Fluke, or, I Know Why the Winged Whale Sings Chapter 21~22

CHAPTER TWENTY-ONE I Lick the Body Electric The Maui sunset had set the sky on fire and everything in the bungalow had taken on the glowing pink tone of paradise – or hell, depending on where you were standing. Clay dismembered the bird and put the severed pieces on a platter to transport them to the grill. â€Å"You'll need something to bring those in on,† Clair said. Her dress was a purple hibiscus-flower print, and the orchid she wore in her hair looked like lavender dragonflies humping. She was dicing pickles into the macaroni salad. â€Å"What's wrong with this?† Clay held up the plate with the raw chicken. â€Å"You can't use the same plate. You'll get salmonella.† â€Å"Fine, fuck it,† Clay said, tossing the plate into the yard. The chicken parts bounced nicely, breading themselves with a light coating of sand, ants, and dried grass. â€Å"When did chicken become like plutonium anyway, for Christ's sake? You can't let it touch you or it's certain fucking death. And eggs and hamburgers kill you unless you cook them to the consistency of limestone! And if you turn on your fucking cell phone, the plane is going to plunge out of the sky in a ball of flames? And kids can't take a dump anymore but they have to have a helmet and pads on make them look like the Road Warrior. Right? Right? What the fuck happened to the world? When did everything get so goddamn deadly? Huh? I've been going to sea for thirty damned years, and nothing's killed me. I've swum with everything that can bite, sting, or eat you, and I've done every stupid thing at depth that any human can – and I'm still alive. Fuck, Clair, I was unconscious for an hour underwa ter less than a week ago, and it didn't kill me. Now you're going to tell me that I'm going to get whacked by a fucking chicken leg? Well, just fuck it then!† He didn't know where to go, so he came back in and slammed the screen door behind him, then opened it and slammed it again. â€Å"Goddamn it!† And he stood there, breathing hard. Not really looking at anything. Clair put down her knife and pickle, then wiped her hands. As she came toward Clay she pulled a large bobby pin from the back of her hair, and her long, thick locks cascaded down her back. She took Clay's right hand and kissed each of his fingertips, licked his thumb, then took his index finger in her mouth and made a show of removing it slowly and with maximum moisture. Clay looked at the floor, shaking. â€Å"Baby,† she said as she placed the bobby pin firmly between Clay's wet thumb and index finger, â€Å"I need you to go over to that wall and take this bobby pin and insert it ever so firmly into that electrical outlet over there.† Clay looked up at her at last. â€Å"Because,† she continued, â€Å"I know that you aren't mad at me and that you're just grieving for your friends, but I think you need to be reminded that you aren't invulnerable and that you can hurt even more than you do now. And I think it would be better if you did it yourself, because otherwise I'll have to brain you with your own iron skillet.† â€Å"That would be wrong,† Clay said. â€Å"It is a cruel world, baby.† Clay took her in his arms and buried his face in her hair and just stood there in the doorway for a long time. Amy had been missing for thirty-two hours. That morning a fisherman had found her kayak washing against some rocks on Molokai and had called the rental company in Maui. A life jacket was still strapped on the front of the boat, he said. The Coast Guard had stopped looking already. â€Å"Now, let me go,† Clair said. â€Å"I have to get that chicken out of the yard and rinse it off.† â€Å"I don't think we should eat that.† â€Å"Please. I'm going to cook it up for Kona. You're taking me out.† â€Å"I am?† â€Å"Of course.† â€Å"After I stick this in the outlet, right?† â€Å"You can grieve, Clay – that's as it should be – but you can't feel guilty for being alive.† â€Å"So, I don't have to stick this in the outlet?† â€Å"You used foul language at me, baby. I don't see any way around it.† â€Å"Oh, well, that's true. You go get Kona's chicken out of the yard. I'll do this.† On the second morning after Amy was lost at sea, Clay walked to the seaside, a rocky beach between some condos north of Lahaina – too short for morning runners, too shallow for a bathing crowd. He stood on an outcropping of rocks with the waves crashing around him and tried to let pure hatred run out of his heart. Clay Demodocus was a guy who liked things, and among the things he had liked the most was the sea, but this morning he held nothing but disdain for his old friend. The sapphire blue was indifferent, the waves elitist. She'd kill you without even learning your name. â€Å"You bitch,† Clay said, loud enough for the sea to hear. He spit into her face and walked back home. That old trickster Maui had been sitting on a rock nearby watching, and he laughed at Clay's hubris. Maui admired a man with more balls than brains, even a haole. He cast a small blessing at the photographer – just a trinket for the laugh, a trifling little mango of magic – and then he headed off to the great banyan tree to fog the film of Japanese tourists. Back in what was now only his office, Clay dug Amy's resume out of his files and made the call. He braced himself, trying to figure out how, exactly, he was going to tell these strangers that their daughter was missing and assumed to have drowned. He felt sad and alone, and his elbow hurt from the jolt of electricity he'd taken the night before. He didn't want to do this. He reached for the phone, then stopped and closed his eyes, as if he could make the whole thing go away, but on the back of his eyelids he saw the face of his mother as he had last seen her, looking up at him out of her barrel of brine, â€Å"Make the call, you pussy. If anyone knows how not to get bad news, it's you. Part of loyalty is following up, you sniveling coward. Don't be like your brothers.† Ah, sweet Mama, Clay thought. He dialed the phone – a number with a 716 area code, Tonawanda, New York. It rang three times, and the recorded operator came on, saying that the number he'd reached was not in service at this time. He checked it, then dialed the next number down, which also turned out not to be working. He called Tonawanda information for Amy's parents, and the operator told him there was no such listing. At a loss, he called Woods Hole Oceanographic Center, where Amy had gotten her master's. Clay knew one of her advisers, Marcus Loughten, an irascible Brit who had worked at Woods Hole for twenty years and was famous in the field for his work in underwater acoustics. Loughten answered on the third ring. â€Å"Loughten,† Loughten said.: â€Å"Marcus, this is Clay Demodocus. We worked together on –  » â€Å"Yes, Clay, I bloody know who you are. Calling from Hawaii, are you?† â€Å"Well, yes, I – ; â€Å"Probably, what, seventy-eight degrees with a breeze? It's seven below zero Fahrenheit here. I'm out installing bloody sound buoys in a monthlong blizzard to keep right whales from getting run over by supertankers.† â€Å"Right, the sound buoys. How are those working out?† â€Å"They're not.† â€Å"No? Why not?† â€Å"Well, right whales are stupid as shit, aren't they? It's not like a supertanker is quiet. If sound was going to deter them, then they'd be bloody well deterred by the engine noise, wouldn't they? They don't make the connection. Stupid shits.† â€Å"Oh, sorry to hear that. Uh, why keep doing it then?† â€Å"We have funding.† â€Å"Right. Look, Marcus, I need some information on one of your students who came out here to work with us. Amy Earhart? Would have been with you guys until fall of last year.† â€Å"No, I don't know that name.† â€Å"Sure you do, five-five, thin, pale, dark hair with kind of unnatural blue highlights, smart as a whip.† â€Å"Sorry, Clay. That doesn't fit any of my students.† Clay took a deep breath and trudged on. Biologists were notorious for treating their grad students as subhuman, but Clay was surprised that Loughten didn't remember Amy. She was cute, and if Clay could judge from a night of drinking he'd done with Loughten at a marine mammal conference in France, the Brit was more than a bit of a horndog. â€Å"Great ass, Marcus. You'd remember.† â€Å"I'm sure I would, but I don't.† Clay studied the resume. â€Å"What about Peter? Would he –  » â€Å"No, Clay, I know all of Peter's grad students as well. Did you call to confirm her references when you took her on?† â€Å"Well, no.† â€Å"Good work, then. Abscond with your Nikons, did she?† â€Å"No, she's missing at sea. I'm trying to contact her family.† â€Å"Sorry. Wish I could be of help. I'll check the records, just to be sure – in case I've had a ministroke that killed the part of the brain that remembers fine bottoms.† â€Å"Thanks.† â€Å"Good luck, Clay. My best to Quinn.† Clay cringed. It turned out he really wasn't up for bearing bad news. â€Å"Will do, Marcus. Good-bye.† Clay hung up and resumed staring at the phone. Well, he thought, I knew absolutely nothing about this woman that I thought I knew. Libby Quinn had already called (sobbing) to say that they should have some kind of joint service at the sanctuary for Nate and Amy, and that Clay should speak. What was he going to say about Amy? Dearly beloved, I think we all knew Amy as scientist, a colleague, a friend, a woman who showed up out of nowhere with a completely manufactured history, but I think, because she saved my life, that I came to know her better than anyone here, and I can tell you unequivocally, she was a smart aleck with a cute butt. Yeah, he'd need to work on that. Damn it, he missed them both. Clay decided to kill the day by editing video: time-eating busywork that supplied at least an imaginary escape from the real world. The afternoon found him going through the rebreather footage he'd taken on the day the whale had conked him, for the first time going past the point where he was unconscious, just to see if the camera picked up anything usable. Clay let the video run: minutes of blue water, the camera tossing around at the end of the wrist lanyard, then Amy's leg as she comes down to stop his descent. He cranked the audio. Hiss of ambient noise, then the bubbles from Amy's regulator, the slow hiss of his own breathing through the rebreather. As Amy starts to swim to the surface, the camera catches his fins hanging limply against a field of blue, then Amy's fins kicking in and out of the frame. Both their breathing is steady on the audio track. Clay looked at the time signature of the video. Fifteen minutes when the motion stops. Amy making her first decompression stop. On the audio he hears the chorus of distant singing humpbacks, a boat motor not too far off, and Amy's steady bubbles. Then the bubbles stop. The camera settles against his thigh and drifts, the lens up, catches light from the surface, then Amy's hand holding on to his buoyancy vest, reading the data off his dive computer. Her regulator is out of her mouth. On the audio there's only his breathing. The camera swings away. Ten minutes more pass. Clay listens for Amy's breathing to resume. The motion from her hooking into the rescue tank on the rebreather should move the camera, but there's just the same gentle drift. They move up. Clay guesses maybe to seventy-five feet. Amy is doing another decompression stop, doing it by the book, despite the emergency. Except he still can hear only one person breathing. She pulls him to more shallow depth. The frame lightens up, and the camera swings around, the wide angle showing Clay's unconscious form and Amy kicking, the regulator out of her mouth, looking at the surface. She hasn't used the bail-out tank on Clay's rebreather, and she hasn't taken a breath for, as far as Clay can tell, forty minutes. This can't be right. He listens, watching until the time signature shows sixty and the tape ends – the entire thing having been dubbed to the hard drive. He rewinds it on-screen, slowing down when the camera shows anything but blue, listening again. â€Å"No fucking way.† Clay backed away from the monitor, watching as the video ran out again and froze on the image of Amy holding him steady at twenty or so feet down, no regulator in her mouth. He ran out the door, calling, â€Å"Kona! Kona!† The surfer came shuffling out of his bungalow in a cloud of smoke. â€Å"Just tracking down navy spies, boss.† â€Å"Where did you guys put the rebreather? The day they took me to the hospital?† â€Å"She's in the storage shed.† Clay made a beeline for the bungalow they used to store dive and boat equipment. He waved Kona after him. â€Å"Come.† â€Å"What?† â€Å"Did you guys refill the oxygen or the bail-out tanks?† â€Å"We just rinsed it and put it in the case.† Clay pulled the big Pelican case off a stack of scuba tanks and popped the latches. The rebreather was snug in the foam padding. Clay wrenched it out onto the wooden floor and turned on the computer that was an integral part of it. He hit buttons on the display console and watched the gray liquid-crystal display cycle through the numbers. The last dive: Downtime had been seventy-five minutes, forty-three seconds. The oxygen cylinder was nearly full. The bail-out air supply was full. Full. It hadn't been touched. Somehow Amy had stayed underwater for an hour without an air supply. Clay turned to the surfer. â€Å"Do you remember anything that Nate showed you about what he was working on? I need details – I know in general.† Clay wasn't sure what he was looking for, but this had to mean something, and all he had to fall back on was Nate's research. The surfer scratched the dreadless side of his head. â€Å"Something about the whales singing binary.† â€Å"Come show me.† Clay stormed through the door and back to the office. â€Å"What you looking for?† â€Å"I don't know. Clues. Mysteries. Meaning.† â€Å"You gone lolo, you know?† CHAPTER TWENTY-TWO Deep Below, Bernard Stirs About the time that Nathan Quinn had started to master his nausea in the whale ship's constant motion (four days on board), another force started working on his body. He felt an uneasiness come over him in waves, and for twenty or so seconds he would feel as if he needed to crawl out of his skin. Then it would pass and leave him feeling a little numb for a few seconds, only to start up again. Poynter and Poe were moving around the small cabin looking at different gobs and bumps of bioluminescence as if they were gleaning some meaning from them, but, try as he might, Nate couldn't figure out what they were monitoring. It would have helped to be able to get out of the seat and take a closer look, but Poynter had ordered him strapped in after he made his first break for the back orifice. He'd nearly made it, too. Had dived at it just like he'd seen the whaley boys do, except that only one arm had gone through, and he ended up stuck to the floor of the whale, his face against the rubbery skin, his hand trailing out in the cold ocean. â€Å"Well, that was phenomenally stupid,† said Poynter. â€Å"I think I've dislocated my shoulder,† Nate said. â€Å"I should leave you there. Maybe a remora or two will latch on to your hand and teach you a lesson.† â€Å"Or a cookie-cutter shark,† said Poe. â€Å"Nasty bastards.† The whaley boys turned in their seats and snickered, bobbing their heads and blowing the occasional raspberry, which could inflict considerable moisture off a four-inch-wide tongue. Evidently Quinn was a cetacean laugh riot. He'd always suspected that, actually. Poynter got down on his hands and knees and looked Nate in the eye. â€Å"While you're down there, I'd like you to think on what might have happened if you'd been successful at launching yourself through that orifice. First, we're at – Skippy, what's the depth?† Skippy chirped and clicked a number of times. â€Å"A hundred and fifty feet. Beyond the fact that you'd probably have blown out your eardrums almost immediately, you might think on how you were going to get to the surface on one breath of air. And should you have gotten to the surface, what were you going to do then? We're five hundred miles from the nearest land.† â€Å"I hadn't worked out the whole plan,† Nate said. â€Å"So, actually, I might be looking at success, right? You just wanted to test the outside water temperature?† â€Å"Sure,† said Nate, thinking it might be best to stay agreeable. â€Å"Can you feel your hand?† â€Å"It's a little chilly, but, yes.† â€Å"Oh, good.† And so they'd left him there a couple of hours, his hand and about six inches of his arm hanging out in the open sea as the whale ship swam along, and when they finally pulled him up, they put him in his seat and kept him restrained except to eat and go to the bathroom. He'd tried to relax and observe – learn what he could – but then a few minutes ago these waves of uneasiness had started hitting him. â€Å"He's got the sonic willies,† said Poe. Poynter looked away from Skippy's console. â€Å"It's the subsonics, Doc. You're feeling the sound waves even though you can't hear them. We've been communicating with the blue for about ten minutes now.† â€Å"You might have said something.† â€Å"I just did.† â€Å"Couple of hours you'll be in the blue, Doc. You can stand up again, walk around a little. Have some privacy.† â€Å"So you're communicating with it in low-frequency sound?† â€Å"Yep. Just like you thought, Doc, there was meaning in the call.† â€Å"Yeah, but I didn't think this, that there were guys, and guylike things, riding about inside whales. How in the hell can this be happening? How can I not know about this?† â€Å"So you're giving up on the being-dead strategy?† asked Poe. â€Å"What is it? Space aliens?† Poynter unbuttoned his shirt and showed some chest hair. â€Å"Do I look like a space alien?† â€Å"Well, no, but them.† Nate nodded toward the whaley boys. They looked at each other and snickered, a sort of wheezing laughter coming from their blowholes, paused, looked back at Nate, then snickered some more. â€Å"Maybe on their planet sentient life evolved from whales rather than apes,† Quinn continued. â€Å"I can see how they might have landed here, deployed these whale ships, and kept under the radar of human detection while they looked around. I mean, man obviously isn't the most peaceful of creatures.† â€Å"That work for you, Doc?† asked Poynter. â€Å"On their planet they developed an organically based technology, rather than one based on combustion and manipulation of minerals like ours.† â€Å"Oh, that is good,† said Poe. â€Å"He's on a roll,† said Poynter. â€Å"Unraveling the mystery, he is.† Skippy and Scooter nodded to each other and grinned. â€Å"So that's it? This ship is extraterrestrial?† Quinn felt the small victory rush that one gets from proving a hypothesis – even one as bizarre as space aliens riding in whale ships. â€Å"Sure,† said Poe, â€Å"that works for me. You, Cap?† â€Å"Yeah, moon men, that's what you guys are,† Poynter said to the whaley boys. â€Å"Meep,† said Scooter. And in a high, squeaky, little-girl voice, Skippy croaked, â€Å"Phone home.† The whaley boys gave each other a high four and collapsed into fits of hysterical wheezing. â€Å"What did he say?† Nate nearly snapped his neck trying to turn around against the restraints. â€Å"They can talk?† â€Å"Well, I guess, if you call that talking,† Poe said. He exchanged high fives with Poynter at the expense of the whaley boys, who paused in their own laughter to roll the whale ship in three quick spirals, which tossed the unsecured Poe and Poynter around the soft cabin like a couple of rag dolls. Poynter came up with a bloody lip from connecting with his own knee. Poe had barked his shin on one of the whaley boys' heads as he went over. Strapped in, Nate concentrated on not watching a rerun of his lunch of raw tuna and water. â€Å"Bastards!† said Poe. â€Å"That what you expected in your race of super-intelligent, space-faring extraterrestrials, Nate?† Poynter wiped blood from his lower lip and flung it at Scooter. Carl Linnaeus, an eighteenth-century Swedish doctor who specialized in the treatment of syphilis, is credited with inventing the modern system that is used for classifying plants and animals. Linnaeus is responsible for naming the humpback whale Megaptera novaeangliae, or â€Å"big wings of New England,† and later naming the blue whale Balaenoptera musculus, or â€Å"little mouse†: at 110 feet long, over a hundred tons, an animal whose tongue alone is larger than a full-grown African elephant – the largest animal to ever live on the planet. â€Å"Little mouse†? Some speculated that this ironic misnomer was perpetrated entirely to confuse Linnaeus's lab assistants, as in Run out and bring me back a â€Å"little mouse,† Sven. Others think that the pox had gone to Carl's head. Quinn was crouched over the back orifice, Skippy and Scooter holding him by either arm, Poynter and Poe crouched before him, saluting. He could feel the texture of the opening under his bare feet, like wet tire tread. â€Å"It's been a pleasure, Doc,† Poynter said. â€Å"Have a great trip.† â€Å"We'll see you back at base,† said Poe. â€Å"Now, just relax. You're barely going to contact water. Hold your nose and blow.† Quinn did. Poynter counted, â€Å"One, two –  » â€Å"Meep.† Nate was sucked out the orifice, felt a brief chill and some pressure pushing back against his ears, and found himself in a chamber only a little taller than that in the humpback, with a fairly amused woman. â€Å"You can stop blowing now,† she said. â€Å"Yet another phrase I didn't think I'd be hearing in this lifetime,† Nate said. He let go of his nostrils and took a deep breath. The air seemed fresher than in the humpback. â€Å"Welcome to my blue, Dr. Quinn, I'm Cielle Nu;ez. How do you feel?† â€Å"Pooped.† Quinn grinned. She was about his age, Hispanic with short dark hair peppered gray and wide brown eyes that caught the bioluminescence off the walls and reflected what looked like laughter. She was barefoot and wearing generic khakis like Poynter and Poe. He shook her hand. â€Å"Cute,† she said. â€Å"Come forward with me, Doctor. I'm sure it's been a while since you were able to stand up straight.† She led him down the corridor, which reminded Nate of when, as kids, he and his buddies had explored storm drains in Vancouver. It was tall enough to walk in, but not tall enough to stand in comfortably. â€Å"Actually, Cielle, I'm not a doctor. I have a Ph.D., but the doctor thing –  » â€Å"I understand. I'm captain of this rig, but if you call me ‘Captain, I'll ignore you.† â€Å"I wanted to hear the humpback sing before I left. You know, from the inside.† â€Å"You will. There'll be time.† The corridor started to widen as they moved forward, and Nate was actually able to walk normally, or as normally as one can walk when barefoot on whaleskin. This skin had a mottled appearance, whereas on the humpback it had been nearly solid gray. He noticed that on this ship there were wide veins of bioluminescence on the floor, casting a yellow light up upward that gave everything a sinister green glow. Nuà ±ez paused by what appeared to be portals on either side of them. â€Å"This is as good a place as any,† she said. â€Å"Now, turn sideways and take my hand.† Quinn did as he was asked. Her hand felt warm but dry. She was a small woman, but powerfully built, he could feel the strength in her grip. â€Å"Now, we're just going to walk as the ship moves. Don't stop until I say, or you'll fall on your ass.† â€Å"WHAT?† â€Å"Okay, Scooter, roll it.† â€Å"Scooter?† â€Å"All pilots are called Scooter or Skippy. They didn't tell you?† â€Å"They weren't very forthcoming with information.† â€Å"Humpback crews are a bunch of yahoos.† Nuà ±ez smiled. â€Å"You know the type, like navy fighter pilots topside? All ego and testosterone.† â€Å"I got more cretin than yahoo,† Nate said. â€Å"Well, with that particular bunch, yes.† The whole corridor started to move. â€Å"Here we go, step, step, step, that's good.† They were walking across the walls as the ship rolled. When they were standing on the ceiling, the roll stopped. â€Å"Nice, Scooter,† Nuà ±ez said, obviously communicating through some sort of hidden intercom. Then, to Nate, â€Å"He's so good.† â€Å"We were upside down to make the transfer?† â€Å"Exactly. You're a smart guy. Look, these are cabins. She touched a lighted node on the wall, and a skin portal folded back on itself. Again Nate was put in mind of the blowhole of a toothed whale, but it was so big, nearly four feet across, it was just†¦ unnatural. Lines of light pumped to life past the portal to reveal a small cabin, a bed – apparently made of the same skin as the rest of the interior – but also a table and a chair. Nate couldn't make out what material they might be made of, but it looked like plastic. â€Å"Bone,† Nu;ez said, noticing him noticing. â€Å"They're as much a part of the ship as the walls. All living tissue. There are shelves and cubbyholes for your stuff in the bulkheads, closed now. Obviously everything has to be stowed for little maneuvers like the one we just performed. The motion isn't as bad as on the humpbacks. You'll find you'll get used to it, and then you can move about just as if you were on land.† â€Å"You're right. I didn't even notice we were moving.† â€Å"That would be because we're not,† said Nu;ez. The sound of whaley-boy snickering wheezed down the corridor toward them. â€Å"You guys are supposed to be working,† Nu;ez said to the air. â€Å"Prepare to get under way.† She turned to Quinn. â€Å"Can I buy you a cup of joe? Maybe answer some of your questions?† â€Å"You're offering?† Quinn felt his heart jump with excitement. Information, without Poynter and Poe's goofing obfuscation? He was thrilled. â€Å"That would be fantastic.† â€Å"Don't pee all over yourself, Quinn. It's just coffee.† The corridor opened up into a large bridge. The head of the blue was huge compared to the humpback's. On either side of the entry a whaley boy stood grinning at them as they passed. They were both taller than Quinn, and unlike the Scooter and Skippy of the humpback, their skin was mottled and lighter in color. Nate paused and grinned back at them. â€Å"Let me guess – Skippy and Scooter?† â€Å"Actually, Bernard and Emily 7,† said Nu;ez. â€Å"You said they all were –  » â€Å"I said all pilots were named Skippy and Scooter.† She gestured to the front of the bridge, where two whaley boys sitting at control consoles were turning in their seats and grinning. Maybe, thought Nate, they always appeared to be grinning, much like dolphins. He'd made an amateur mistake, assuming that their facial expressions were the analog of human expressions. People often did that with dolphins, even though the animals had no facial muscles to facilitate expression. Even sad dolphins appeared to be smiling. â€Å"What are you two grinning at?† asked Nuà ±ez. â€Å"Let's get on the way.† The pilots frowned and turned back to their consoles. â€Å"Well, crap,† Nate said. â€Å"What?† â€Å"Nothing, just another theory shot in the ass.† â€Å"Yeah, this operation does that, doesn't it?† Nate felt something stirring in his back pocket and spun around to see a thin, fourteen-inch-long pink penis that was protruding from Bernard's genital slit. It waved at him. â€Å"Holy moly!† â€Å"Bernard!† Nuà ±ez snapped. â€Å"Put that away. That is not procedure.† Bernard's unit drooped noticeably from the scolding. He looked at it and chirped contritely. â€Å"Away!† Nuà ±ez barked. Bernard's willy snapped back up into his genital slit. â€Å"Sorry about that,† Nuà ±ez said to Nate. â€Å"I've never gotten used to that. It's really disconcerting when you're working with one of them and you ask them to hand you a screwdriver or something and his hands are already full. Coffee?† She led him to a small white table around which four bone chairs protruded from the floor. They looked like old-style Greek saddle chairs – no backs, organic curves, and the high gloss of living bone – but more Gaudi than Flintstone. Quinn sat while Nuà ±ez touched a node on the wall that opened a meter-wide portal that had concealed a sink, several canisters, and what looked like a percolator. Nate wondered about the electricity but forced himself to wait before asking. While Nuà ±ez prepared the coffee, Quinn looked around. The bridge was easily four times the size of the entire cabin in the humpback. Instead of riding in a minivan, it was like being in a good-size motor home – a very curvy, dimly lit motor home, but about that size. Blue light filtered in through the eyes, illuminating the pilots' faces, which shone like patent leather. Nate was starting to realize that even though everything was organic, living, the whale ship had the same sort of efficiency found on any nautical vessel: every spaced used, everything stowed against movement, everything functional. â€Å"If you need to use the head, it's back down the corridor, fourth hatch on the right.† Emily 7 clicked and squealed, and Nu;ez laughed. She had a warm laugh, not forced; it just rolled out of her smooth and easy. â€Å"Emily says it seems as if it would be more logical for the head to be in the head, but there goes logic.† â€Å"I gave up logic a few days ago.† â€Å"You don't have to give it up, just adjust. Anyway, facilities in the head are like everything on the ship – living – but I think you'll figure out the analogs pretty quickly. It's less complicated than an airliner bathroom.† Scooter chirped, and the great ship started to move, first in a fairly radical wave of motion, then smoothing out to a gentle roll. It was like being on a large sailing ship in medium seas. â€Å"Hey, a little more warning, Scooter, huh?† said Nu;ez. â€Å"I nearly dumped Nathan's coffee. Okay if I call you Nathan?† â€Å"Nate's good.† Moving with the roll of the ship, she made it back to the table and put down the two steaming mugs of coffee, then went back for a sugar bowl, spoons, and a can of condensed milk. Nate picked up the can and studied it. â€Å"This is the first thing from the outside that I've seen.† â€Å"Yeah, well, that's special request. You don't want to try whale milk in your coffee. It's like krill-flavored spray cheese.† â€Å"Yuck.† â€Å"That's what I'm saying.† â€Å"Cielle, if you don't mind my saying, you don't seem very military.† â€Å"Me? No, I wasn't. My husband and I had a sixty-foot sailboat. We got caught in a hurricane off of Costa Rica and sank. That's when they took me. My husband didn't make it.† â€Å"I'm sorry.† â€Å"It's okay. It was a long time ago. But, no, I've never been in the military.† â€Å"But the way you order the whaley boys around –  » â€Å"First, we need to clear up a misconception that you are obviously forming, Nate. I – we, the human beings on these ships – are not in charge. We're just – I don't know, like ambassadors or something. We sound like commanders because these guys would just goof off all day without someone telling them what to do, but we have no real authority. The Colonel gives the orders, and the whaley boys run the show.† Scooter and Skippy snickered like their counterparts on the humpback ship, Bernard and Emily 7 joined them – Bernard extending his prehensile willy like a party horn. â€Å"And whaley girls?† Nate nodded toward Emily 7, who grinned – it was a very big, very toothy grin, but a little coquettish in the way one might expect from, say, an ingenue with a bite that could sever an arm. â€Å"Just whaley boys. It's like the term ‘mankind, you know – alienate the female part of the race at all costs. It's the same here. Old-timers gave them the name.† â€Å"Who's the Colonel?† â€Å"He's in charge. We don't see him.† â€Å"Human, though?† â€Å"I'm told.† â€Å"You said you'd been here a long time. How long?† â€Å"Let me get you another cup, and I'll tell you what I can.† She turned. â€Å"Bernard, get that thing out of the coffeepot!†

