Assessment and Planning of Discharge Needs in Geriatrics Essay Example for Free

Assessment and Planning of Discharge Needs in Geriatrics Essay Elderly patients have unique discharge planning needs. As such, the hospital nurse and case management team may find themselves challenged to not only identify the needs of each patient, but to also address those needs when planning the patient’s discharge. In the case of Mr. Trosack, a 72-year-old widower being discharged following a total hip replacement (THR), careful assessment of his home situation needs to be completed prior to discharge to ensure his safety and continued recovery once home. Healthcare Issues  After reviewing the patient’s chart and performing interviews with the patient and his family, the case manager identifies three healthcare issues that need to be addressed on discharge.  ·The patient admits he has not seen a doctor in over 10 years prior to this hospitalization.  ·The patient has been diagnosed with two new health issues: hypertension and diabetes.  ·He has been prescribed new medications for each new diagnosis that he will need to continue taking after discharge.  ·The patient cannot identify pills he currently takes at home, stating simply that they are â€Å"vitamins† for â€Å"energy. Importance of Healthcare Issues Each of these issues needs to be addressed to ensure Mr. Trosack’s safety and continued recovery after discharge: The patient has not seen a doctor in over 10 years prior to this hospitalization. It is important for the case worker to find out why the patient has not seen any doctors, as it may be detrimental to his well-being. For example, did he have a bad experience with a previous provider and refuses to go back? Or, has he just not felt ill? Is his reasoning ability still sound? Or, is there some confusion? Is he in denial or facing fear that has kept him from seeing someone? If the patient is able to make sound decisions and simply has no concerns, he may do well at home. However, it may also be that he is unaware he should be seeing a physician, as â€Å"elderly patients may not report symptoms that they consider part of normal aging† (Besdine, 2009, para. 9). And, if he has had a bad experience in the past with a physician, it may have lead to a mistrust of the entire profession. If he has been refusing to see a doctor despite some concerns over the years, it could foreshadow similar situations in the future. He may not call when new problems or questions arise about is new medications. And, as evidenced by the cabinet of unused medications in the bathroom, he has a history of poor compliance, which could further impact his health. By discussing the reasons behind his lack of preventative care, the case manager will better understand the patient’s mindset and any concerns he may have. If a previous provider’s treatment or behavior has caused a mistrust of the profession, the case manager can recommend or introduce the patient to other providers, especially those that specialize in caring for geriatrics, as these providers have specialized training in caring for the elderly. If cost is a factor, the case manager can refer the patient to applicable programs such as food stamp programs, insurance and Medicare supplement policies, state-based programs, drug company assistance programs and more. If transportation is an issue, the case manager can refer to area agencies or senior citizen centers to utilize low-cost or volunteer-driven services that assist in transporting seniors. The patient has been newly diagnosed with hypertension and diabetes. New medical diagnoses can be scary for any individual, but with elderly patients, it can often bring about a new level of uncertainty and anxiety. Like all patients, they have questions about the new diagnosis and prescribed medications. However, the elderly patients of today grew up in a time when medical problems were not openly discussed. And now, society often looks at senior citizens as â€Å"lesser† citizens—a source for humor and pity in the media, weaker, less productive and expected to retire as they age (Day, 2011). Because of the way in which they were raised and the beliefs of society today, elderly patients may not feel comfortable asking questions. Knowing this, the nurse will look for additional clues from the patient’s interview as to how Mr. Trosack is feeling about his new diagnoses. During his interview with the case manager, the patient seems reluctant to accept his new diagnoses. Stating he doesn’t need any â€Å"darn† medications and doesn’t like being â€Å"disabled,† the patient also shows frustration. When a patient expresses this level of frustration and denial, there is an increased risk for lack of compliance. The need for education is greatly increased in this elderly patient. Because he has no outward symptoms of his new diagnoses, the patient does not feel he needs the new medications. The nurse needs to help the patient understand that his medications need to be continued to help prevent future symptoms from occurring. In addition, the nurse needs to be aware of additional challenges the patient may incur. Since elderly patients have often lost several members of their family (parents, siblings, even children in some cases), they are very much aware of their own mortality. A new diagnosis can bring a new awareness of that mortality, sometimes leading to a depression. When planning other discharge needs, the case manager needs to include these factors into her plan. Home health nurses can assist by visiting the patient at home during the week to ensure proper medication administration as well as assessing the patient for signs of depression and worsening hypertension, diabetes or depression. The patient has two new medications to continue upon discharge and cannot identify pills he currently takes at home. With the patient’s new diagnoses, he has been prescribed new medications. He has already voiced opposition to the idea of continuing these new medications because he does not feel he needs them. Because he does not feel they are needed, he is likely to have poor compliance in taking the medications. The patient would benefit greatly from education about why the medications have been prescribed and thatwith appropriate compliancehe will be more likely to remain free of symptoms. The patient being unable to state which pills he does take on a daily basis is cause for concern. Without the name of the pills, there is no way to verify its overall safety. Furthermore, the nurse and case manager cannot be sure there are no contraindications to taking the newly prescribed medications with the pre-admission supplements. The patient’s inability to recall the name of the pills also reiterates the concerns above regarding the new medications he has been prescribed. The case manager needs to work with the patient’s nurse to ensure the patient understands the importance of maintaining a current medication list, including over-the-counter â€Å"vitamins† for â€Å"energy,† to avoid future problems when being seen for other medical concerns. The Interdisciplinary Team For the patient’s discharge to be a success, the case manager needs to incorporate appropriate members of the healthcare team to make a discharge plan. In the case of Mr. Trosack, this interdisciplinary team needs to include the patient’s nurse, physical and occupational therapy staff, a dietician, a pharmacist, and staff from the local home health agency or public health district. Each member of the team will bring to the discharge plan a unique vision for the patient’s recovery. The nurse is familiar with the patient’s medical history, as well as his feelings regarding his new diagnoses and medications. S/He has learned how best to communicate with the patient and worked to educate the patient on his new health problems and medications. In creating a discharge plan, the nurse will share this information with the home health nurse, include the medication and treatment regimens that are to be continued, and identify goals for the patient related to each. The physical therapist will instruct the team on the patient’s abilities and limitations in relation to the patient’s ambulation and transfers. He may visit the patient’s home to complete an evaluation of additional needs. And, he will create an exercise regimen for the patient to continue once home and make recommendations for assistive devices that the patient may be able to use. The occupational therapist will also identify assistive devices and continued therapy needs, however, these recommendations will be in relation to the patient’s activities of daily living (ADLs) rather than ambulation. She will watch the patient get completely dressed to identify any special needs and assess risk (can the patient tie his shoes or will the laces be a fall hazard? ). She will assess the patient’s ability to shower or bathe, looking for shortcomings or safety concerns. She may also visit the home to complete a home safety evaluation, watch the patient has he carries out his ADLs, and make recommendations for ways to alter his methods to ensure safety. The dietician will make nutritional recommendations based on the patient’s needs for adequate healing. In doing so, she will take into consideration his abilities and limitations identified by the physical and occupational therapists. The dietician may suggest menus for the patient to