Arguably, Star Trek is one of the most popular television shows ever produced. Today Star Trek includes four television series and nine motion pictures . Like some of the other television shows, Star Trek has been subject to the vagaries of producers and writers so it is difficult to generalize about the intent of the authors of Star Trek or the viewpoint of the readers. Yet, it is also clear that Star Trek has at various times been reflective, informative, and critical about the culture -American culture- that produced it. Star Trek has addressed a wide variety of issues, including war, capitalism, individualism, technology, race, gender, prejudice, religion, etc. The list can be extended to many other issues but here I will focus on race, gender, prejudice and religion only. As portrayed on television such issues are representations of socio-cultural perspectives on broad human concerns. For taking a closer look to those issues, in the continuing parts I will give some examples fro m a number of Star Trek episodes that had written in different times. RELIGION: The portrayal and treatment of religion in the Star Trek television series and films provides an important cultural commentary on the place of religion in society. Although no single coherent approach to religion appears in Star Trek, the series is nevertheless variously reflective of, informed by, and critical of societal attitudes toward religion. The portrayal and treatment of religion in much of the Star Trek franchise is negative: religion is often presented as superstitious, outdated, and irrational. An underlying and consistent theme of the Star Trek series is the presentation of rational scientific humanism as an alternative to religious faith. A newer theme, notably found in episodes from the Deep Space Nine and the Voyager series, explores the potentially positive value of religion. Since the viability and popularity of Star Trek have spanned such a long period of time, it is inevitable that the series would begin to diverge from original assumptions in response to changing cultural attitudes. The recent potentially positive portrayal of religion within Star Trek both reflects and reinforces a particular cultural change. Gene Roddenberry was Star Treks creator and executive producer. While he was alive and continued to have a direct hand in the production of the show, religion as a theme was rarely treated. When it was -I believe- the portrayal of religion reflected Roddenberrys own distrust of an antipathy toward organized religion. In Star Trek, organized religion tends to be portrayed as the product of a pre-rational age, antithetical to science and reason, and God is depicted as a category mistake -an advanced alien form- from mistaken for a god. However after his death, and particularly evident in Star Trek: Deep Space Nine and Star Trek: Voyager, religion as a theme far more often tends to be treated in a more sophisticated and sympathetic manner2. The setting of Deep Space Nine is a Federation space station situated next to the planet Bajor. The people of Bajor are united by their common religious faith guided by a religious oligarchy. Invisible spiritual guides called the Prophets directed them. The two hour premiere episode of Deep Space Nine: Emissary featured than -Commander Siskos encounter with the Prophets, one that led both to his emotional healing and to his identification as a Bajorans long-awaited spiritual Emissary. This introductory episode so explicitly involving a spiritual motif set a compelling tone for the exploration of religious themes in this series. On Deep Space Nine religious faith is treated as more than simply the product of superstition and the suspension of rationality depicted in the earlier series. On the other hand, certain episodes, like Shakaar, deal with the Bajoran

What are the most useful insights that psychology has contributed to Essay

What are the most useful insights that psychology has contributed to the study of foreign policy - Essay Example er of a foreign policy†, according to Morgenthau, â€Å"can be ascertained only through the examination of the political acts performed and of the foreseeable consequences of these acts.† (1978:5). By this, not only the performance of the political leaders could be traced out, but also, from the predictable consequences the objectives of their acts can be surmised. Foreign policy, as a discipline, is as old as human society itself is, though as a study, it is the invention of eighteenth century. â€Å"Foreign policy practice does not come into language†, states Benedict Anderson (1991), â€Å"until Jeremy Bentham coins the term ‘international relations’ in the 18th century†. The world has emerged as an enormous global village in the contemporary era. No country on the planet can survive while living in a state of isolation or without interacting with other countries. In order to meet their everyday needs, all the countries seek out foreign assistance and support. Even the biggest economies of the world devise foreign policy to entail international markets, for not only acquiring raw material and sale their finished products according to their growing needs, but also they look for strategic bondage and diplomatic cohesion more emphatically. In addition, countries seek political, economic and technological backing for the uplift of their nation. Rationalism is the key to construct national and international strategy. Psychology, being one of the most significant disciplines and a vast phenomenon of analysing the mind and perception of an individual and his personality, has won appreciable popularity as the source of scientific examination of human behaviour. It not only determines individual’s attitude and behaviour, but also carries weight while estimating the policies of nations at large. A step taken by a sovereign while co-operating or conflicting with some other state(s) maintain some psychological aspects in its wake. This leads towards the formation of

Film Analysis Paper-Sunrise(1927) Essay Example | Topics and Well Written Essays - 1750 words

Film Analysis Paper-Sunrise(1927) - Essay Example Sunrise successfully utilized mise en scà ¨ne to contrast the fast paced city lifestyle vs. cozy country lifestyle, as well as the different characteristics of the actors, to show that true love is the only way to help the man get out of evil seduction. The settings were a mix of real locations and artificial sets. Either way, they provided a perfect background to the scenes. John Bailey, the movie’s cinematographer, explained that the marsh was a studio set, the train in the first scene was a model made to look large in the foreground, the extras were real people and the projected city was from a matte drawing (Ebert: para 12 & 13). The rest of the settings were real. In most cases, the final product was manipulated with camera tricks, creating an imagery of dreaminess. For example, there were scenes where superimposed, ghost-like images were added. One scene showed the man being surrounded by the image of the woman from the city, but she was not physically present. Another scene showed exciting activities in the city with dancers and musicians providing the promised fun, but these images seemed to merely float in a void. Bailey explains that such images were borne out of creative camera use. The camera men used the advance d trick of that time of masking and exposing, controlling the lens and counting the individual frames where they would apply the trick. The finished product was clean without any hint of roughness. It is impressive that all these were done several decades ago when digital technology was not yet in existence, so talent and creativity played major roles in the genius of film makers then. In the city setting, several long shots were taken to shoot the scenes. This was to capture all the action that goes on in one frame. This strategy saved the time and effort to show how busy everyone was in the city, so viewers can get a feel of the