Leadership Essay

Values of great leaders can be found in various types of people. People who are of different ethnicities and are from different points of the world have shown to have unusual characteristics of leadership. There were many different approaches developed in studying leadership, one being the trait approach. The trait approach is based on the presumption that leaders are not developed into the leadership role but born with the characteristics of leadership that permits them to be great leaders. It has been discovered that there are strengths and also weaknesses within the trait approach relating to studying leadership. Strengths From a trait approach, there are many strong characteristics in leadership. A big role of a leader’s success is their personality. Their personality allows them to be effective when interacting with other people. Sometimes it takes a leader’s personality to set or change the tone in a work place, helping to create a positive mood and encouraging an environment of motivation to succeed and goal achievement. High energy, optimistic, a strong motivator, the ability to communicate and constancy are signature abilities that are believed to be recognized in the trait approach which aids a leader to be successful driven and adaptable (American Library Association , 1997-2013) Although this trait has been known to be very valuable in a successful leader it is has also been said that, â€Å"this massive research effort failed to find any traits that would guarantee leadership success. (Gary Yukl, page 13, 2010)† Weaknesses Although a personality has the ability to be effective it also has the ability to be  ineffective as well. A leader’s personality can be felt as being too strong and overwhelming at times causing some resistance and rebelling to take place with the followers. Many employees function on different learning levels in the workplace. If a supervisor leads with a sense of expectancy, his expectations may be seen as little high by the employees which in turn may damage the positive work environment. Also a supervisor’s personality can be taken as negative one if they do not take the employees’ feelings into consideration. To believe that a great supervisor is born with the leadership traits means that, as a company, the employees cannot be developed or effective in the workplace. When a company refrains from filling management positions from the inside of the company, employees can began to believe that they are in a glass ceiling environment. Creating future leaders within the company has been proven to build the morale of the employees. Conclusion Many abilities that identify great leaders have been found through the trait approach. Although these abilities are good, leadership is not limited by them. It has been exemplified through President Obama that in life, being a leader can be learned. President Obama was not born a leader, but through education and leadership experiences, he now has the ultimate leadership position in this country. Knowing this to be true, other approaches to studying leadership were developed such as the situational approach, the integrative approach, the behavior approach, and the power-influence approach.