follow. And, her knowledge of nutrition will allow for suggestions on easy-to-carry foods, snacks or supplements that require no refrigeration and can be stored outside the kitchen, making it easier for the patient to obtain. The pharmacist will provide the other members of the team with information related to his medication regimen. He will alert the other team members to possible side effects, adverse reactions and interactions that may occur. This information will be helpful to the other members of the team as they make their own recommendations for needs after discharge. The dietician will nclude foods that have less chance of interacting with medications and the therapy staff will be alerted to side effects that may impact the patient’s safety. Because the patient will be homebound, he will likely be referred to home health. The staff from the home health agency or public health district will take the information from all of the team members in making their own plans for assignment and recommendations after discharge. They will perform safety evaluations of their own to identify risks for patient and staff alike. They will assign staff to the patient based on the recommendations from the nurse and therapists. They may sign the patient up for meals-on-wheels, or a similar program, based on the recommendations of the dietician and assessments of the patient’s ability to cook and clean up as needed. They will reiterate the teaching provided by the nurse and therapists while visiting the patient and look for side effects or adverse reactions while working with the patient. In short, they will develop a complete plan of care to incorporate all of the feedback from the interdisciplinary team. Safety Assessment There are several areas of concern in regards to safety at the patient’s residence. First, the patient requires a walker and lives on the second floor in a building with no elevator. This presents a safety issue, as well as a potential psychosocial problem. Not only will the patient be unable to safely enter his apartment without assistance; but, he will also not be able to safely leave. The patient, should he reach his apartment after discharge, would be isolated from friends and family and completely homebound. He would not be able to assist in the bakery located downstairs; instead, becoming dependant on his brother to maintain the business. Additionally, the family members interviewed by the case manager share concerns about the patient’s safety once inside his apartment, due to the small and cluttered environment. They worry that the apartment is too cluttered with memorabilia from World War II for him to safely ambulate with a walker. Per the safety assessment, there are also several rugs throughout the space. Each rug represents a trip hazard and should be removed from the environment prior to the patient’s discharge home. Additionally, there are no safety devices in the bathroom. While these devices can be installed, the patient is at risk until the installation is complete. And, until the devices are installed, the patient cannot be assessed by the occupational therapist to ensure safe use. With the safety issues present in his current apartment, it is unlikely the patient will continue to improve in this environment. Not only is he at a high risk for fall and injury in this apartment, but his mobility will also be greatly limited by the crowded environment, reducing his physical activity. Such limitation would reduce the patient’s physical improvement, which is vital in recovery from a total hip replacement. Discharge Planning Needs Per the family interview, there is a lack of support available to the patient. For any patient to recovery successfully after discharge from the inpatient setting, they must have adequate support from friends and family. Elderly patients are especially reliant on adequate support, as they are more likely to experience a functional decline from baseline in the two weeks following a hospital discharge (Naylor et al. , 1994). Mr. Trosack has a brother and a married middle-aged son. Mr. Trosack co-owns the bakery with his brother, who is now running the bakery on his own. His son is somewhat estranged due to a difference in religious beliefs, has a young family of his own, and works nearly 60 hours a week, as does his wife. None of the people closest to Mr. Trosack can make him a priority in their lives. During the family interview, the case manager learns that they were planning on taking turns assisting the patient in his home. However, their busy lifestyles leave little time for that and they do not want to bring in outside assistance. Further, the family does not seem to understand the importance of regular medication administration in addition to denying the two new medical conditions exist since the patient has shown no outward symptoms of being sick. Their answer to cleaning up the apartment is throwing away some of the patient’s most treasured items. Rather than asking for suggestions in making the apartment safer, the family would prefer to have Mr. Trosack dispose of his memorabilia from World War II. This, combined with the social isolation brought on by being homebound and unable to participate in his long-time business, would worsen his chances of developing depression. Should the patient develop depression, his recovery would be further impacted by lack of compliance with medications (Carney, Freedland, Eisen, Rich, Jaffe, 1995). Further, depression can lead to elderly patients becoming confused or forgetful, eating less, poor hygiene, and becoming further isolated from friends and family (A. D. A. M. Medical Encyclopedia, n. d. ), all of which would further delay a complete recovery. Social Isolation Psychological Factors With the patient’s physical limitations, if he were to discharge to his apartment, he would be isolated from the outside world. Because he still relies on a walker, he would be unable to climb or descend the stairs and unable to participate in his own bakery business. He would also rely on visitors for his groceries, trash removal as well as any social interaction. Despite the fact that family members are physically close to his apartment, the relationships are strained and their schedules do not allow for him to become a priority in their lives. When patients are socially isolated, they tend to do poorly. Not only do socially isolated people tend to become anxious and depressed, but they are also more likely to develop high blood pressure. Additionally, isolation has been significantly correlated both with an extended wound-healing time (Cacioppo Hawkley, 2003). Despite the length of time the patient has been in the hospital setting, he is still recovering and his body is still healing. The patient needs to be in an environment that promotes healing. Furthermore, isolation has also been shown to cause impaired vision and hearing, which could increase the likelihood of fall and injury in the patient’s cluttered apartment (Frintner, 2008) In addition to the health-related dangers of social isolation, there are emotional reactions to isolation that one should consider when planning Mr.  Trosack’s discharge. Isolation and loneliness not only affect the body’s immune and cardiovascular systems, but it can also lead to sleep disturbances and depression (Marano, 2003). Depression makes social interactions difficult and sometimes even stressful, causing the depressed person to withdraw from family and friends even more. And, with the patient being unable to fulfill his duties at his family-owned business, the likelihood of dev eloping depression increases, due to a reduced sense of purpose (Smith, Robinson, Segal, 2011). The patient’s risk for isolation upon discharge home indicates that the patient may do better in another setting. Recommendation Upon review of Mr. Trosack’s chart, interviews with the patient and family and the safety assessment performed, it is the recommendation of this writer that the patient not be discharged home. This recommendation would be different if the patient lived on a first-floor apartment or had access to an elevator. However, given the safety and isolation issues present in his home, the patient would be better served in an assisted living facility. Because the patient does not need skilled nursing care, and can perform his most of his ADLs, the patient does not require nursing home placement. An assisted living facility would allow the patient to have some independence in regards to his individual space and performing his ADLs while ensuring the patient a safe environment. An assisted living facility allows for monitoring of the patient overall wellness and general health and can coordinate medication administration and monitor compliance (Maryland State Bar Association, 1998). The services provided by the assisted living facility would help to ensure that the patient stays safe by keeping a watchful eye on the patient—routine safety checks are performed and fall risks are identified and corrected as needed. The facility can also monitor his overall health through the routine safety checks as well as monitor his medication compliance, ensuring the patient takes his medications as scheduled. Furthermore, several facilities offer social activities, which would increase the patient’s likelihood of continued physical activity and reduce the risk of depression and decline after discharge.

New Ternary Fe-Ni-Cu Invar Alloys Preparation

New Ternary Fe-Ni-Cu Invar Alloys Preparation Preparation and Characterization of New Ternary Fe-Ni-Cu Invar alloys S Ahmada, A B Ziya[1], a, A Ibrahimb, S Atiqb, N Ahmada and F Bashirc Abstract. Six alloys of Fe65Ni35-xCux(x= 0, 0.2, 0.6, 1, 1.4, 1.8 at.%) have been prepared by conventional arc-melting technique and characterized by utilizing in-situ X-ray diffraction (XRD) technique and differential scanning calorimetry (DSC) at a range from room temperature to 773 K for determination of phase. The studies show that these alloys form face centered cubic (FCC) throughout the investigated temperature range. The X-ray integrated intensities of various reflections were used to determine the coefficient of thermal expansion ÃŽ ±(T), mean square amplitude of vibrations and characteristic Debye temperature ÃŽËœD. The ternary substitution of copper has a minor effect on the lattice parameter but the Debye temperature ÃŽËœD is found to decrease with the increase of copper content in the alloy. The coefficients of thermal expansion ÃŽ ±(T) were found to be comparable to those for conventional Fe-Ni invar alloys. Keywords:  Invar alloys; lattice parameters; thermal expansion; X-ray diffraction Introduction Iron rich invar alloys have been of keen interest for researchers and developers, for their own reasons and interests, since their discovery in 1898 Guillaume and Hebd (1987) because of their unique set of properties labeled as invar anomaly or invar effect. A number of theories and models have been postulated to explain these deviations in the behavior of these alloys from other materials but still there are many queries unresolved Sanyal and Bose (2000); Iwase et al (2003); Matsushima et al (2006); Goria et al (2010); Yichun et al (2009); Tabakovic et al (2010); Pepperhoff et al (2001); Duffaut et al (1990); Matsushita et al (2008). One of the most important property of these alloys that made them most sought for material for applications in especially the electrical/ electronic precision instruments is their very low coefficient of thermal expansion around room temperature as compared to other metals and alloys. But, these materials also have their limitations and to overcome them , the researchers have either made ternary additions to the basic alloy or have turned their focus onto other combinations of elements termed as invar type Ono et al (2007); Matsushita et al (2004); Gorria et al (2006); Zhichao et al (2002); Rongjin et al (2010); Kaji et al (2004); Matsushita et al (2009); Matsushita et al (2007). For example, in some electrical/electronic applications another important property required in candidate material is good electrical conductivity. Iron based invar alloys cannot be grouped as good electrical conductors. Consequently, to develop invar alloys that exhibit inherent low coefficient of expansion and comparatively better electrical conductivity, ternary additions of elements like copper have been studied Stolk et al (1999); Bernhard et al. (1987). Not to mention such addition is expected to decrease the manufacturing cost. Many research groups have undertaken the study of effect of addition of copper onto invar properties of binary iron nickel a lloys but lacked correlation between the copper addition to change or no change in invar properties. This study has been carried out to correlate the invar effect to ternary addition of copper to base iron nickel invar alloy by replacing nickel with copper and to determine thermal properties of the newly developed alloys for comparison with same properties of binary invar alloys. Experimental methods For this study, one binary Fe65Ni35 (subscript indicates atomic percent of the element) and five ternary Fe65Ni35-xCux where x was selected to be equal to 0.2, 0.6, 1, 1.4 and 1.8 were prepared. High purity elements (>99.9%) were weighed and combined on water cooled hearth of a vacuum arc melter. The process was carried in 600 mbar argon atmosphere created after evacuating the chamber to 10-5 mbar pressure. The alloys were melted several times to ensure thorough mixing of the ingredients. To ensure homogeneity, the samples were then heated under vacuum in a Nebertherm furnace at 1273 K approximately for one hundred and seventy hours. Homogenized samples were then weighed as well as chemically analyzed and found to be well within the selected range of set composition. Each sample was then cold rolled to about 0.2 mm thickness and then heated at 1273 K for four hours to remove rolling stresses. Samples of suitable dimensions were then cut from each strip for characterization through X-ray diffraction (XRD) and differential scanning calorimetry (DSC). XRD was carried out in a Bruker D8 Advance diffractometer equipped with MRI high temperature chamber fitted with PtRh heater element. Operating conditions for the X-ray tube were set at 40 kV and 40 mA. The diffraction patterns were recorded in the step scan mode in the 2ÃŽ ¸-range from 20 to 120o with a step of 0.01o. The in-situ high temperature X-ray diffraction of all samples was carried out in 10-6 mbar vacuum with Ni-filtered CuK radiation from room temperature to 473 K with a step of 20 K and thereon with a step of 50 K till 773 K. DSC of all samples was carried out on SBT-Q600 differential scanning calorimeter from room temperature to 1473 K at a heating rate of 20 K/minute under argon atmosphere. 3. Results and discussion 3.1. Structure and lattice parameters DSC scans of the six selected invar alloys were measured (not shown here). No sharp exothermal or endothermal peak was observed in the investigated temperature range, it is thus assumed that the samples were single phase. Room temperature XRD patterns of binary classical invar alloy of Fe65Ni35 and ternary alloys of Fe65Ni35-xCux (x=0.2, 0.6, 1, 1.4 and 1.8) are shown in Figure 1. It can be seen that all alloys are single phase and possess face centered cubic (FCC) lattice structure in confirmation to already published data on similar alloy systems Ono et al. (2007). The lattice parameters of the samples under study were determined by the extrapolation of lattice parameters for all reflections against Nelson-Riley function to minimize the random errors Ziya et al (2006). The values of calculated lattice parameters are given in Table 1. It can be seen that copper addition to the binary composition causes marginal decrease in the lattice parameter as expected because the copper with sm aller atomic radii replaced nickel atoms in the structure of relatively larger radius. 3.2 Thermal parameters To investigate invar effect in the newly developed alloys, it was planned to measure / calculate three major thermal properties / parameters vis-à  -vis temperature; namely, coefficient of thermal expansion, Debye temperature and mean square amplitude of vibration. The results obtained for each of them are discussed in succeeding sub sections. 