Fear in the Things They Carried

Tim O’Brien’s decision to go to Vietnam was out of the fear from disappointing his family and community. How does shame affect and play a role in the life of the soldiers in The Things They Carried? The Things They Carried is a book set in Massachusetts but the core of the book is based in Vietnam. A group of Soldiers go to war and Tim O’Brien decides to document the true effects of war but beneath his words, there were a lot of factors and double meaning to them.The motif ‘Shame† played a huge part in every character in this book as it was a trait they all shared in common Shame in this context is not necessarily a bad thing as with the power of hindsight, we found it to have been a motivating factor for them during the war in more ways than one. They could decide to inflict injury on themselves as a way to get discharged from their military service but the fear of shame further guided them to be heroes for their country. The interesting thing about this book is that shame was a common factor shared by all men.Their fear of shame and weakness propelled them to act braver than they were. It is not a secret knowing that the soldiers were a little bit afraid of the war but they all did a good job in masking their shame and fears. In The Things They Carried, â€Å"They carried the common secret of cowardice barely restrained, the instinct to run or freeze or hide, and in many respects this was the heaviest burden of all, for it could never be put down, it required perfect balance and perfect posture† (77).In analyzing this quote, their instinct to run or hide had to be restrained due to fear of being made fun of by colleagues and being called a coward. The chapter â€Å"On the Rainy River† summarizes Tim’s moral fight against being drafted into an unjust war. The Vietnam War was one he strongly opposed and his decision to fight is not down to his bravery or him being a patriot, but that of the ‘fear of sh ame’ and being tagged a coward. Therefore he succumbed to the pressure. â€Å"I survived, but it's not a happy ending. I was a coward. Related essay: Shame is Worth a TryI went to the war† (79). This statement is an example of how shame had him motivated. Him calling himself a coward was the fear of ‘shame’ out powering his principles. He initially thought of running off to Canada after being drafted but was scared that if he did not acknowledge the draft, he would be ridiculed/punished and that would be him disappointing his community and family. In order to avoid this shame facing him, he decided to be brave and go to war and fight for his country. He ended up going and survived the ains of the war due to shame being his motivating factor in his decision. Additionally, looking at Curt Lemons in â€Å"The Dentist†, shame was an igniting force leading to some of the characters bravery and heroism. Curt Lemon suffered an embarrassing fate in this chapter where he fainted before being observed by the visiting dentist. In fear of social acceptance and how the soldiers in the platoon would look at him, he decided to face his fears and shame by having his tooth removed although there was nothing wrong with it.One can attribute the survival of some of the soldiers to shame as it gave them the needed extra incentive to survive. With his renewed ego, this would make him feel stronger and ready for the worst (increasing his bravery while mitigating his shame). Shame, no matter how negative the definition seems to be, the characters in The Things They Carried made the most out of it by making it an unorthodox form of motivation for going to war and trying to survive it. Safe to say O’Briens characters (soldiers) value pride more than their life. Olumide Shodipo

Marketing And Social Media Essay Example | Topics and Well Written Essays - 1750 words

Marketing And Social Media - Essay Example he social media, because of active integration of technology in the lives of the masses around the world has resulted in the playing of a major catalytic role in regards to the formation of a large number of followers in the virtual world. It can be said that in the today’s date, the social media represents a series of programs that run explicitly by exploiting the functionalities of Web 2.0 (Wankel, 2010, p. 9) Talking in regards to the product lifecycle, it can be said that there are four stages such as introduction, growth, maturity and decline. The social media holds a tremendous value in the first two stages as it is deeply integrated with regards to value communication of the products to the masses. Just because social media is largely diversified in its forms through the presence of various social networking and micro blogging sites likes Facebook, Twitter, LinkedIn etc. it can be said that the marketing power of the social media is tremendously high (Zarrella, 2010, p. 3). Talking more in connection to the power of marketing of the social media and the product life cycle, it can be said that the social media plays a very influential role in regards to the process of introducing new products and services in the markets by simply helping in the process of communicating the values of the products and services to the desired target audience. It also needs to be highlighted that during the course of attaining the growth phase of product development, the social media helps in a great way in manipulating the demand for the products and services by helping the marketers of the respective products and services to maintain a bilateral method of communication with the desired target audience. 2. It is important to mention that in today’s date, the social media has...Talking about the social networking sites, it can be said that the growth of the social networking sites has been largely augmented by the tremendous favoring of the growth prospects of t he United States. Like as witnessed in the case of dotcom bubble of the late 1990’s, the mere presence of the social networking sites in the virtual web space does not help in any way in the process of generating revenue. Every social networking site needs to operate on the basis of a business model, which will help in generating revenue for the online business. It is of significant and utmost importance to mention that the business models that are applicable in the case of social networking sites should not only focus on the process of generating monetary value, but also on the lines value creation, identification of the core competencies of the online business as well as proper value communication to the right target audience. Considerable amount of interest also needs to be given on the lines of creating competitive edge for the online business. It is of considerable importance to mention that an online business is built on four key model components. The first one is the value creation, which distinguishingly addresses the value that will be provided to the customers. The second factor is the issue of target market, which necessarily takes into account the factor of the desired target audience.

Law of Obligations (Tort Law)LLB Essay Example | Topics and Well Written Essays - 1000 words

Law of Obligations (Tort Law)LLB - Essay Example The employer, on the other hand, may have a claim for damages against Beatrice for her negligence. Employer's Duty of Care and its Breach. In the recent case of Jones v BBC, 2007 WL 2187023 (QBD), where Jones, a freelance sound recordist for defendant BBC claimed that he suffered personal injury when a windmill rotor fell onto his back causing severe spinal injury rendering him paraplegic. In ruling for the claimant, the court stated that since BBC's safety crew had identified a risk of the falling mast, a discussion before filming should have been made to warn the crew not to go beneath it. But the safety crew did not give the warning. Such failure of BBC, through the safety crew, is considered negligent which caused Jones' accident. Thus, the BBC was liable for Jones' injuries. Also, the cameraman and Jones worked as a team because their equipment was linked. Jones with his equipment was following the cameraman who had decided to pass beneath the mast thereby leading Jones into the hazardous area. The cameraman was then in breached of his duty of care and the BBC was vicariousl y liable for that negligence. In Wilsons & Clyde Coal Company, Limited v English, [1938] A.C. 57, the House of Lords stated as follows: " primarily the master has a duty to take due care to provide and maintain a reasonably safe system of working in the mine, and a master, who has delegated the duty of taking due care in the provision of a reasonably safe system of working to a competent servant, is responsible for a defect in the system of which he had no knowledge" By the Jones and Wilsons cases, it is clear that the employer is under a duty of care to provide the employee with competent fellow employees including a qualified medical personnel, properly maintained site and facilities, and to provide a safe place and system of work. The question of whether the employer breached that duty of care depends on the standard of care owed by the employer to its employee and whether it has taken reasonable steps considering the circumstances. (Latimer v A.E.C. Ltd.[1953]) In Jones, the bre ach of the employer's duty consists in BBC's failure (through its safety crew) to discuss with the cameraman and Jones the risk of the falling mast and to warn the cameraman and Jones in unequivocal terms that they must not go beneath it. In Wilsons, the breach by the employer consists of its failure to provide competent fellow employees, properly maintained mine and equipment, and to provide a safe place and system of work. In the case of the employee here, the failure of the employer considering its nature of business to properly provide and maintain a safe place and system of work free from insects such as wasps, to provide sufficient number of medical personnel and qualified immediate treatment which caused the employee's permanent disability to do manual work constitute a breach of the standard care required from the employer. Considering that the company is engaged in hazardous chemicals, not having any emergency doctor onsite is a breach of its standard of care. It can reason ably be expected that injuries are bound to occur in a chemical factory because, by the very nature of its business alone, the environment with chemicals is susceptible to accidents. Hence, the

Nature vs. nurture debate within the context of the biopsychosocial Essay

Nature vs. nurture debate within the context of the biopsychosocial approach using a pretend cloning scenario - Essay Example ’s life story is important in knowing to its full extent the story of how the illness started and how the social and psychological domains affect the patient. It integrates the social interactions of individuals mentally, physically and emotionally in conceptualizing decease and illness. It has also been presented that the infliction and gravity of pain depends on sub-aspects such as gender, race, ethnic origin and tradition (Frankel et.al., 2003). The biopsychosocial aspects are the factors which shape an individual, it provides an individual experience and knowledge. Because of this, an individual who was born and lived during the 1950’s will have different characteristics if that individual was born and lived during the 1970’s. This is because that individual would have a different environment due to change and development, and most experiences will be different from one point or the other. These are the reasons why in a biopsychosocial point of view, parents and nor child will not prosper (Levine, 2009). The issue of cloning is closely connected to the debate of nature versus nurture in terms of how the cloned organism lives. Scientists speculate that cloned organisms will have more or less the same characteristics as its parents (Levine, 2009). This is because the genes and DNA structure of the cloned individual have the same structure as the parent of the clone. This is the nature aspect of the issue. On the other hand, it is also important to look into the nurture aspect which defines the environmental and social influences that impacts the life of the cloned individual. Yes, the cloned individual may have the same physical and biological attributes as the parent clone, but it may not have the same reaction to the present conditions wherein it will live because of the learning experience it will encounter. Although it has the same physical attributes as the parent clone, it may react differently to the situations around it because of the how it will

Dangers of Genetically Altered Foods Essay Example | Topics and Well Written Essays - 500 words

Dangers of Genetically Altered Foods - Essay Example However, the studies revealed that it was not the added lectin that was responsible for these side effects, but the engineering process itself. This is because a control group that was fed with potatoes containing the substance was not affected as they had not undergone the genetic modification processes (Pusztai, p.1). According to the researcher’s studies, food genetics should therefore not be altered for the purpose of making them disease-resistant or improving production to feed the hungry people since the process may bring adverse effects on humans. Regulation and testing of the process of modifying foods genetically has inefficiently been carried out in the past with interventions coming from various interested parties. For instance, in order to quell the public furor that was caused by the researcher’s studies, Philip James, a director at Rowett Institute, fired Pusztai because he had been influenced to take the action by a biotech firm located in the U.S. throug h a $224,000 grant they had received (Pusztai, p.2). In the U.S., their administration on food along with drugs has slowly drifted away from their regulation that food companies within the country should ensure the safety of their products before releasing them to the consumers. The foods are currently being introduced in a stealthy and quiet manner according to reports despite the public’s lack of comprehension concerning the risks that are posed by these foods. It is only due to the criticism that these foods have received across the nation and on the international arena that the American regulators are now thinking of creating new regulations to govern their manufacture (Pusztai, p.3). The production of genetically modified foods should not be advocated since they have many disadvantages that they come with. This is mainly because the engineering may bring imprecise technologies, different side

Marketing Case Study Example | Topics and Well Written Essays - 500 words - 4

Marketing - Case Study Example Several brands have registered success in the social media usage. Currently, social media usage must be employed to meet the younger generation. Marketing of products using online tools has increased sales volume because the clients employ online purchase of items. Apart from employing the online tools, social media have a massive impact on the success of the country both in business and politics. The Arab revolution is a product of social media usage in the airing of the grievances of the citizens. Facebook is the leading social media platform with massive subscribers and increased success in terms of usage. Facebook as a social media tool enjoys massive support from the youths who have employed it in communication and information transfer. Companies use social media marketing strategy to improve brand image and resonance (Beverly and Thomson 123). Marketing involves the employment of all the necessary platforms of promotion and advertising with the SNSs offering a better platform for communication. Social media platforms offer the opportunity for collection of feedback. Traditionally, feedback collection of products released in the market was hard to obtain owing to the nature of information sharing systems. However, with the introduction of social media platform companies are able to prepare the market for the introduction of new product, while also collecting the customer preferences about the product. The success of products in the current society has been pegged on the marketing plan and action employed by the company (Beverly and Thomson 145). Public relations use social media to improve product perception and facilitate the development of positivity towards the company. Social media can be employed both in communication and persuasive advertising with enormous success. Facebook, MySpace and Twitter, are some of the widely used social media platforms

Anthropology (movie) Essay Example | Topics and Well Written Essays - 1000 words

Anthropology (movie) - Essay Example m, it is submitted that Marc Forster’s approach clearly mirrors Ebert’s review of the film by providing an engaging narrative with the overriding purposes to provide a socio-political commentary on the instability in Afghanistan through the presentation of complex cultural norms. Moreover, the film’s visual portrayal of Hosseini’s secular narrative in the book is precisely what resonates with the audience in the superimposition of â€Å"human faces and a historical context on the tragic images of war from Afghanistan† (Ebert, 2009:373). Ebert’s review of the film suggests a visual emphasis on presenting Afghan culture outside the presumptions of the war torn state (2009). This is supported by the scenes of the boys flying kites as a precursor to the loss of innocence, the burden of living with guilt and the need for redemption as symbolised through Amir’s character development after his betrayal of Hassan. As such, the cinematic portrayal of the relationship between Hassan and Amir with other boys in the kite flying season presents a novel perception of Afghanistan and Afghani culture prior to the â€Å"Taliban, the Americans and the anarchy† (Ebert, 2009:373). The film clearly presents this part of Afghan culture by using special effects to visually emphasise the freedom and importance of family bonding in kite flying. Additionally, Ebert suggests that the film presents the freedom and exhilaration of kites to their owners, which is utilised by Forster to underline the cultural and class divide between Amir as the kite flyer and Hassan as the kite runner. To this end, Ebert suggests that â€Å"perhaps that sad wisdom in Hassan’s eyes comes from his certainty that all must fall to Earth, sooner or later† (Ebert 2009:374). In watching the film, the vulnerability of the actor playing Hassan reinforces the precarious nature of his societal position as a Hazara in Afghanistan, which leaves him powerless in the shocking rape scene and its aftermath.