3.2.1 Thermal expansion To investigate invar effect in these newly developed alloys, high temperature XRD technique was employed. A common observation from the scans of all the samples was that these samples are single phase alloys and no phase change occurred in any of the alloy up to scan temperature (773 K). This observation is consistent with the results of DSC measurements. One of the major parameter relating to invar effect is coefficient of thermal expansion which is primarily a reflection of change in lattice parameter with temperature. Temperature dependence of lattice parameter was calculated for each sample from the high temperature XRD data collected during this study. Scan at smaller step, 20 K up to 473 K and then larger step of 50 K to the maximum temperature, 773 K was set based upon the results published in literature for similar type of invar alloys. For calculation purpose data pertaining to (311) peak of binary alloy, (220) peak of Fe65Ni34.8Cu0.2 and (400) peak for all other composition was used. Selection of these peaks was solely made due to their better temperature dependence over the entire temperature range. It can be seen that in all the samples the lattice parameter almost remains unchanged up to about 473 K and there onward, the lattice parameter increases negligibly to a maximum of about 0.004 Aà Ã‚ ¦ at the maximum test tempe rature. However, the effect of increase in temperature on increase in lattice parameter in binary alloy is gradual and almost linear whereas, in ternary alloys, the increase in lattice parameter up to 473 K is insignificant but beyond this temperature it is visible and becomes steep with increase in copper content. Coefficient of thermal expansion ÃŽ ±(T) was then calculated by least square fitting the calculated lattice parameter data to second degree polynomial: ÃŽ ±(T) = A + BT + CT2 Where constant A represents lattice parameter of alloy at absolute zero, while B is the linear term coefficient and C represents the nonlinear term. The calculated values of ÃŽ ±(T) and these constants are tabulated in Table 2 whereas ÃŽ ±(T) versus temperature is plotted in figure 2. It was found that no appreciable change occurs in the thermal coefficient (ÃŽ ±) with temperature which is in line with the conclusion from the lattice parameter calculations. Further, the values of thermal coefficient ÃŽ ±(T) calculated in this study match very well to the values reported earlier for Fe-Cu alloys by other researchers such as (Goria et al. 2004 ). He (Goria et al. 2004) has reported ÃŽ ± (T) for said alloys in the range of 3Ãâ€"10-6K-1 at a temperature of 350 K whereas in the present study same value of ÃŽ ±(T) has been found up to the temperature of 450 K. Based upon above presented results and their analysis it can be concluded that these ternary alloys possess invar characteristics up to test temperature range. 3.2.2  The Debye temperatures and the mean square amplitudes of vibration Debye temperature is usually determined from the slope of ln(Iobs/Ical) versus temperature curves which is then subsequently used to find mean square amplitude of vibrations. Detailed procedure is already presented elsewhere [30]. Accordingly, the ratio of the observed and calculated intensities for each composition over the investigated temperature range was determined for selected Bragg reflections after stripping KÃŽ ±2-components from peak intensity. The peaks selected were (200) for binary, 0.2 at.% Cu and 1.4 at.% Cu containing alloys, (220) for 0.6 at.% Cu and (400) for 1 at.% and 1.8 at.% Cu containing alloys. Again the reflection lines were selected based on their relatively better dependence on temperature and integrated intensities were then determined from selected data by employing a line profile fit software. The results are presented in figure 3. It may be noted that for alloy containing 1.8 at.% Cu, the intensity data below 350 K has not been included because of exces sive scatter. Apart from this exception, for all other compositions and temperatures the points lie well along the fitted line. Debye temperature(ÃŽËœD) was then determined and plotted for all samples over the test temperature range in figure 4. First of all, these values have been found to be in close concurrence to those reported in literature (Gorria et al. 2009). In addition, from the comparison of these curves with each other two major facts can be deduced; firstly, the value of ÃŽËœD decreases as the amount of copper in the alloy increases, secondly up to the temperature of 473 K, ÃŽËœD for each composition remains almost unaffected by the increase in temperature. However, beyond this temperature and up to the maximum increased temperature, the value of ÃŽËœD decreases. These observations are in line with earlier findings that in these alloys invar effect is present up to 473 K because increase in length due to anharmonicity is compensated with magnetostricion. Furthermore, de crease in ÃŽËœD value both with increase in Cu contents as well as increase in test temperature indicates softening of the material. Mean square amplitude of vibrations ( was then calculated from the ÃŽËœD values as explained in reference (Ziya and Ohshima 2006). The result is tabulated in Table 3. Again the results indicate that there is very slight variation in with increase in temperature for every alloy composition. 4.  Conclusions Effect of copper addition in different percentages to binary iron nickel invar alloy has been investigated through in-situ XRD over a temperature range of 298 to 773 K. Thermal properties, i.e. the coefficient of thermal expansion, Debye temperature and mean square amplitude of vibrations of each of the ternary alloy has been determined and compared to the binary invar alloy prepared for this study as well as with the results published by other researchers for similar alloys. The results indicate that the newly developed ternary alloys exhibit Invar effect up to added copper contents although the temperature range is marginally decreased with the increase in copper contents. References Bernhard H, Volker B, and Jurgen H 1987 J. Mag and Mag. Mat 70 423 Duffaut F and Tiers J-F 1990, Industerial application of Invar, J. Written(Ed), The Invar Effects, TMS, Palo Alto, CA, P. 238 Guillaume Ch. E and Hebd C R 1987 Seances Acad. Sci. 125 235 Goria P , Martinez-Blanco D, Jesus A B, Ronald I S 2010 J. Alloys and Compounds 495 495 Gorria P, Martinez-Blanco D, Iglesias R, Palacios S L, Perez M J, Blanco J A, Barquin F, Hernanddo A, Gonzalez M A 2006 J. Mag and Mag. Mat 300 229 Gorria P , Martinez-Blanco D, Blanco J A, Hernando A, Garitaonandia J S, Barquin L F ,Campo J and Ronald I S 2004 Phys Rev B 69 214421 Gorria P, Martinez-Blanco D, Blanco J A, Maria J P, Hernando A, Maria A L, Daniel H, Souza-Neto N, Ronald I S, Marshall W G, Garbarino G, Mezouar M, Fernandez-Martinez A, Chaboy J, Barquin L F, Rodriguez Castrillon J A, Moldovan M, Garcia A J, Zhang J, Liobet A and Jiang J S 2009 Phys Rev B 80 06442 Iwase A, Hamatani Y, Mukomoto Y, Ishikawa N, Chimi Y, Kambara T, C.Muller C, R. Neumann, Ono F 2003 Nuclear Instruments and Methods in Physics Research B 209 323 Kaji S, Chiyoda S, Saito R, Oomi G, Yoshimura M, Tokunaga A and Kagayama T 2004 J. Mag and Mag. Mat 272-276 792 Liu Y, Lei L, Jiake L, Shen B, Wenbin Hu 2009 J. Alloys and Compounds 478 750 Lu Z, Dern L, and Junyi L 2002 J. Mag and Mag. Mat 239 502 Matsushima Y, Sun N Q, Kanamitsu H, Matsushita M , Iwase A, Chimi Y, Ishikawa N, Kambara T and Ono F 2006 J. of Mag and Mag. Mat 298 14 Matsushita M, Inoue T, Yoshimi I, Kawamura T, Kono Y, Irifun T, Kikgaw T, Ono F 2008 Phy Rev B 77 064429 Matsushita M, Endo S, Miura K, and Ono F 2004 J. Mag and Mag. Mat 269 393 Matsushita M, Ogiyama H and Ono F 2009 J of Mag and Mag. Mat 321 595 Matsushita M, Endo S and Ono F 2007 J of Mag and Mag. Mat 310 1861 Ono F, Matsushima Y, Chimi Y, Ishikawa N, Kambara T, Iwase A 2007 J. Mag and Mag. Mat 310 1864 Ono F, Chimi Y, Ishikawa N, Kanamitsu H, Matsushita Y, Iwase A, and Kambara T 2007 Nuclear Instruments and Methods in Physics Research B 257 402 Pepperhoff W and Acet M 2001 Constitution and Magnetism of Iron and its Alloys, Springer, Berlin p. 106 Rongjin, Huang, Zhixiong W , Xinxin C, Huihui Y, Zhen C and Laifeng L 2010 Solid stat sci 12 1977 Sanyal S and Bose S K 2000 Phy. Rev. B 62 12730 Stolk J and Manthiram A 1999 Mat. Sci and Eng. B 60 112 Tabakovic I, Inturi V, Thurn J and Kief M 2010 electchem. Acta. 55 6749 Ziya A B and Ohshima K 2006 J. alloys and compound 425 123 [1] To whom all correspondence should be addressed; Email: [emailprotected] Tel. No.: +92-61-9239942; Fax: +92-61-9210068

Clinical Reasoning And Decision Making In Nursing Nursing Essay

Clinical Reasoning And Decision Making In Nursing Nursing Essay All nurses use clinical judgement to make decisions while caring for patients. These decisions have an effect on the actions of the healthcare professional and the delivery of health care the patient receives Jones and Beck (1996). Its the nurses responsibility to make clinical decisions based on their learnt knowledge and skills. Simple decisions such as, would a bed pan or commode be more appropriate? To making quick, on the spot decisions, such as what steps to take if a patient began to rapidly deteriorate. Nurses rely on sound decision making skills to maintain positive outcomes and up to date care. Orme and Maggs (1993) identified that decision-making is an essential and integral aspect of clinical practice. Nurses are accountable for their decisions, therefore it is crucial that they are aware of how they make these decisions Muir (2004). This essay will discuss two decision making models, factors that may improve or interfere with clinical reasoning and decision making in pat ient centred care and how they vary across the different fields of nursing. The decision making models that will be discussed are Risk Analysis and Evidence Based. Risk assessment plays a major part in the process of supporting patients and it greatly helps to maintain safety in hospital settings. Its main purpose is not only to identify potential risks but also remove and prevent them. Assessment is considered to be the first step in the process of individualised nursing care Neno and Price (2008). Risk analysis provides information that is vital in developing a plan of action that can help improve personal health. It has the potential to decrease the severity of chronic conditions, helping the individual to gain control over their health through self-care RCN (2004). Not only is risk analysis for the patients safety but its also there to ensure staff safety Kavaler and Spiegel (2003). It is imperative that nurses use suitable risk assessment tools as a guide to enable them to make effective decisions. Once the tool has been implemented, using the gathered information and using their own clinical judgement, the nurse will then be able to provi de the right safety precautions for patients Holme (2009). There are many different types of risk assessment tools available for patients and staff within the clinical setting. For patients there is the Waterlow score risk of pressure sores and ulcers, the MUST tool Malnutrition Universal Screening Tool, FRAT Falls Risk Assessment Tool and Pain Assessment Tools are only to name a few and they are commonly used in clinical practice. Staff have Infection Control Assessments and Discharge Risk Assessments only to name a couple but they should be kept up to date and reassessed regularly Daniels (2004). The pressure ulcer risk assessment/prevention policy tool, is frequently used in clinical practice. Pressure risk-assessment tools have been described as the backbone of any prevention and treatment policy Waterlow(1991). The Department of Health set annual targets for an overall reduction of pressure ulcers by 5-10% over 1 year (DoH, 1993), so it is vital that nurses accurately determine which patients are at risk of developing pressure ulcers. A pressure ulcer is an area of localised damage to the skin and underlying tissue caused by pressure, shear, friction or a combination of these EPUAP (1998). The intention of the Waterlow pressure sore risk assessment is to recognise service users who are highly at risk of developing pressure sores, to avoid them becoming worse and/or even developing them at all, to serve as an early predictive index before the development of pressure damage Nixon and McGough ( 2001). It is imperative that patients are assessed using this tool, especially patients with Intrinsic risk factors such as restricted mobility and /or are confined to their bed for long periods of time, patients with poor nutrition, elderly patients, patients with underlying health conditions such as diabetes and patients who are urinary incontinent and bowel incontinent are also highly at risk of developing pressure sores, this due to the moisture, moist skin can be weak and susceptible to breakdown Andrychuk (1998). Accordi ng to the NICE clinical guideline 29 (2005) pressure ulcer grades should be recorded using the European Pressure Ulcer Advisory Panel Classification System. There are four stages that pressure ulcers are graded at and it is down to the nurses own clinical judgement to decide what stage the ulcer is. Depending on the grade of the pressure sore, it will depend on the type of mattress that will be needed. There are factors to be considered before selecting a mattress for the patient which include, making sure the mattress does not elevate the patient to an unsafe height and to ensure the patient is within the recommended weight range for the mattress NICE (2005). Using their learnt skills, experiences and own clinical knowledge, nurses have to decide what dressings should be used in the treatment of pressure ulcers. They have to take into consideration the grade of the sore, any manufacturers indications for use and contraindications, previous positive effects of certain dressing and preference for comfort or lifestyle reasons Bouza et al (2005). Specially designed dressings and bandages can be used to speed up the healing process and help protect pressure sores such as hydrocolloid and alginate dressings which will be used at the nurses digression NHS Choices (2010). Nurses should always be aware of any potential risk factors that may worsen or add to the development of pressure ulcers when using any pressure risk assessment tool. The nurse will have to decide the frequency of re-positioning the patient, implementing a turning chart to keep times and dates documented and to communicate to other members of staff what time the patient needs turning. This involves moving the patient into a different position to remove or redistribute pressure from a part of the body Walsh and Dempsey (2010). By analysing the evidence on the effectiveness of repositioning this can help to reduce patient suffering and improve their quality of life, lighten the work load of staff and help reduce the financial burden on the health service Luoa and Chub (2010). In paediatric nursing, a child is to be assessed within six hours of being admitted and then reassessed daily. Most paediatric pressure ulcer risk assessment scales were developed using clinical experience, or by modifying adult scales Bedi (1993). The Glamorgan Paediatric Pressure Ulcer Risk Assessment Scale was developed using detailed paediatric inpatient data Willock et al (2008). It is a clinical tool designed to help nurses assess the risk of a child developing a pressure ulcer, it uses a scoring system that takes things like mobility, equipment, haemoglobin levels and temperature into account and guides the nurse as to what interventions need to be put in place, such as what type of mattress or dressings will be needed. In learning disability and mental health nursing, a range of pressure sore assessment tools are used such as the Norton, Braden and Waterlow risk assessment scales, these are mainly used for patients who are