The Effects of Metformin on Polycystic Ovarian Syndrome Term Paper

The Effects of Metformin on Polycystic Ovarian Syndrome - Term Paper Example Center of discussion in this paper is Polycystic Ovarian Syndrome (PCOS) that actually indicates the presence of multiple cysts in the ovaries of certain women. This naturally impedes the normal ovarian function and also gives rise to a number of associated conditions in the physiology of such women. The presence of PCOS also induces the patients to develop diabetes mellitus. Metformin has been recognized as an effective medication for PCOS patients. There are a host of genetic, physiological and environmental factors behind the presence of PCOS in women. It has become a very common gynecological condition in most modern women. In the earlier days, physicians used the traditional method in the treatment of PCOS. This method consisted of suppressing the normal ovarian function of the patients with the help of a number of medicines. Oral contraceptives, progestins and GnRH agonists were prescribed to the patients to improve their physiological functioning. In recent times, the treatmen t of PCOS has veered towards the insulin sensitivity based treatment of the disease. Metformin is one such insulin sensitizing agent which mainly aims at reducing the insulin level of PCOS patients and thus generates beneficial effects to deal with their other medical conditions. It has gradually come to be accepted as an integral part of the modern nursing care. The review of the literature first endeavors to understand the emergence and complexity of Polycystic Ovarian Syndrome reflecting on the factors which have made the disease more complex in nature. Secondly, it cites the various conventional approaches, pharmacological and non –pharmacological, which have been used in the past in an attempt to curb the incidence of the disease and assesses the efficacy of each. Finally, it focuses on the use of Metformin in the treatment of the disease, outlining the advantages and disadvantages associated with its use in treating Polycystic Ovarian Syndrome in cases of pregnancy as w ell as in normal cases. Polycystic Ovarian Syndrome PCOS should not in itself be properly described as a disease. Rather, it is observed as a combination of different symptoms, which in turn reflects various ailments. Radosh (2009) observed that Polycystic Ovarian Syndrome is more complex during the reproductive stage of a women’s life. Multiple ‘cysts’ is one of the hallmark of PCOS. The emergence of ovarian cysts is due to the result of hormonal imbalances between the pituitary and ovarian organs. During the reproductive period, women affected by PCOS tend to have a plethora of problems. These include consecutive miscarriages, inability to conceive, extreme obesity, excessive hair on the body, face and chest, and prolonged menstruation. The existence of PCOS in women is increasingly linked to metabolic dysfunction leading to severe diabetic and cardio-vascular complications. It is further observed that the effect of such complications can give rise to excessive mental stress and loss of self – esteem (Radish, 2009). Age Groups Affected by PCOS PCOS affects the female population both in the younger and later years. Ushiroyama, Hosotani, Mori, Yamashita, Ikeda and Ueki(2006) observed that PCOS starts at a young age, revealing hormonal abnormality through symptoms such as menstrual

The global flow of visual cultural Assignment Example | Topics and Well Written Essays - 250 words

The global flow of visual cultural - Assignment Example The other one was the patrol American man who thought that he could not deal openly with a Mexican and cancelled the artist resident card (Guillermo 2:58; 4:24). In La Pocha Nostra scrapbook, picture Pocha Nostra-065 gives a description of a hybrid. The man is Indian dressed, and the lady is blonde American with a dress that is of Chinese culture. Picture GGP_081026_00325 describes diaspora. The woman is wearing a covering over her head covering her upper body plus her head leaving her eyes and holding a gun. People from the Middle East usually wear such attire. Other hybrid and diaspora picture are Vip-0499, Pocha Nostra-591 and GGP_081026_00052. He is a Mexican, who passed the border to America through a green card and became a citizen of America. In his borderland married some an alien to help them get a green card. After his residence, alien card was dismissed and tried to apply for citizenship (Gomez-Pena 2:58). The borders I have come across are of Mexican, Chinese, French, Indian, and

Fossils in Kenya Essay Example for Free

Fossils in Kenya Essay Kenya lies in a strategic place in Africa. Its capital city is Nairobi with a current total population of 39. 11 million it has an area of 224,960 square miles. Two main discoveries in Kenya have made a great contribution to the evolution tree. These discoveries were made in the year 2000 by an association of international scientists, most of who were from France in collaboration with scientists associated with the National Museums of Kenya (NMK), working under an umbrella project known as the Koobi Fora Research Project lead by Louse Leakey who was at the time of the discoveries affiliated to the National Museums of Kenya and their findings were published in the science journal Nature. These studies preceded the earlier controversial findings by Kenyan researcher Richard Leakey on the exact age hominids found on Koobi Fora Area that lies east of Lake Turkana. The first specimen to be found was unearthed from the grounds of Kapsomon in Tugen hills that are found in the Kenyan district of Baringo in October 25, 2000. The main parts of the human that were excavated included jaws that contained teeth, upper and lower teeth that were also isolated from each other, and both the arm and finger bones. Initial studies on the finger bones seemed to lead to the suggestion that the hominid discovered were trees climbers while similar studies on the leg bones established them to be two legged creatures that walked on the ground. Similar initial studies on teeth showed that the canines were shorter than the apes however; they were longer if compared to the current human canine. This probably indicated that they lived on wild fruits particularly hard-skinned fruits. The leg bones on initial observation seemed to have chewed probably by a large carnivore that used to feed on the individuals who existed then. The researchers thought the carnivore might have been a cat for the simple reasoning that the cat feeds on its catch while on a tree and it’s during this process that the remains fell on the water below. Their research findings were published in 9th august 2007. The studies were done on samples that were found in Turkana which is in the Northern dry Kenya. Scientists who were studying the evolution history in Kenya reported on their findings disputing on early findings that Homo habilis and Homo erectus evolved one after the other being in a straight line to Homo sapiens. In stead their analysis based on two specimens, one being a Homo habilis dated 1. 44 million years, this being the youngest species ever found by scientists who were studying the evolution of human, and a homo erectus dated 1. 55 million years ago, lived concurrently alongside each other for an estimated period of five hundred thousand years. This disqualifies the thought that Homo habilis evolved from home erectus consequently rearranging the initial straight line to Homo sapiens. This indicated that there was an overlap between the Homo habilis and Homo erectus ages and further, it indicated that the fact they the two species managed to live concurrently on the same lake basin then it is right to suggest that they probably had different ecological niches as a result avoiding direct competition that would have led to elimination of one of the species. Stringer Chris one of the scientists involved in the study, who was then studying at the Natural History Museum in London in the field of human origins suggest the possible life styles. In his view the larger and more mobile erectus was possibly a more active hunter while the less active and smaller Homo habilis was a scavenger. This study took several years to prepare the specimen so as to be exactly sure of the identification of the specimen. It took around seven years for the group of scientists lead by Leakey to analyze and announce the results. This interpreted to the view that almost two to three million years ago both Homo habilis and Homo erectus must have originated from a common ancestor. This common ancestor is thought to have lived the age dating almost two to three million years ago, a time that there is no much fossil information. This discovery further indicates that the early general understanding that man evolved from a more ape like being to a more human like being is still poorly researched. However, the discovery does not contrast much from the early thought that homo habilis is the direct ancestor of Homo sapiens. The Homo erectus fossil discovered at Lake Turkana, dated 1. 55 million years ago, was a surprise discovery, according to Dr. Spoor a professor of professor at the University College London concerned with evolutionary anatomy; the skull had a striking feature as compared to early discoveries: it was the smallest. This small size was relatively close in size to Homo habilis than the previously discovered Homo erectus species. This new finding made scientists to consider re-examining early skulls they had already collected from various parts and dozes of partial fossils which together totaled to thirty in number. However, its neck, jaw and teeth and the cranium with a distinctive feature had the characteristics that indicated it was a Homo erectus. In addition, the skull of the individual that was found in Kenya was probably an adult in its young ages or a â€Å"sub-adult† in its late ages the scientists estimated the age to be between 18 and 19. The early discoveries had indicated that the large skull of the Homo erectus was a clear indication that home erectus was the most recent in the ancestry of the human being the only difference being that human beings had a larger brain that the former ancestor: Homo erectus. However, the small skull changed this view suggesting that Homo erectus was less human like than earlier assumed. However, different reporters on the Lake Turkana tend to give different opinions on the small size of the skull of Homo habilis that was found. One such reporter is Susan Anton an anthropologist at the University of New York. In her report she postulates that the small skull is an indication of the varying in skull sizes of erectus specimen with more emphasis on the differences between the male and the female of the erectus species. This difference in the two is what she called sexual dimorphism. She further writes to illustrate that on average the human males are in general almost 15% larger than their female counterparts. This same characteristic applies to chimpanzees and gorillas as well. The theory of sexual dimorphism, lead to other anthropologists to come up with other views for example; Dr. Lieberman of the Harvard university suggested that the initial discoveries of homo erectus must have been male since they were large in size while the specimen that were found at Lake Turkana are likely to be females due to small size. Susan Anton attributes sexual dimorphism to either reproductive strategy or sexual selection. In an example in support of this view she documents that in the silverback the male are far much large than females and one male usually has several females. In contrast in male gibbons are almost similar in size to their female counterparts consequently they mate in pairs. In other words in the a primate family where the male and the female have the same size skull the male tends to be monogamous whereas a family that has different sizes the male tends to be polygamous. Conclusion The discovery of fossils in Kenya and the rest of Africa especially Ethiopia and the subsequent dating procedures have provided a wide array of time frame work which has given a new dimension in answering questions of the origin and evolution of hominids. With improvement in dating techniques it is now easier to estimate, without a lot of doubts, the ages of a given carbon containing specimen as compared to earlier estimates that were in most cases were debated hotly before a consensus would be agreed upon. The improvement in dating techniques can be attributed to the incorporation of 40Ar-39Ar dating technique. With the new discoveries the evolutionary tree seems to scientists to be chaotic rather than being heroic. This is because the old evolution theory where it was thought that origin of man started from homo habilis to home erectus and finally to modern man or homo sapiens seems to be proven wrong and in a more simple manner. The new discoveries have further brushed off the idea that human beings evolved from Neanderthals. It is important to note that as new discoveries are made the evolutionary tree will keep on changing. However, according to Kimbel this should be considered as a basis for getting more convincing evidence, getting questions answered more clearly and formulating more clearer theories. References Asfaw B. , Hart W. K. ,Beyene Y. , Renne P. , Gilbert W. H. , WoldeGabriel G. et al. (2002): Remains of Homo erectus from Bouri, Middle Awash, Ethiopia. Nature, 416:317-20. Balter M. and Gibbons A. (2002): Were Little People the first to venture out of Africa? Science, 297:20-8. Clark J. D. , WoldeGabriel G. , Renne P. , Beyene Y. , Hart W. , Gilbert H. et al. (2003): Stratigraphic and chronological contexts of Pleistocene Homo sapiens from Middle Awash, Ethiopia. Nature, 413:767-82. George M. , Wilson G. , Noble S. , (2004) Fossils Link Pre-human in the West Europe to Earlier Date. London Academic Press New York University (August 13, 2007,). New Kenyan Fossils Challenge Established Views On Early Evolution Of Our Genus Homo. New York Richard Leakey (2002) the origins of human kind: a search of what makes us human. London. Harper-Collins Publishers.