not very mobile as in the adult field. Nursing is more concentrated on their patients psychological health OTuathail and Taqi (2011). It is the nurses duty to provide the best possible care for their patients and this involves using Evidence-based practice. EBP enables the nurse to make decisions about patient care based on the most current, best available evidence. It allows the nurse to provide high quality care to patients based on knowledge and research Rodgers (1994). Principles of evidence-based practice and the crucial elements involved in the process are explained by Cleary-Holdforth and Leufer (2008) in five steps. Steps are there to equip nurses with the necessary knowledge and skills to use evidence-based practice effectively and to make positive contributions to patient outcomes. The five steps Ask, Aquire, Appraise, Apply, Analysis and Ajust are to simply guide healthcare professionals in making effective clinical decisions when problem solving. Early Warning Score (EWS) is an evidence based method. Carberry (2002) identifies that the purpose of EWS is to provide nursing and medical staff with a physiological score generated from recordings of vital signs. NICE Clinical Guideline 50 (2007) suggests that physiological track and trigger systems should be implemented to monitor all adult patients in acute hospital settings, providing guidance on the standardization of EWS. Physiological signs that should be monitored and recorded are heart rate, blood pressure, respiratory rate, oxygen saturation, temperature and level of consciousness. Vital signs should be recorded upon admission, at regular intervals during a patients stay and also before, during and after certain procedures Castledine (2006) and the frequency of monitoring, if abnormal physiology is detected should increase. EWS uses a scoring system 0, 1, 2, and 3 and colour codes white, yellow, orange and red, number 3 and the colour red being the highest risk indicators Morris and Davies (2010). Nurses should adapt to following guidelines the Early Warning Score offers, to help make clinical decisions that are best for their patients. Factors that may improve or prevent effective decision making while using the EWS could be down to capability, knowledge and ignorance. If health care professionals are well able and confident in recording and documenting patients vital signs, then any changes can be observed and prevented or dealt with quickly. The EWS implementation adds automated alerts hours before a rapid response would be initiated and can decrease treatment delays by up to three hours Subbe et al (2003). It only takes one nurse to lack competence when using the EWS, therefore putting patients lifes at risk. Early Warning Score is also used in the Mental Health and Learning Disability fields of nursing although it may not be used as often as in Adult nursing, it is imperative that patients who are physically or mentally unwell, require monitoring of their vital signs in an acute setting. Nurses may have to use their knowledge to improvise different ways of obtaining vital signs from some patients with learning disabilities or mental health problems, such as turning it into a game or distracting them especially if they lack the mental capacity and are unwilling to comply Hardy (2010) Medication can have serious effects on a patients health. Indications of these effects may be noticed in their EWS, combined with the knowledge and clinical judgement of health care professionals NIMH (2008) . If the EWS tool is not used as it should be in these fields then it will be hard for the health care professionals to obtain the needed evidence to make accurate clinical decisions. In the child field of nursing a similar tool to the EWS is used called PEWS, Paediatric Early Warning Scores. There are currently four PEWS charts used within the NHS for different age groups, 0-11months, 1-4 years, 5-12years and 13-18 years, the difference being the ranges for childrens vital signs NHS (2013). A key factor that may hinder accurate PEWS scoring could be due to the fact the child is scared when it comes to checking their vital signs, also very young children can be unwilling or fidgety Kyle (2008), this is where the nurse would have to use their knowledge to overcome such problems. The nurse could make it fun for the child, explain the equipment and what they are going to do and why. It is vital that the nurse gains consent from the childs parent before carrying out any procedure. It is important that the family play an important role in the care of the child DOH (2001). I have learnt various things while researching into the chosen decision making models and methods. I have been made aware of potential risk factors that may arise while using both tools in all fields of nursing and what could be done to prevent them. I feel confident in looking out for any risks involving the EWS and Pressure ulcer risk assessment tools while out in practice and believe that using these tools correctly can ultimately save lives.

Transcendentalism And A Belief In A higher Power :: essays research papers

Transcendentalism and A Belief In A "Higher Power" We do not have good reasons to believe in something transcendental. Most of the arguments in favor of God, or a so-called "higher power" are based on faith and emotion, and not a clear logical argument. In fact, these arguments are often in favor of throwing logic out the window. In many ways, this question is similar to someone attempting to prove the existence of an invisible elephant. It is far easier to prove that the elephant does not exist than it is to prove that it does. Socrates' principle of examination states that we must carefully examine all things. The tools we humans use to do this are logic and the scientific method. In order to believe in something transcendental, you cannot examine your beliefs using logic and science. If you do, there is no way to prove the existence of a higher power. The primary argument against the existence of a Judeo-Christian all- knowing, all-powerful, righteous God is the argument from evil. This argument argues against the presence of a higher power using facts of ordinary life. This argument states that most would agree that some of the pain and suffering (evil) in this world is unnecessary. To be considered a necessary evil, the occurrence must be the only way to produce something good, which outweighs the evil. Many events, such as infant deaths, would not be classified in this category. If such an all-knowing deity existed, it states, He would know that this evil was occurring. If He was all-powerful, He would have the power to stop this evil. If He was righteous, He would stop the evil from occurring Therefore, the existence of evil cannot be compatible with the existence of this type of God. The primary response to the argument from evil is the appeal to human freedom. This argument states that God sees evil as necessary so that we humans may be free to choose our own path. The fatal flaw in this argument is that there are evils that exist not as a direct result of human choice. Natural evils such as floods, earthquakes, and tornadoes serve no purpose according to this definition, and are therefore unnecessary evils. A theist might respond to this with another weak rebuttal, stating that every evil produces compassion and understanding in others, and creates good in that regard. This is an overly positive, almost delusional view of evil. Almost everyone will be able to come up with at least one example of someone who has suffered an evil that has not directly or indirectly led to anything good.

Staffing Essay -- essays research papers

All About Staffing I. Nature of Staffing Staffing is an organization-wide function, comparable to other functions such as marketing, focused on solving problems and adding value with a company's human, social, and intellectual capital. Staffing includes attracting and hiring talented people, as well as developing, appraising, and rewarding them through performance management and training programs. Staffing has a heavy legal emphasis, since employment and labor laws significantly impact both employee and employer rights and responsibilities. Staffing is the process of recruiting, selecting and training of personnel. It means putting the right men on the right jobs. All business organizations should focus their attention and be concerned about the effectiveness and efficiency of their employees specially their managers. The function of staffing has to do with manning an organization structure so that it can completely operate in the present and in the future. II. Recruitment Recruitment is the process of encouraging, inducing or influencing applicants to apply for a certain vacant position. Whenever there are vacancies, it is necessary to find a person to fill those vacancies. Some organizations do not wait until the vacancy arises, but they anticipate such vacancies and new openings in the short and long run and thus plan for future needs. Steps in Recruitment 1. Study the different jobs in the company and writing the job description and specification. 2. Requisition for new employee. 3. Recruiting qualified applicants. 4. Reception of applicants. 5. Application form. 6. Testing. 7. Checking the applicant’s work experiences, school records and personal references. 8. Interview. 9. Matching the applicant with the job. 10. Final selection by immediate supervisor or department head. 11. Physical and medical examination. 12. Hiring. III. Training Training is the systematic development of the attitude/knowledge/behavior patterns for the adequate performance of a given job or task. All employees on a new job undergo a learning process whether or not formal training exists. Learning to perform or be more efficient in performing a job is made easier for employees where there are formal training. For the growth of the individual and the organization, these activities are carried out continuously in many organizations. The quality of this initial training ca... ...on to another without increasing his duties, responsibilities or pay. B. Promotion It refers to the shifting of an employee to a new position to which both his status and responsibilities are increased. 1. Horizontal Promotion – an advancement in pay that does not involve a move into a anew job classification. 2. Vertical Promotion – an advancement that moves an employee into a job with a higher rank or classification. C. Separation Separation from employment of the company may either be temporary or permanent, voluntary or involuntary. 1. Lay-off is temporary and involuntary, usually traceable to a negative business condition. 2. A discharge is a permanent separation of an employee, at the will of the employer, a person may be discharged if he is not competent in his job even after an honest effort has been made. 3. Resignation is the voluntary and permanent separation of an employee due to low morale, low salary, etc. 4. Retirement can either be voluntary or involuntary. It is voluntary if an employee retires upon reaching the number of years of services in the company as provided for by its policies. It is involuntary if one retires upon reaching the retirement age of 65.

Alcohol Peer Pressure in College Essay

In the article â€Å"Above the Influence,† the main idea focuses on how alcohol in college has clinched onto society and is now considered a norm. The goal of this study was to explore how non drinking college students negotiated communication about a potentially stigmatized behavior abstinence from alcohol (675). The concept of the paper goes into depth on how students who don’t drink alcohol are usually an outcast or fall into peer pressure to fit in. In order to support the claims, researchers conducted an experiment to prove their hypothesis. They used both strict non drinkers and drinkers and placed the participants on a party school campus where alcohol is greatly abused. The actions of the kids varied on whether they would keep their non drinking low key or allow others to know about their situation. The research allowed the experimenters to see the variation of how the abstinent drinkers used communication to still fit in. The claims I most agreed with was allowing different non drinkers with various backgrounds to be put in similar situations. The diversity gave a better out look on how they would try to still be social even without the alcohol consumption. When the students used their different tactics to party without upsetting the other drinkers, I believe the empty cup was the best plan (679). When you’re communicating and trying to avoid any issues or quarrels, it is best to please the opposite party. Although some of the students did not drink, holding a cup would allow them to socialize without being hounded. Drinking has become a normality in both college and adult culture. It can even be seen as disrespectful to some to refuse the offer or abstain from it. The empty cup allows positive face to take place without questioning or disturbance from drunken or concerned peers. Participant Kristen stated that the cup gave her â€Å"control† of the situation and did give any negative vibes toward others. She was able to fit in the crowd with no problem. The non alcoholic cup could also allow the student to assimilate with new friends without feeling awkward or left out. It can give power to those who feel uncomfortable and out of place when faced with alcohol. Being a minority can always be harsh but the cup trick allowed a path into the majority without losing morals and beliefs. The claims that I did not agree with the most was blatantly telling fellow party goers that they were not drinkers. Choosing to abstain from alcohol should be kept as a private matter and does not need to be show boated or announced. A non drinker who states their lifestyle can be seen as a prude or over responsible. Their actions can belittle a social drinker and even stir up an argument (678). As shown in the article, participant Andy was caught in an argument with a girl after declaring his abstinence. He could have hurt his relationship if the issue had gotten out of hand. His honesty without privacy has caused an uneasy feeling among others. Some of the students could have tried to please themselves and their peers by using a prop to get out of pressure. College students already know how hard it is to assimilate without adding alcohol to the mix and should try to avoid any persecution. In many cases it is great to own up to a positive lifestyle, but dealing with young adults is in another spectrum. The brutality and insults given by peers can damage a person both emotionally and mentally. The bashing can also cause one to change their outlook or mentality about drinking. By being unaccepted into the norm, a person can try to change their selves to fit in. Not only can denying drinking be an issue to the victim, but also a fellow peer. Alcohol is not always the center of a party or get together, but it is shown that when someone refuses a drink, the offered can feel offended, as if he or she were being dismissed as a person (677). Looking to keep the best interest of both parties is not to inform others about personal decisions. The experiment overall did allow many questions to be debunked, but I don’t agree with using a college as a normal situation. In college, students are given a great amount of freedom which causes curiosity and experimenting. Whether it is with drugs or alcohol, college students use foreign or illegal items excessive when they are accessible. Most students are able to kick the negative habits when they are thrown into the real world and given real problems. The experiment should have been used in both college and adult life to give a feel on how being a non drinker is abnormal. I believe that a non drinker would be more accepted in a real world situation because being responsible is admirable when older. When put into a college realm, people tend to be very judgmental due to the level of maturity. Peer pressure never disappears but it does subside when the level of maturity develops fully. Adults do not force or ridicule others when they are giving off a positive action. Although non drinkers can fall into stereotypical types such as a recovering alcoholic (676), it is easy to kick the labels when older. Therefore I do believe this article and research met the goal of different communication skills when dealing with abnormal choices in society. The experiment allowed to explore the responses of people when deciding on how they deal with abstaining from alcohol. Some of the feedback gave positive and accepting results while other communication methods created tension and unwanted stress. Although some forms of communication worked better in social situations rather than others, having an array of different attitudes helped determined which faces worked best in college. The positive face allowed participants to have both a good time and maintain their safety. The other participants who chose their own route did have a hard time being accepted by others. Both methods created different paths, but allowed their abstinence of alcohol to be accepted in either a positive or negative light.