Effects of Living With A Pacemaker

Effects of Living With A Pacemaker Mackenzie Crowe Millions of people live with the help of a pacemaker on a day to day basis. An enormous 600,000 pacemakers are implanted each year and a total of 3 million people worldwide are living with a pacemaker.1 Like most scenarios, health hazards do not really affect someone until a family member or close friend is diagnosed. We usually do not become curious until someone we truly care about requires some sort of help. That’s just what my family member’s heart needed. My family member lived with a pacemaker quite a few years before he passed. Along with his age, he had other health complications that lead to arrhythmias, or irregular heartbeats, and his body became too weak to keep up with the demand of pumping blood to all parts of the body; so they implanted a pacemaker. A pacemaker, also known as an implantable cardioverter defibrillator (ICD), is a miniaturized computer that sends electrical stimulation to the heart whenever it senses that the heart is not beating or is beating too slowly.2 The pacemaker is about the size of two stacked silver dollars and weighs approximately 17-25 grams.2 This device’s main purpose is to help the heart maintain its repetitive rhythm, but it can also store information for a doctor to retrieve which will allow the best possible therapy per individual.2 Newer pacemakers can also treat heart failure by resynchronizing the electrical impulses in the heart’s four chambers- therefore improving the hear t’s ability to pump blood.2 From the time my family member had one implanted to the time that he passed, he had gone through two pacemakers. Like anything else, pacemakers can malfunction. In my family member’s case, his pacemaker just wasn’t working properly and so they just simply implanted a new one. From then on, everything pertaining to his pacemaker went rather smoothly. When I was young my cousins and I always asked him questions as to why he had it, what it did for him, and sometimes he would even open his shirt and let us feel where the pacemaker was in his chest. Although I didn’t live with my grandparents I did spend a lot of time at their house and the fact that my family member had a pacemaker rather bothered me. I wanted to know everything about it. I wanted to know what to do if something were to go wrong. I wanted to know if there could be complications that others needed to be aware of. I wanted to know that having a pacemaker wasn’t going to prohibit him from doing normal daily activities. As I spent more time with him and did some research of my own, I learned a lot more about pacemakers. I learned what it’s like to live with someone who has one compared how an individual’s life can change from getting a pacemaker implanted. This paper aims to help the reader understand exactly what a pacemaker is, and what it does for someone. The reader will also learn about problems associated with having a pacemaker, latest trends and treatments, and trends in nutrition, which will include medication(s). I also hope to see the reader understand how a family can be affected by living with someone who has a pacemaker, and how caring and monitoring a person with a pacemaker can be difficult at times. In a medical aspect, this paper will connect pacemakers and dentistry together. The reader will learn of risks associated to pacemakers in a dental office, dental implications, dental complications, and how to educate a patient of good oral hygiene with the use of pacemaker in place. I have also attempted to identify important questions for the patient and what to do in the instance of an emergency. Due to the vast amount of pacemakers used throughout the United States, researching and learning about pacemakers will help me be prepared for the evaluation of a patient with this medical history. I know that as a dental hygiene student it is my responsibility to be prepared for patients that present items that could interfere with the dental practice and be ready to make modifications as needed. As a health professional it is also my job to put the health of that patient at the forefront of my care plan when preparing for treatment. A pacemaker is not to be confused with the heart’s natural pacemaker. This artificial medical device uses electrical impulses, delivered by electrodes contracting the heart muscles, to regulate the beat of the heart.3 Its primary purpose is to keep the heart beating adequately, either because the natural heart is not fast enough, or there is a block in the electrical conduction system. Some pacemakers are combined with a defibrillator in a single device, while others have multiple electrodes stimulating different positions within the heart to help improve irregularity of the lower chambers of the heart.3 Pacemakers are a necessity for many people. Millions of people wouldn’t be able to participate in day to day activities if not for their pacemaker. Pacemakers give a sense of normality to those who would otherwise be struggling to complete an activity that seems so easy to someone whose heart functions fine without assistance. Some complications with pacemakers during or after implantation (acute) could be bleeding, infection at implantation site, allergic reaction, swelling, or a collapsed lung, all of which are uncommon and can be treated easily and effectively.4 Later complications (chronic) can be generator failure and lead failure, both of which are extremely rare.5 If patients follow a precise routine of physician care appointments, most complication can be detected before becoming serious. Patients should be aware of symptoms such as weakness, being easily fatigued, lightheadedness, dizziness, and loss of consciousness.5 If these symptoms appear after implantation, the patient’s doctor should be notified immediately so that the pacemaker can be checked in correspondence with these symptoms. Patients with pacemakers should try to adhere to a heart healthy diet after the implantation process in order to have a successful and quick recovery. This type of diet includes low fat and low simple sugars and high fiber contents.6 The patient’s diet should also be based on height, weight, current diet pattern, medical history, and level of physical activity. Family members who are in the role of caretaking for post-surgery patients should encourage the patient to try and maintain their current weight or lose weight is the patient is considered overweight by a physician. They should emphasize eating whole foods such as whole cereals, grains, beans, and fresh fruits and vegetables.6 Proteins such as eggs, milk, fish high in omega-3 fatty acids, and poultry should also be included.6 Fatty foods, fried and salty foods, sweets, or bakery items like cookies and cakes, along with carbonated beverages should be avoided.6 The patient should also try to avoid any kind of stress wheth er is it physical or psychological, and they should take further measures to quit smoking.6 If the patient drinks alcoholic beverages, it can be continued but should be done in moderation such as limiting it to one per day or as otherwise discussed with the physician.6 Most pacemakers now allow for patients to get engaged in physical activities which is an important aspect in congruence with a healthy diet. Exercise will not only help maintain body weight, but it will also help improve the patient’s cholesterol.6 Before beginning any physical activity, exercise should be discussed with the patient’s specialist or dietician. Family members are the best advocate to help keep the patient on track and in line with multiple aspects of their diet, stress levels, smoking, and physical activity. As of now, no drugs are used along with a pacemaker because treatment consist of upgrading or reprogramming the pacemaker. Sometimes medications are given to the patient when the implantation process begins so that they patient is able to relax but still be aware of their surroundings.7 They will still be able to hear and talk to the medical team throughout the process. The patient will also receive anesthetic (numbing) medication at the site of the incision.7 Certain patients with atrial flutter/fibrillation or venous problems may be on medications such as Coumadin or patients that have had previous stent replacement may be on Plavix to reduce the chances of blockage.8 These medications are not normally prescribed after implantation but if the patient is already taking them before implantation they are normally switched over to a Heparin IV drip for surgery and then slowly moved back over to their medications afterward.8 Caring for patients with pacemakers can be difficult if the patient does not value their health as much as they should. It can be hard to take care of someone who would rather let the caretaker do all the work. Patients should be motivated to stay healthy. While most know that this is easier said than done, family members should try to emphasize a healthy diet and how it can really make a difference in their daily living. Elderly patients will need more recuperation time and won’t be able to participate in strenuous activity like a middle aged patient. It is imperative that the caregiver try to get the patient to be self-sufficient so that when the time comes for them to take care of themselves, they will know where to take off from what their caregiver was doing for them. The implantation of a pacemaker can affect the patient’s ability to undergo various medical procedures. Dental procedures, X-rays, MRI’s, CAT scans, bone density tests, mammograms, and ultrasounds can all affect pacemakers because of the reactions of the energy waves involved in the tests and the electronic component of the pacemaker.9 If the pacemaker is not programmed to resists these types of interferences, complications can arise. Dental care, like any specialized treatment, is a necessary and routine healthcare issue. Most dental care visits include x-rays, ultrasonic scaling, drilling, and other procedures that might produce high electromagnetic energy. To avoid malfunctions to the pacemaker and possible harm to the patient, it is extremely important to tell the clinician about the pacemaker in advance. The oral cavity is a likely source of bacteria that may elicit infections on pacemaker and ICD devices after systemic transmission.10 According to the American Dental Association, studies show that dental patients with a pacemaker are particularly at risk for developing endocarditis.11 This infection or inflammation of the heart occurs as a result of bacteria that enters the bloodstream from the mouth.11 Under certain conditions, patients with heart problems will be given antibiotic medications before procedures to help prevent bacteria from spreading to the bloodstream.11 This is a proactive approach that protects the patient and the dentist. Certain dental procedures often involve the use of electrical equipment that may come into close proximity to an implanted pacemaker. There is a possibility that exposure to some of this equipment may temporarily affect the function of the pacemaker. Some potential interactions that might take place are: inhibition of pacing: pacing not provided when needed, asynchronous pacing: pacing provided at a fixed rate whether needed or not, and inappropriate shocks: shock therapy provided when not needed.12 Some manufacturers contraindicate product use in patients with pacemakers, but there are also other things that can be done to avoid complications.12 The clinician should seat patients away from power sources or adjust equipment to the lowest possible setting and should also avoid draping cables over the implantation site.12 If the patient begins to feel lightheaded, have increased heart rate, experiences a shock, or hears beeping from their device they should move away from the source of interference or the clinician should power down the device.12 This will allow for the pacemaker to return to normal. According to the Boston Scientific Analysis of Dental Equipment, drills and cleaning equipment, dental x-rays, and apex locators all showed no signs of interference.12 Ultrasonic scalers can cause disturbances but are very unlikely unless notified by the manufacturer.12 To be on the safe side, the majority of dentists would not use an ultrasonic scaler to perform a scale in a patient fitted with a pacemaker or an implantable cardiac defibrillator (ICD).13 Other dental office equipment that may cause interferences are dental chairs with magnetic headrests and electrocautery.12 Both are temporary affects although if patient’s pacemaker is programmed not to respond to magnetic headrests then patients may sit in these chairs.12 Patients considered to be at risk from external interference can have a magnet placed over the pacemaker to switch the pacemaker to fixed-rate mode making it immune to external signals.14 Use of mini magnets in prosthetic dental procedures is safe for patie nts with implanted pacemakers.15 Clinicians should be prepared to make accommodations for patients that have pacemakers. The use of hand instruments will be critical if a patient shows signs of being sensitive to electrical devices. It is the job of the clinician to be able to adapt to that patients’ needs rather than making the patient adapt to the office; this includes helping the patient make changes at home as well. Some patients with pacemakers may need assistance when it comes to good home care. The patient will most likely need accommodations to be made shortly after surgical implantation. It may be hard for the upper chest and dominant hand to move a toothbrush around the oral cavity. Clinicians should be aware of this need and should be ready to make suggestions based on the individual. Some ideas that may be beneficial are having another person brush for the patient for the first few days after the surgery. If the patients then feels better suited to take over they could begin brushing once a day along with a mouth rinse and slowly move up to brushing twice a day and flossing when they feel fit to do so. This may be easier for the patient and at the same time they are still accomplishing good oral health care. Before beginning treatment in a dental office the patient should make sure that their clinician knows of their personal health status with their pacemaker included and that their clinician is prepared if an emergency would arise. It’s best to have a clinician certified in CPR and that is knowledgeable on how to use an automated external defibrillator (AED) if necessary. CPR chest compressions can be done as usual on a patient with an implanted pacemaker.16 Implantable pacemakers are also designed to withstand the shock of an external defibrillator but the pads should not be placed over the device or the pacemaker can sustain damage.16 If the patient has an implanted medical device, an alternative AED pad position is advised, such as the anterior-posterior position.17 It is best to place the pads as far from the source of the pulse as possible and to use the lowest power clinically acceptable to try and deliver a shock that will not damage the device but will restart the patien t’s heart.16 Pacemakers are a vital source of life for many Americans. They enable people to keep living a normal lifestyle. Although there will always be aspects that patients can do to sustain better care for themselves, having a pacemaker is really quite easy. Monitoring the device is important and routine doctor visits are necessary for upkeep and general health. My family member was able to go on living his life as he normally would’ve because he had the help of his pacemaker. Without that, I may not have had as much time with him as I was able to have, and for that I am truly grateful. Modern technology is continually growing and the pacemaker system is developing with it. I hope that this paper gives you a general knowledge about pacemakers, health importance at home and with family members, and their connection to the dental office. Sources Available at: http://circ.ahajournals.org/content/105/18/2136.full. Accessed November 9, 2013. Available at: http://health.sjm.com/arrhythmia-answers/treatment-options/implantable-devices/pacemaker. Accessed October 9, 2013. Available at: http://en.m.wikipedia.org/wiki/Artificial_pacemaker. Accessed March 14, 2014. Available at: http://www.mayoclinic.com/health/pacemaker/MY00276/DSECTION=risks. Accessed October 9, 2013. Available at: http://cdn.intechopen.com/pdfs/13786/InTech-Common_pacemaker_problems_lead_and_pocket_complications.pdf. Accessed March 14, 2014. Pat. A Heart Healthy Diet for Pacemaker Implant Recovery. November 10, 2008. Available at: http://www.diethealthclub.com/blog/diet-tips/a-heart-healthy-diet-for-pacemaker-implant.html. Accessed October 9, 2013. Available at: http://health.sjm.com/arrhythmia-answers/treatment-options/implantable-devices/pacemaker. Accessed October 9, 2013. Available at: http://www.pacemakerclub.com/public/jpage/1/p/story/a/storypage/sid/13421/content.do. Accessed March 25, 2014. Available at: http://www.ehow.com/way_5601960_implanted-pacemaker-dental-precautions.html. Accessed October 9, 2013. Eberhard, J., Stumpp, N., Ismail, F., Schnaidt, U., Heuer, W., Pichlmaier, M., . . . Stiesch, M. (2013). The oral cavity is not a primary source for implantable pacemaker or cardioverter defibrillator infections. Journal of Cardiothoracic Surgery, 8, 73. doi:http://dx.doi.org/10.1186/1749-8090-8-73 Available at: http://www.ehow.com/way_5601960_implanted-pacemaker-dental-precautions.html. Accessed October 9, 2013. Available at: http://www.bostonscientific.com/lifebeat-online/assets/pdfs/resources/ACL/ACL_Dental_Equipment_020209. Accessed October 9, 2013. Thompson, S. A., Davies, J., Allen, M., Hunter, M. L., Oliver, S. J., Bryant, S. T., Uzun, O. (2007). Cardiac risk factors for dental procedures: Knowledge among dental practitioners in wales. British Dental Journal, 203(10), E21; discussion 590-1. doi:http://dx.doi.org/10.1038/bdj.2007.889 Jowett, N., Cabot, L. (2000). Patients with cardiac disease: Considerations for the dental practitioner. British Dental Journal, 189(6), 297-302. doi:http://dx.doi.org/10.1038/sj.bdj.4800750a Schulmeister, L. (1999). Pacemaker interference. Nursing Management, 30(3), 14. Retrieved from http://search.proquest.com/docview/231428997?accountid=14752 Available at: http://www.bostonscientific.com/templatedata/imports/HTML/CRM/A_Closer_Look/pdfs/ACL_CPR_and_External_Defibrillation_063008.pdf. Accessed March 18, 2014. Jevon, P. (2012). Defibrillation in the dental practice. British Dental Journal, 213(5), 233-5. doi:http://dx.doi.org/10.1038/sj.bdj.2012.778