Pescriptive Versus Emergent

When described with historical perspective since it arrived in the mid 1960s, strategic or prescriptive planning has been embraced as a way of â€Å"outflanking competitors with big plays that yield long term rent from a sustainable advantage† (Bhide, 1986).Although it faltered in the 1980s and 1990s mainly due to the unstable economy in that period and the rise of emergent strategy, it is still being practised today (John A Pearce II, 1987). Emergent strategy is the view that â€Å"strategy emerges as intentions collide with a changing reality† (Moore, 2011). This literature review places the article ‘Crafting strategy’ (Mintzberg, 1987) in the wider context of prescriptive and emergent debate followed by strengths and weakness of the article. Placing the article in wider literature debateIn ‘Crafting strategy’ Mintzberg distinguishes between planning strategy and crafting strategy. Mintzberg view on strategic planning is clear. â€Å"Strateg ic planning isn’t strategic thinking. One is analysis and the other is synthesis† (Mintzberg, 1994). According to Mintzberg the current practise of strategic planning ‘separates thinking from doing’. He claims the current implementation of strategic planning can be best described as strategic programming, â€Å"the articulation and elaboration of strategies, or visions that already exists† (Mintzberg, 1994)Thereby limiting intuition and creativity. Mintzberg idea on strategic planning is further emphasised by Brian Boyd who suggest prescriptive strategy limits organisation creativity and innovative skills (Boyd, 1991). Psychologist on prescriptive planning says â€Å"Articulation of strategy locks it into place, thereby impeding willingness to change it† (Kiesler, 1971). The fact is that organisations who implement prescriptive strategy plan not to be flexible but to realize detailed intentions.According to Mintzberg the key to crafting strate gy is  the ‘intimate connection between thought and action’. [p68]. John Oliver emphasised in his book the importance of effective use of the action learning process hence emergent strategy in developing a future business strategy. (Oliver, 2006) The inflexible nature of deliberate strategy greatly reduces its litheness for creative and reactive process. Emergent strategy therefore possesses a much greater adaptability, particularly in tentative times and more difficult business environmental conditions.However Michael Porter argues that Industry structure drives competition and profitability. Success is not determined by whether an industry is mature or emerging (Porter, 1979). This is a typically prescriptive view on strategy, as it suggests breaking down intentions into communicated steps and formularizing those steps into the structure of the organisation. This premise is contradicted by various perspectives, as they believe accumulated learning and experience pro vides rare advantage that is difficult for other competitors to copy (Gerry Johnson, 2008).This suggests that strategy can be crafted as organisations learn from previous success and failures. Mintzberg in ‘Crafting strategy’ promotes the idea that prescriptive strategy ‘misguides organisations that embrace it unreservedly.’[p66]. He pushes the idea that crafting strategy is a more effective representation of strategy. ‘Craft evokes traditional skills perfection through the mastery of detail†¦.developed through experience and commitment.’[p66]. This is essentially emergent strategy as it describes â€Å"patterns realized despite or in the absence of intentions† (Henry Mintzberg, 1985) James Moncrieff (Moncrieff, 1999) states in his article â€Å"deliberate responses to issues emerging within the competitive environment can still usually be labelled emergent strategy as it is based on response to emerging opportunities and threat.â € Mintzberg supports Moncrieff idea by using National Film Board of Canada as an example ‘Strategies like the NFB’ that appear without clear intentions-or in spite of them-emergent strategies’ [p69]. This shows when actions are taken in responds to a new challenge patterns eventually forms. However, it would be ignorant and inaccurate to place the article solely as emergent. In this article Mintzberg states there is no such thing as ‘Purely deliberate strategy or a purely emergent one’. [p69] Emergent strategy as an extreme is essentially the absence of strategy (Andrew Inkpen, 1995).The  crafting of strategy is definitely far from deliberate strategy but would be implausible to be classified as purely emergent strategy. In Mintzberg words ‘Strategy making walks on two feet, one deliberate and the other emergent’ In other words learning must be used in conjunction with control. Mintzberg expands on this idea when he said â€Å"We t hink in order to act†¦..but we also act in order to think.† (Mintzberg, 1994) This in turn converges into practical pattern that becomes strategy. This article best supports ‘deliberately emergent approach’ or umbrella approach as Mintzberg conveyed the idea that processes should be consciously managed to ‘allow strategies to emerge en route.’ In this case senior management provides broad guidance and leaves the detail to those lower down in the organisation.Strengths and WeaknessesKey strength in this article is Mintzberg ability to utilize pathos, logos and ethos effectively to appeal to his readers. The article is brilliantly written and well structured thereby appealing to readers from all intellectual level. In addition, Mintzberg paints a vivid picture of the ideal form of strategy in the readers mind with the use of crafting as a metaphor. He intertwines the quality of a good porter to that of a manger, consequently illustrating the role o f a manager in crafting strategy ‘Managers are craftsmen and strategy is their clay.’ Mintzberg deliberately uses the metaphor to differentiate his concept of strategy from the mechanized models of deliberate planning that is void of creativity.A key element emphasised in ‘Crafting strategy’ is the ability for businesses to learn from experiences and ‘allow strategies to emerge en route.’ However what is not clearly indicated is if such type of approach is applicable to all sectors. McKiernan (McKiernan, 1997) argues that Mintzberg theory places too much emphasis on established businesses as new entrants won’t have the available experience to learn from. Furthermore Burgelman (Robert A. Burgelman 1991, Andres S. Grove, 2007) believes such approach can only be applicable to businesses without existing strategy, as strategy is embedded with experience and learning, thereby making it harder for management to implement constant incremental c hanges in responds to the environment.In this article, Mintzberg fails to discuss on the weakness of emergent strategy. He proposes that businesses should learn from mistakes that occur, however he neglects the consequences of mistakes such as the cost and wasted time due to trials and errors. These unrealistic expectations of emergent strategies are identified by Lynch. (Lynch, 2006) Mintzberg’s failing to discuss on the weakness of emergent strategy limits the usefulness of emergent strategy in practice. However authors such as Snyder and Cummings (William Snyder, 1998) carried out empirical study and designed models which aimed to align organisational learning with performance. Adcrof (Adcroft, 2009) also emphasises purely emergent strategy would be â€Å"a trial and error driven activity where intuition is wrong as often as it is right, which gives rise to levels of risk that may be unacceptable† ConclusionIn conclusion, initially Mintzberg favoured emergent strate gy over prescriptive strategy. However, he stated both strategy are needed in order to successfully implement strategy and advised the used of deliberately emergent and umbrella approach to strategy. Overall Mintzberg idea of strategy is still relevant to the world today as they reflect the fact that plans do fail and the age of five years plans are slowly fading away as businesses are becoming more responsive to the ever changing environment.