Nursing Discipline Overview and Reflective Account

Nursing Discipline Overview and Reflective Account NURSING DISCIPLINE MENTAL HEALTH BRANCH From the 16th Century mental health patients were contained in asylums until mental health hospitals were introduced during the 1950s. Sometimes people who were a disruptive or were only reacting in a normal way to difficulties in their lives were put away. Often patients were excessively medicated and subject to treatment which would be totally unacceptable today such as muffling or being put in a swing chair. In the 1960s, inadequacy and cost resulted in mental health hospitals closing and care moving to general hospitals. Patients who were allowed home at the weekends recovered more quickly and therefore care increasingly moved to the community (Hannigan and Coffey 2003), where most people with mental health problems are cared for today (NHS 2010). Legislation such as the 1959 and subsequent 1983 Mental Health Act, and the Care Community Act (1990) are relative to modern community mental health nursing. In 1999 the Government confirmed mental health was a top priority in the Health Service (Jackson Hill 2006). Since then guidelines such as the Department of Health guidance (2003), the National Service Framework for Mental Health (1997) and the NHS Plan (2000) (cited in Jackson et al 2006) have been introduced to reform and improve services for people with mental health problems and their carers. The Department of Health have also investing significantly in inpatient mental health settings due to issues such as a not enough beds being available, the lack of privacy and dignity of patients and wards not supporting provision of self care (DOH 2009). As a result many new opportunities have been created for mental health nurses over the last few years, for example the modern matron and nurse consultant, and new skills have been dev eloped, such as nurse prescribing and psychosocial interventions (Brimblecombe 2009). Mental health nurses will work with children and adults who suffer with various mental health problems. The primary role being to form therapeutic relationships with patients (sometimes called clients) and their families to help them recover from their illness and promote independent living (NHS 2010). Mental health nursing is varied and complex, for example treatment may include conventional nursing interventions such as administering drugs and injections or it may be to encourage patients to take part in art, drama or occupational therapy. In order to care for people in a fair and anti-discriminatory way and deliver care holistically, mental health nurses need to have good knowledge of the theories of mental health and illness, psychological and biophysical sciences and personality and human behavior (Hannigan et al 2003). One in four people will suffer with a mental health illness at some point during their life and one in twelve will require medical intervention (Mind 2010). Women are 1.5 times more likely to suffer with anxiety and depression whilst men are more likely to suffer from substance abuse and anti social personality disorders. For some patients a mental illness is triggered by a crisis in their life, which they cant cope with, such as depression following the death of a partner (NHS 2009). Some of the more familiar mental health illnesses are anxiety, depression, schizophrenia, eating disorders, drug and alcohol addition, personality disorders and impulse control such as gambling. Some of these illnesses will require treatment in hospital but many will be treated in primary care settings, such as outpatient clinics, schools, community mental health centres, residential facilities, prisons and day treatment centres (Hannigan et al 2003). Care is person-centered and mental health nurses will work within a professional multi-disciplinary team which will include GPs, psychiatrists and social workers and other health care professionals. A mental health nurse will require good interpersonal and communication skills. They will to demonstrate sensitivity when caring for patients, for example there is still some stigma attached to people with mental health problems and it is important for a nurse to help the individual and their families deal with this (NHS 2010). Dealing with the human mind and behavior is not an exact science and sometimes people with mental health problems can be violent, one skill a nurse will be required to have is to recognise building tension and diffuse it when necessary to maintain the patients and others safety (NHS 2010). Sometimes nurses may find themselves faced with awkward situations, and be required to apply ethical principles, such controversial issues which cannot be disclosed and where confidentiality needs to be maintained (NMC 2008). On the other hand if someone is at risk of serious harm, have an infectious disease or criminal activity is involved they may have to inform the appropriate bodies (Hannigan et al 2003). Nurses may find themselves giving care or treatment which is against their beliefs, for example someone addicted to drugs may request a supply even though medically it is not in their best interest or an anorexic patient might protest when food when the nurse tries to care for them (Hannigan et al 2003) . In practice, mental health nurses will come across difficult situations were an assessment of the capacity and ability of a person to consent will be required. People with mental health disorders have the same rights to consent or refuse treatment as those with physical illnesses unless some mental health issue means they are unable to make a decision. Nurses need to support patients to take responsibility for their own well-being and make informed decisions by providing information which is accessible and understandable (Mind 2010). This may mean working with the clients, advocates and carers to ensure it happens. Although giving certain treatments might be in the clients best interest it not enough to impose treatment without consent. In some circumstances a small number of people with mental health problems will be detained under the Mental Health Act (1983) (Hinchcliff et al 2003). To conclude mental health care has developed considerably over the last few years. Mental health nursing is not an exact science but is varied and complex and is about building therapeutic relationships with people and understanding and reacting appropriately to individual circumstances and needs to promote recovery and maximise life potential. NURSING DISCIPLINE LEARNING DISABILITIES BRANCH People with learning disabilities have been treated as second class citizens for many years, once being seen as possessed by evil spirits or being punished by God for a sin they may have committed. In the 19th century they were removed from their families and lived in purpose built institutions, treated as sick and in need of treatment (Brown Benson 1995). During the 1970s care moved to the community (Brigden Todd 1993) where it largely remains today. Approximately 1.5 million people have a learning disability, the majority of which live at home with their families or in community care settings (Mencap 2009). Relatively few live by themselves or with a partner (Emerson, Davies, Spencer, Malam 2005). Turnbull and Chapman (2010) describe a learning disability as being a lifelong condition, which may be genetic or environmental and vary in degree of impairment. Sowney (2006) suggests all learning disabilities have common features including impaired intelligence and social functioning which has a lasting effect on development. According to Mencap (2009) people with learning disabilities live an average of 50-55 years and sometimes up to 70 years old. A learning disability nurse can therefore expect to nurse a range of patients from birth to the elderly and will need to demonstrate a patient centred approach and work in partnership with the patient to help them meet their health, social, emotional, developmental and behavioral needs ( NHS 2009). Although a learning disability is not an indication of a physical disability or ill health, people with learning disabilities generally have more complicated problems and require more nursing interventions than the general population. In the young person some of the more common problems include respiratory problems, epilepsy, sensory and motor impairments, hypertension, thyroid disease and cancer and in elderly adults common problems include loss of hearing, vision and mobility, heart conditions, diabetes, fractures and osteoporosis (Davis 2008). Generic issues include communication difficulties, conditions relating to specific syndromes, challenging behavior and delayed development (University of Nottingham 2010). A learning disability nurse needs the skills to work within both simple and complex health areas. Communication is a vital skill for the learning disability nurse, hospitalisation for a patient with a learning disability can be very distressing and it is important to build therapeutic relationships based on trust and understanding. In the past access to healthcare services for patients with learning disabilities has sometimes unintentionally been denied. A learning disability nurse can help to overcome these prejudices by ensuring people with learning disabilities are not discriminated against and have the same opportunities as the rest of the population (Brittle 2004). People with learning disabilities are the most vulnerable and socially excluded in our society (DOH 2001). A learning disability nurse works in partnership with both the patient and family carers to provide healthcare, and should recognise each persons uniqueness, individuality and differing abilities. The learning disabilities nurses main aims will be to support the well-being and social inclusion of people with learning disabilities, their rights, choices and independence by improving or maintaining their physical and mental health so they can pursue a fulfilling life whatever their ability (DOH 2009). For example teaching someone the skills needed to find work can help them lead an independent life with equal opportunities (NHS 2009). Many complex issues working with patients with learning disabilities relate to ethical aspects of care, and may be related to an individuals rights and welfare, public welfare or inequality. For example a learning disability nurse may need to assess the capacity and ability of a person to consent to treatment (Hinchcliff, Norman Schober 2003). Every effort should be made to provide information in a format the patient can understand, which might be in the form of pictures, alternative communication methods, using short sentences, repeating explanations and giving them time to make a decision (Brittle 2004). Previous experience may mean a person with a learning disability has not been given the opportunity to make their own choice regarding their individual treatment and care (Turnbull et al 2010) and involving family, friends or an advocate, where possible may help them understand the care and treatment offered to enable them to make their own decision (DOH 2001). In some situations people with learning disabilities may have the capacity to consent to straightforward nursing activities but may lack capacity to consent to more complex procedures (DOH 2001). Other ethical issues may involve the family or carer, for example, a person with learning disabilities may receive some benefits which they may wish to have control over and decide how it is spent. The carer on the other hand may see it as part of the household income and wish to control of it. Or maybe the parents or carers, due to ill health are unable to continue with full time care of a person with learning disabilities in their own home. Nurses will require good negotiation skills to support individuals and carers through dilemmas such whilst working within ethical guidelines, with the person being supported remaining the central focus (Thomas Woods 2003). Other ethical issues might involve psychosocial and lifestyle issues such as overeating or drug abuse which might raise concerns about control and freedom of choice (Davis 2008). Opportunities for learning disabilities nurses exist in both hospital environments and the community. They will specialise in many areas which might include education, sensory disability or the management of services (NHS 2009). They will work within the multi-disciplinary team of their preferred environment, for example a learning difficulty liaison nurse will work with other staff, patients and carers to develop therapeutic relationships and ensure people with learning disabilities have a positive healthcare experience (Brittle 2004). To conclude people with learning disabilities have very similar health issues to that of the general population. However it is important that the learning disabilities nurse exercises a person centered approach, develops a therapeutic relationship and understands a person with learning disabilities personal needs in order to support their wellbeing and promote social inclusion, rights, choices and independence to enable them to enjoy the same health care rights as everyone else. NURSING DISCIPLINE CHILDRENS BRANCH The Childrens branch of nursing is relatively new, in 1959 The Minster of Heath first recommended that children have the right to be nursed by specially trained, qualified staff who understood childrens individual needs but it wasnt until 1988 dedicated training courses were set up to provide nurses with the specific skills and knowledge to nurse children whose physical, physiological and social needs are different to that of adults (Hubbard Trig 2000). Sick childrens rights have only recently been acknowledged despite children making up 25% of the population. But now many reports and policies are aimed at improving childrens services and recent statute law has given children increased rights (Hubbard et al 2000).The Childrens Act (1989 2004) highlights their rights; Every Child Matters endorses working in partnership with other organisations to ensure children are safeguarded and receive the best care available and The National Service Framework (NSF) 2004) outlines a vision to provide a high quality child centred care for both children and their parents (Chambers Licence 2005). These policies give direction today and will shape the future of childrens nursing. Nurses need to understand how they apply and what implications there might be when caring for children. For example, one of the most common reasons for children being admitted to hospital is due to injury from accidents, however if the injuries cannot be explained and phys ical or mental child abuse is suspected, the nurse will have an ethical duty to work with other agencies and professionals such as the Child Protection Services (Hubbard et al 2000). Childrens nurses work with children from birth up to 18 years old in many settings from special baby care units to adolescent services (Chambers et al 2005). In order to provide care in a fair and anti-discriminatory way they need to understand the effect age and development has on a childs health and how the delivery of treatment and care will need to be modified accordingly. This will differ considerably from a newborn baby to an adolescent. For example when assessing medication the weight and development of a child, will need to be taken into consideration as well as which drugs come in a form which can be easily administered. Appropriate care plans will need developing and updating for evaluation and referrals made as necessary for Doctors to review (Robertson South 2006). The age and development of a child will influence ability to cooperate with procedures; a young child may become bored, tired or hungry and their capability to concentrate may be limited and procedures may the refore take more than one attempt (Robertson et al). The DOH (2006) promotes optimal care for young people who have illnesses which previously wound have been fatal in childhood but are now surviving. Childrens nurses work in both hospital and primary care settings such as schools, GPs surgeries and in the community. Childrens nurses specialise in many areas, a few examples are; intensive care, child protection, cancer, diabetes, pediatric emergencies, infections, neonatal problems, burns and plastics, respiratory, cardiac or skin disorders (Robertson et al). Childrens nursing is very much centred on the family (NMC 2008). Nurses should provide a safe, secure and comfortable environment and form good relationships with both the child and their family (Hinchliff, Schober Norman 2003) and support both children and their families to make informed decisions regarding treatment and care options (Chambers et al 2005). Hubbard and Trig (2000) declare the family is central to a childs wellbeing, and whilst respecting and promoting the rights of a child, should also be sensitive to the needs and views of the parents wherever possible during the treatment and care of children. This may sometimes result in conflicting situations and the NMC (2008) imply the importance of understanding the personal, socio-economic and cultural influences surrounding a childs welfare. A nursing model often used to assist the nursing process is the Casey Model of nursing which focuses on working in partnership with both children and their families (Smith 1995). Lansdown, Waterston and Baum (1996) suggest childrens nurses should avoid jargon, use age appropriate language and in a child friendly way give children information they need in order for them to make informed decisions. Hubbard and Trig (2000) agree and suggest that play is used to communicate with a sick child, with the aid of toys, diagrams, picture books, photos and videos applicable to the childs age and cognitive levels to clarify images and gain trust and understanding. For example in order to alleviate fears for a child who has a needle phobia, the injection technique could be demonstrated with the aid of an orange. Consent is an area where conflict may arise; English common law is vague about the age of consent to medical treatment (Alderson 1990). According to Dimond (2005) Children under16 can give valid consent to treatment if they are considered to be Gillick competent. If they refuse to give consent, parents may give consent against the childs wishes, if the benefits outweigh the risks, for example a child who is suffering with cancer, refuses chemotherapy (Chambers et al 2005). Generally consent for young children is given by the family, but parents might have difficulty giving consent for someone other than themselves. In line with the Childrens 1989 Act, childrens nurses should ensure children are not cohersed into giving or refusing consent and their views should be taken account of where possible following the Fraser guidelines in respect of consent and confidentiality (Dimond 2005). Under the family reform Act of 1969 children over the age of 16 can give or refuse consent, unless the y lack capacity, for example in emergency situations (Dimond 2005). Reducing costs for the government is key and one of their main priorities is to increase primary care for children in their own homes and reduce hospital admissions. In addition it is believed that care in the home is better for both children and their families, primary care was first recommended in the Platt Report (1958) (Hubbard et al 2000). Increasingly children are being cared at home by their parents supported by the community childrens nurse (NMC 2008) whose role is to provide guidance, care and to teach parents the skills necessary to provide care for their child, for instance administration nutritional requirements via a nasogastric tube (Hubbard et al). NURSING DISCIPLINE ADULT BRANCH Prior to the influences of Florence Nightingale, hospitals were often unclean and contaminated by infection and nurses were seen as the ones to do the Doctors dirty work. Nursing schools were set up in the 1880s, although it wasnt until the 1950s that the nursing profession was governed by the regulation body, UKCC. Today nurses are accountable to the NMC (2008) and must work within the code of conduct, demonstrating that they are able to deliver, manage and develop an excellent standard of evidence based nursing care (Abel-Smith 1960)(NMC 2008). Adult nurses primarily nurse sick and injured adults back to health and have a prominent role in the provision of health care, whilst working closely with other professionals, patients and their families (NHS 2010). Traditionally nursing was task oriented and patient care focused on specific illnesses and conditions. Today nursing is much more patient centred. An adult nurse will provide holistic care to number of patients 18 years and above at any one time to meet their physical, psychological, social and spiritual needs, using the nursing process which will include assessing, planning, implementing and evaluating the care delivered (NMC 2008). Adult nurses care for adult patients with a wide range of acute and long term illnesses and are involved in many different health arenas such as health promotion and disease prevention or they may specialise in specific diseases or disorders, such as diabetes, respiratory problems or cancer care. Others may specialise in accident and emergency, practice nursing or care of the elderly (NHS 2010). Although purposely trained to nurse adults, adult nurses will almost certainly be required to care and treat other groups of patients such as children, people with learning difficulties and patients with mental health issues, for example if they present in an accident and emergency unit, or are admitted to a ward with diabetes issues (Hinchcliff, Norman Schober 2003). Adult nurses will work within a multi professional team to deliver care to patients, which will include other health professionals such as doctors, pharmacists, healthcare assistants, physiotherapists, occupational therapists and radiographers (NHS 2010). Adult nurses work in a range of settings which can be hospital based or in the community where more and more health care is being delivered such as GP surgeries, clinics, occupational health services, schools, nursing and residential homes and voluntary organisations such as hospices. The government is driving health care towards a primary health care led service within which nurses roles are expanding and developing (DOH 2010). Opportunities are also available in the armed forces, prisons, and leisure, eg cruise ships (NHS 2010). Adult nurses all cover the same programme even though their work destinations differ considerably and it has been suggested that it is time to consider a new branch of nursing that equips people to work in primary care (Smith M 2003). Adult nurses will need to demonstrate many skills such as problem solving, flexibility, caring, counselling, managing, teaching and interpersonal skills to maintain and improve the quality of patients lives, sometimes in difficult situations (NHS 2010). They may find themselves caring for patients who are the same age as their family, friends or themselves and it is important not to get too personally involved with patients or they may find themselves in discussions regarding ethical issues such as euthanasia where clearly legally it is unlawful but the patient may feel it is in their best interest (Hinchcliff et al 2003). To assist the nursing process, nursing models are used such as the Roper, Logan and Tierneys (2000) 12 activities of daily living, often used in acute settings and the Orems model (1985) which promotes self care, particularly useful in rehabilitation setting. An adult nurse must comply with legislation and obtain consent before any treatment can be given, this may be verbal for routine nursing procedures, or written for more complex ones. Nurses must allow the patient to have autonomy when making decisions regarding care and treatment, respect that decision and always act in the patients best interest (Dimond 2005). The governments agenda and The Human Rights Act (1998) have had significant impact on how adult nursing has evolved to meet peoples needs in an ever changing environment. New jobs are being created to extend the nurses role and get them involved in advanced procedures such as the modern matron, consultant nurses, nurse practitioners and chief nursing officers. The DOH strategy for nursing recommends consultant posts, for example care of older people and pain management taking nursing to another level (cited by Sines, Appleby Frost 2005). According to the NMC (2007) nurses now carry out roles previously carried out by Doctors, for example theatre nurses now perform surgery and community care nurses co-ordinate packages. Changes in the way care is delivered has taken place in accordance with the government directive which laid down a plan to make primary health care accessible to people in the community, at work and at and home (Hinchcliff et al 2003). New opportunities are being created to meet the needs of older people. Older people are living longer and are the largest group of people using health services (Hinchcliff et al 2003). Common health issues for elderly patients are strokes, falls and mental health problems. The NHS Plan (2000a)(cited by Sines et al 2005) promotes independence and encourages them to have support in their home environment rather than residential homes. The government also recognises the need to increase and improve services for young adolescence patients to address their individual needs. For example as child moves into adulthood they may take risks, take part in anti-social behaviour, or they might be vulnerable and frightened (Hinchcliff et al 2003). Nurses have a role to play providing care, treatment and information to help them stay safe and healthy. To conclude adult nurses work with a wide range of patients with many different health issues across numerous health arenas. Nursing has developed considerably since it was first regulated and as patient care is a key government priority todays adult nurses need to have the necessary skills to deliver appropriate care and treatment in an ever changing environment whi Reflective Account The Role of a Rehabilitation Nurse Introduction This reflective account will discuss the role of a rehabilitation nurse in a community hospital. I am going to use the Gibbs (1988) Reflective Cycle which encompasses 6 stages; description, thoughts and feelings, evaluation, analysis, conclusion and action plan which will improve my knowledge of nursing practice and develop my self confidence in relation to caring for others (Siviter 2008). To comply with the NMC Code (2008) and maintain confidentiality all names have been changed. Description On my second week of my placement, I met my associate mentor for the first time. She asked if she could look at my placement documentation and personal development plan. We then discussed the skills and knowledge I want to achieve during the placement which is on a community rehabilitation ward. After our discussion, my mentor suggested to that I spend some time reflecting on the role of a community hospital rehabilitation nurse. Thoughts and Feelings Although my associate mentor did not require a formal piece of reflection, I thought it would be good to document my reflection for my personal development. When she asked me if I would reflect on the roles of nurse in a community hospital, I had already been thinking how different is was from that of a nurse in an acute hospital during my first week so I welcomed the challenge, although I had some reservations about what I could say on a positive note about community nursing. From what I had seen during my first week I was skeptical about the skills of nursing in a community hospital as the pace seemed much slower with less opportunity to practice clinical skills than in my previous acute placement. I was feeling quite disappointed and whilst I appreciate personal health care is an important nursing skill, the majority of my first week I had been left to work with nursing assistants and not invited by my mentor to be watch or carry out any clinical skills, who as a sister spends les s time than staff nurses on hands on nursing and more time on office tasks. This really worried me as I dont want to just cruise through my nursing training, I want to take every opportunity to broaden my knowledge and skills in all aspects of nursing. However I was now feeling more positive as my first impression of my associate mentor was that she was extremely knowledgeable, committed and caring and I hoped I would find her inspirational as I got to know her. Evaluation Being left for a whole week working without any real mentorship was demorilising for me and having no support or guidance the first week resulted in me having a negative view of the rehabilitation ward and community nursing in general (Taylor 2008). However, meeting with my associate mentor for the first time was a good experience. She was interested in me and committed to developing my knowledge and skills and by the end of our conversation had a good understanding of what I wanted to achieve from the placement and was able to challenge my knowledge on the current placement. Taylor (2008) states an inspirational mentor is a necessity to assist student nurses with their learning and development needs and nurture them to become first-class nurses. Understanding the skills and knowledge required by a community hospital rehabilitation nurse will build on my current knowledge which has been in the acute sector and be good for my personal development and future nursing career. Analysis Rehabilitation is an important aspect of any nurses role, but more prevalent for nurses working with the elderly in community hospitals (Brooks 2010). It is the nurses role to promote independence and to empower patients to carry out the activities of daily living adopting new skills and knowledge where necessary. Many different models of nursing are used for rehabilitation purposes, two popular ones are the Roper, Logan and Tierneys (2000) 12 activities of daily living and the Orems (1985) model of self care. Sinclair and Dickinson 1998 define rehabilitation as: A process aiming to restore personal autonomy in those aspects of daily living considered most relevant by patients or service users and their family carers. Many patients find themselves on a rehabilitation ward as a result of a traumatic incident or disease and rehabilitation nurses will work with the patient, family and other member of the multi disciplinary team to support and encourage patients to maximise their independence with physical functioning (White and Johnstone 2000). They are very often the coordinators of a patients care as they are the ones in contact with patients 24 hours a day. Nursing interventions will include supporting and reinforcing the care devised by other health care professionals such as occupational therapists and physiotherapists (Low 2003). They will need to have underpinning knowledge about adjusting to life changes and understanding of anatomy and physiology, health promotion and illness prevention (Chilvers 2002). To provide holistic care for the patient, nurses will be required to apply their knowledge and skills through the nursing process. The first stage of this process is assessment to identify a patients impairments and disability in order to develop care plans. Identifying emotional effects is as important as physical disabilities, as these are likely to have an effect on patients rehabilitation progress (Vohora and Ogi, 2008). These may include anxiety, grief, depression, frustration, and anger (Stroke Association, 2008). Many of the care plans aims will be to increase a patients independence so that they can resume responsib Nursing Discipline Overview and Reflective Account Nursing Discipline Overview and Reflective Account NURSING DISCIPLINE MENTAL HEALTH BRANCH From the 16th Century mental health patients were contained in asylums until mental health hospitals were introduced during the 1950s. Sometimes people who were a disruptive or were only reacting in a normal way to difficulties in their lives were put away. Often patients were excessively medicated and subject to treatment which would be totally unacceptable today such as muffling or being put in a swing chair. In the 1960s, inadequacy and cost resulted in mental health hospitals closing and care moving to general hospitals. Patients who were allowed home at the weekends recovered more quickly and therefore care increasingly moved to the community (Hannigan and Coffey 2003), where most people with mental health problems are cared for today (NHS 2010). Legislation such as the 1959 and subsequent 1983 Mental Health Act, and the Care Community Act (1990) are relative to modern community mental health nursing. In 1999 the Government confirmed mental health was a top priority in the Health Service (Jackson Hill 2006). Since then guidelines such as the Department of Health guidance (2003), the National Service Framework for Mental Health (1997) and the NHS Plan (2000) (cited in Jackson et al 2006) have been introduced to reform and improve services for people with mental health problems and their carers. The Department of Health have also investing significantly in inpatient mental health settings due to issues such as a not enough beds being available, the lack of privacy and dignity of patients and wards not supporting provision of self care (DOH 2009). As a result many new opportunities have been created for mental health nurses over the last few years, for example the modern matron and nurse consultant, and new skills have been dev eloped, such as nurse prescribing and psychosocial interventions (Brimblecombe 2009). Mental health nurses will work with children and adults who suffer with various mental health problems. The primary role being to form therapeutic relationships with patients (sometimes called clients) and their families to help them recover from their illness and promote independent living (NHS 2010). Mental health nursing is varied and complex, for example treatment may include conventional nursing interventions such as administering drugs and injections or it may be to encourage patients to take part in art, drama or occupational therapy. In order to care for people in a fair and anti-discriminatory way and deliver care holistically, mental health nurses need to have good knowledge of the theories of mental health and illness, psychological and biophysical sciences and personality and human behavior (Hannigan et al 2003). One in four people will suffer with a mental health illness at some point during their life and one in twelve will require medical intervention (Mind 2010). Women are 1.5 times more likely to suffer with anxiety and depression whilst men are more likely to suffer from substance abuse and anti social personality disorders. For some patients a mental illness is triggered by a crisis in their life, which they cant cope with, such as depression following the death of a partner (NHS 2009). Some of the more familiar mental health illnesses are anxiety, depression, schizophrenia, eating disorders, drug and alcohol addition, personality disorders and impulse control such as gambling. Some of these illnesses will require treatment in hospital but many will be treated in primary care settings, such as outpatient clinics, schools, community mental health centres, residential facilities, prisons and day treatment centres (Hannigan et al 2003). Care is person-centered and mental health nurses will work within a professional multi-disciplinary team which will include GPs, psychiatrists and social workers and other health care professionals. A mental health nurse will require good interpersonal and communication skills. They will to demonstrate sensitivity when caring for patients, for example there is still some stigma attached to people with mental health problems and it is important for a nurse to help the individual and their families deal with this (NHS 2010). Dealing with the human mind and behavior is not an exact science and sometimes people with mental health problems can be violent, one skill a nurse will be required to have is to recognise building tension and diffuse it when necessary to maintain the patients and others safety (NHS 2010). Sometimes nurses may find themselves faced with awkward situations, and be required to apply ethical principles, such controversial issues which cannot be disclosed and where confidentiality needs to be maintained (NMC 2008). On the other hand if someone is at risk of serious harm, have an infectious disease or criminal activity is involved they may have to inform the appropriate bodies (Hannigan et al 2003). Nurses may find themselves giving care or treatment which is against their beliefs, for example someone addicted to drugs may request a supply even though medically it is not in their best interest or an anorexic patient might protest when food when the nurse tries to care for them (Hannigan et al 2003) . In practice, mental health nurses will come across difficult situations were an assessment of the capacity and ability of a person to consent will be required. People with mental health disorders have the same rights to consent or refuse treatment as those with physical illnesses unless some mental health issue means they are unable to make a decision. Nurses need to support patients to take responsibility for their own well-being and make informed decisions by providing information which is accessible and understandable (Mind 2010). This may mean working with the clients, advocates and carers to ensure it happens. Although giving certain treatments might be in the clients best interest it not enough to impose treatment without consent. In some circumstances a small number of people with mental health problems will be detained under the Mental Health Act (1983) (Hinchcliff et al 2003). To conclude mental health care has developed considerably over the last few years. Mental health nursing is not an exact science but is varied and complex and is about building therapeutic relationships with people and understanding and reacting appropriately to individual circumstances and needs to promote recovery and maximise life potential. NURSING DISCIPLINE LEARNING DISABILITIES BRANCH People with learning disabilities have been treated as second class citizens for many years, once being seen as possessed by evil spirits or being punished by God for a sin they may have committed. In the 19th century they were removed from their families and lived in purpose built institutions, treated as sick and in need of treatment (Brown Benson 1995). During the 1970s care moved to the community (Brigden Todd 1993) where it largely remains today. Approximately 1.5 million people have a learning disability, the majority of which live at home with their families or in community care settings (Mencap 2009). Relatively few live by themselves or with a partner (Emerson, Davies, Spencer, Malam 2005). Turnbull and Chapman (2010) describe a learning disability as being a lifelong condition, which may be genetic or environmental and vary in degree of impairment. Sowney (2006) suggests all learning disabilities have common features including impaired intelligence and social functioning which has a lasting effect on development. According to Mencap (2009) people with learning disabilities live an average of 50-55 years and sometimes up to 70 years old. A learning disability nurse can therefore expect to nurse a range of patients from birth to the elderly and will need to demonstrate a patient centred approach and work in partnership with the patient to help them meet their health, social, emotional, developmental and behavioral needs ( NHS 2009). Although a learning disability is not an indication of a physical disability or ill health, people with learning disabilities generally have more complicated problems and require more nursing interventions than the general population. In the young person some of the more common problems include respiratory problems, epilepsy, sensory and motor impairments, hypertension, thyroid disease and cancer and in elderly adults common problems include loss of hearing, vision and mobility, heart conditions, diabetes, fractures and osteoporosis (Davis 2008). Generic issues include communication difficulties, conditions relating to specific syndromes, challenging behavior and delayed development (University of Nottingham 2010). A learning disability nurse needs the skills to work within both simple and complex health areas. Communication is a vital skill for the learning disability nurse, hospitalisation for a patient with a learning disability can be very distressing and it is important to build therapeutic relationships based on trust and understanding. In the past access to healthcare services for patients with learning disabilities has sometimes unintentionally been denied. A learning disability nurse can help to overcome these prejudices by ensuring people with learning disabilities are not discriminated against and have the same opportunities as the rest of the population (Brittle 2004). People with learning disabilities are the most vulnerable and socially excluded in our society (DOH 2001). A learning disability nurse works in partnership with both the patient and family carers to provide healthcare, and should recognise each persons uniqueness, individuality and differing abilities. The learning disabilities nurses main aims will be to support the well-being and social inclusion of people with learning disabilities, their rights, choices and independence by improving or maintaining their physical and mental health so they can pursue a fulfilling life whatever their ability (DOH 2009). For example teaching someone the skills needed to find work can help them lead an independent life with equal opportunities (NHS 2009). Many complex issues working with patients with learning disabilities relate to ethical aspects of care, and may be related to an individuals rights and welfare, public welfare or inequality. For example a learning disability nurse may need to assess the capacity and ability of a person to consent to treatment (Hinchcliff, Norman Schober 2003). Every effort should be made to provide information in a format the patient can understand, which might be in the form of pictures, alternative communication methods, using short sentences, repeating explanations and giving them time to make a decision (Brittle 2004). Previous experience may mean a person with a learning disability has not been given the opportunity to make their own choice regarding their individual treatment and care (Turnbull et al 2010) and involving family, friends or an advocate, where possible may help them understand the care and treatment offered to enable them to make their own decision (DOH 2001). In some situations people with learning disabilities may have the capacity to consent to straightforward nursing activities but may lack capacity to consent to more complex procedures (DOH 2001). Other ethical issues may involve the family or carer, for example, a person with learning disabilities may receive some benefits which they may wish to have control over and decide how it is spent. The carer on the other hand may see it as part of the household income and wish to control of it. Or maybe the parents or carers, due to ill health are unable to continue with full time care of a person with learning disabilities in their own home. Nurses will require good negotiation skills to support individuals and carers through dilemmas such whilst working within ethical guidelines, with the person being supported remaining the central focus (Thomas Woods 2003). Other ethical issues might involve psychosocial and lifestyle issues such as overeating or drug abuse which might raise concerns about control and freedom of choice (Davis 2008). Opportunities for learning disabilities nurses exist in both hospital environments and the community. They will specialise in many areas which might include education, sensory disability or the management of services (NHS 2009). They will work within the multi-disciplinary team of their preferred environment, for example a learning difficulty liaison nurse will work with other staff, patients and carers to develop therapeutic relationships and ensure people with learning disabilities have a positive healthcare experience (Brittle 2004). To conclude people with learning disabilities have very similar health issues to that of the general population. However it is important that the learning disabilities nurse exercises a person centered approach, develops a therapeutic relationship and understands a person with learning disabilities personal needs in order to support their wellbeing and promote social inclusion, rights, choices and independence to enable them to enjoy the same health care rights as everyone else. NURSING DISCIPLINE CHILDRENS BRANCH The Childrens branch of nursing is relatively new, in 1959 The Minster of Heath first recommended that children have the right to be nursed by specially trained, qualified staff who understood childrens individual needs but it wasnt until 1988 dedicated training courses were set up to provide nurses with the specific skills and knowledge to nurse children whose physical, physiological and social needs are different to that of adults (Hubbard Trig 2000). Sick childrens rights have only recently been acknowledged despite children making up 25% of the population. But now many reports and policies are aimed at improving childrens services and recent statute law has given children increased rights (Hubbard et al 2000).The Childrens Act (1989 2004) highlights their rights; Every Child Matters endorses working in partnership with other organisations to ensure children are safeguarded and receive the best care available and The National Service Framework (NSF) 2004) outlines a vision to provide a high quality child centred care for both children and their parents (Chambers Licence 2005). These policies give direction today and will shape the future of childrens nursing. Nurses need to understand how they apply and what implications there might be when caring for children. For example, one of the most common reasons for children being admitted to hospital is due to injury from accidents, however if the injuries cannot be explained and phys ical or mental child abuse is suspected, the nurse will have an ethical duty to work with other agencies and professionals such as the Child Protection Services (Hubbard et al 2000). Childrens nurses work with children from birth up to 18 years old in many settings from special baby care units to adolescent services (Chambers et al 2005). In order to provide care in a fair and anti-discriminatory way they need to understand the effect age and development has on a childs health and how the delivery of treatment and care will need to be modified accordingly. This will differ considerably from a newborn baby to an adolescent. For example when assessing medication the weight and development of a child, will need to be taken into consideration as well as which drugs come in a form which can be easily administered. Appropriate care plans will need developing and updating for evaluation and referrals made as necessary for Doctors to review (Robertson South 2006). The age and development of a child will influence ability to cooperate with procedures; a young child may become bored, tired or hungry and their capability to concentrate may be limited and procedures may the refore take more than one attempt (Robertson et al). The DOH (2006) promotes optimal care for young people who have illnesses which previously wound have been fatal in childhood but are now surviving. Childrens nurses work in both hospital and primary care settings such as schools, GPs surgeries and in the community. Childrens nurses specialise in many areas, a few examples are; intensive care, child protection, cancer, diabetes, pediatric emergencies, infections, neonatal problems, burns and plastics, respiratory, cardiac or skin disorders (Robertson et al). Childrens nursing is very much centred on the family (NMC 2008). Nurses should provide a safe, secure and comfortable environment and form good relationships with both the child and their family (Hinchliff, Schober Norman 2003) and support both children and their families to make informed decisions regarding treatment and care options (Chambers et al 2005). Hubbard and Trig (2000) declare the family is central to a childs wellbeing, and whilst respecting and promoting the rights of a child, should also be sensitive to the needs and views of the parents wherever possible during the treatment and care of children. This may sometimes result in conflicting situations and the NMC (2008) imply the importance of understanding the personal, socio-economic and cultural influences surrounding a childs welfare. A nursing model often used to assist the nursing process is the Casey Model of nursing which focuses on working in partnership with both children and their families (Smith 1995). Lansdown, Waterston and Baum (1996) suggest childrens nurses should avoid jargon, use age appropriate language and in a child friendly way give children information they need in order for them to make informed decisions. Hubbard and Trig (2000) agree and suggest that play is used to communicate with a sick child, with the aid of toys, diagrams, picture books, photos and videos applicable to the childs age and cognitive levels to clarify images and gain trust and understanding. For example in order to alleviate fears for a child who has a needle phobia, the injection technique could be demonstrated with the aid of an orange. Consent is an area where conflict may arise; English common law is vague about the age of consent to medical treatment (Alderson 1990). According to Dimond (2005) Children under16 can give valid consent to treatment if they are considered to be Gillick competent. If they refuse to give consent, parents may give consent against the childs wishes, if the benefits outweigh the risks, for example a child who is suffering with cancer, refuses chemotherapy (Chambers et al 2005). Generally consent for young children is given by the family, but parents might have difficulty giving consent for someone other than themselves. In line with the Childrens 1989 Act, childrens nurses should ensure children are not cohersed into giving or refusing consent and their views should be taken account of where possible following the Fraser guidelines in respect of consent and confidentiality (Dimond 2005). Under the family reform Act of 1969 children over the age of 16 can give or refuse consent, unless the y lack capacity, for example in emergency situations (Dimond 2005). Reducing costs for the government is key and one of their main priorities is to increase primary care for children in their own homes and reduce hospital admissions. In addition it is believed that care in the home is better for both children and their families, primary care was first recommended in the Platt Report (1958) (Hubbard et al 2000). Increasingly children are being cared at home by their parents supported by the community childrens nurse (NMC 2008) whose role is to provide guidance, care and to teach parents the skills necessary to provide care for their child, for instance administration nutritional requirements via a nasogastric tube (Hubbard et al). NURSING DISCIPLINE ADULT BRANCH Prior to the influences of Florence Nightingale, hospitals were often unclean and contaminated by infection and nurses were seen as the ones to do the Doctors dirty work. Nursing schools were set up in the 1880s, although it wasnt until the 1950s that the nursing profession was governed by the regulation body, UKCC. Today nurses are accountable to the NMC (2008) and must work within the code of conduct, demonstrating that they are able to deliver, manage and develop an excellent standard of evidence based nursing care (Abel-Smith 1960)(NMC 2008). Adult nurses primarily nurse sick and injured adults back to health and have a prominent role in the provision of health care, whilst working closely with other professionals, patients and their families (NHS 2010). Traditionally nursing was task oriented and patient care focused on specific illnesses and conditions. Today nursing is much more patient centred. An adult nurse will provide holistic care to number of patients 18 years and above at any one time to meet their physical, psychological, social and spiritual needs, using the nursing process which will include assessing, planning, implementing and evaluating the care delivered (NMC 2008). Adult nurses care for adult patients with a wide range of acute and long term illnesses and are involved in many different health arenas such as health promotion and disease prevention or they may specialise in specific diseases or disorders, such as diabetes, respiratory problems or cancer care. Others may specialise in accident and emergency, practice nursing or care of the elderly (NHS 2010). Although purposely trained to nurse adults, adult nurses will almost certainly be required to care and treat other groups of patients such as children, people with learning difficulties and patients with mental health issues, for example if they present in an accident and emergency unit, or are admitted to a ward with diabetes issues (Hinchcliff, Norman Schober 2003). Adult nurses will work within a multi professional team to deliver care to patients, which will include other health professionals such as doctors, pharmacists, healthcare assistants, physiotherapists, occupational therapists and radiographers (NHS 2010). Adult nurses work in a range of settings which can be hospital based or in the community where more and more health care is being delivered such as GP surgeries, clinics, occupational health services, schools, nursing and residential homes and voluntary organisations such as hospices. The government is driving health care towards a primary health care led service within which nurses roles are expanding and developing (DOH 2010). Opportunities are also available in the armed forces, prisons, and leisure, eg cruise ships (NHS 2010). Adult nurses all cover the same programme even though their work destinations differ considerably and it has been suggested that it is time to consider a new branch of nursing that equips people to work in primary care (Smith M 2003). Adult nurses will need to demonstrate many skills such as problem solving, flexibility, caring, counselling, managing, teaching and interpersonal skills to maintain and improve the quality of patients lives, sometimes in difficult situations (NHS 2010). They may find themselves caring for patients who are the same age as their family, friends or themselves and it is important not to get too personally involved with patients or they may find themselves in discussions regarding ethical issues such as euthanasia where clearly legally it is unlawful but the patient may feel it is in their best interest (Hinchcliff et al 2003). To assist the nursing process, nursing models are used such as the Roper, Logan and Tierneys (2000) 12 activities of daily living, often used in acute settings and the Orems model (1985) which promotes self care, particularly useful in rehabilitation setting. An adult nurse must comply with legislation and obtain consent before any treatment can be given, this may be verbal for routine nursing procedures, or written for more complex ones. Nurses must allow the patient to have autonomy when making decisions regarding care and treatment, respect that decision and always act in the patients best interest (Dimond 2005). The governments agenda and The Human Rights Act (1998) have had significant impact on how adult nursing has evolved to meet peoples needs in an ever changing environment. New jobs are being created to extend the nurses role and get them involved in advanced procedures such as the modern matron, consultant nurses, nurse practitioners and chief nursing officers. The DOH strategy for nursing recommends consultant posts, for example care of older people and pain management taking nursing to another level (cited by Sines, Appleby Frost 2005). According to the NMC (2007) nurses now carry out roles previously carried out by Doctors, for example theatre nurses now perform surgery and community care nurses co-ordinate packages. Changes in the way care is delivered has taken place in accordance with the government directive which laid down a plan to make primary health care accessible to people in the community, at work and at and home (Hinchcliff et al 2003). New opportunities are being created to meet the needs of older people. Older people are living longer and are the largest group of people using health services (Hinchcliff et al 2003). Common health issues for elderly patients are strokes, falls and mental health problems. The NHS Plan (2000a)(cited by Sines et al 2005) promotes independence and encourages them to have support in their home environment rather than residential homes. The government also recognises the need to increase and improve services for young adolescence patients to address their individual needs. For example as child moves into adulthood they may take risks, take part in anti-social behaviour, or they might be vulnerable and frightened (Hinchcliff et al 2003). Nurses have a role to play providing care, treatment and information to help them stay safe and healthy. To conclude adult nurses work with a wide range of patients with many different health issues across numerous health arenas. Nursing has developed considerably since it was first regulated and as patient care is a key government priority todays adult nurses need to have the necessary skills to deliver appropriate care and treatment in an ever changing environment whi Reflective Account The Role of a Rehabilitation Nurse Introduction This reflective account will discuss the role of a rehabilitation nurse in a community hospital. I am going to use the Gibbs (1988) Reflective Cycle which encompasses 6 stages; description, thoughts and feelings, evaluation, analysis, conclusion and action plan which will improve my knowledge of nursing practice and develop my self confidence in relation to caring for others (Siviter 2008). To comply with the NMC Code (2008) and maintain confidentiality all names have been changed. Description On my second week of my placement, I met my associate mentor for the first time. She asked if she could look at my placement documentation and personal development plan. We then discussed the skills and knowledge I want to achieve during the placement which is on a community rehabilitation ward. After our discussion, my mentor suggested to that I spend some time reflecting on the role of a community hospital rehabilitation nurse. Thoughts and Feelings Although my associate mentor did not require a formal piece of reflection, I thought it would be good to document my reflection for my personal development. When she asked me if I would reflect on the roles of nurse in a community hospital, I had already been thinking how different is was from that of a nurse in an acute hospital during my first week so I welcomed the challenge, although I had some reservations about what I could say on a positive note about community nursing. From what I had seen during my first week I was skeptical about the skills of nursing in a community hospital as the pace seemed much slower with less opportunity to practice clinical skills than in my previous acute placement. I was feeling quite disappointed and whilst I appreciate personal health care is an important nursing skill, the majority of my first week I had been left to work with nursing assistants and not invited by my mentor to be watch or carry out any clinical skills, who as a sister spends les s time than staff nurses on hands on nursing and more time on office tasks. This really worried me as I dont want to just cruise through my nursing training, I want to take every opportunity to broaden my knowledge and skills in all aspects of nursing. However I was now feeling more positive as my first impression of my associate mentor was that she was extremely knowledgeable, committed and caring and I hoped I would find her inspirational as I got to know her. Evaluation Being left for a whole week working without any real mentorship was demorilising for me and having no support or guidance the first week resulted in me having a negative view of the rehabilitation ward and community nursing in general (Taylor 2008). However, meeting with my associate mentor for the first time was a good experience. She was interested in me and committed to developing my knowledge and skills and by the end of our conversation had a good understanding of what I wanted to achieve from the placement and was able to challenge my knowledge on the current placement. Taylor (2008) states an inspirational mentor is a necessity to assist student nurses with their learning and development needs and nurture them to become first-class nurses. Understanding the skills and knowledge required by a community hospital rehabilitation nurse will build on my current knowledge which has been in the acute sector and be good for my personal development and future nursing career. Analysis Rehabilitation is an important aspect of any nurses role, but more prevalent for nurses working with the elderly in community hospitals (Brooks 2010). It is the nurses role to promote independence and to empower patients to carry out the activities of daily living adopting new skills and knowledge where necessary. Many different models of nursing are used for rehabilitation purposes, two popular ones are the Roper, Logan and Tierneys (2000) 12 activities of daily living and the Orems (1985) model of self care. Sinclair and Dickinson 1998 define rehabilitation as: A process aiming to restore personal autonomy in those aspects of daily living considered most relevant by patients or service users and their family carers. Many patients find themselves on a rehabilitation ward as a result of a traumatic incident or disease and rehabilitation nurses will work with the patient, family and other member of the multi disciplinary team to support and encourage patients to maximise their independence with physical functioning (White and Johnstone 2000). They are very often the coordinators of a patients care as they are the ones in contact with patients 24 hours a day. Nursing interventions will include supporting and reinforcing the care devised by other health care professionals such as occupational therapists and physiotherapists (Low 2003). They will need to have underpinning knowledge about adjusting to life changes and understanding of anatomy and physiology, health promotion and illness prevention (Chilvers 2002). To provide holistic care for the patient, nurses will be required to apply their knowledge and skills through the nursing process. The first stage of this process is assessment to identify a patients impairments and disability in order to develop care plans. Identifying emotional effects is as important as physical disabilities, as these are likely to have an effect on patients rehabilitation progress (Vohora and Ogi, 2008). These may include anxiety, grief, depression, frustration, and anger (Stroke Association, 2008). Many of the care plans aims will be to increase a patients independence so that they can resume responsib