Communication in nursing Essay

Introduction. Communication is a necessary skill to have in the nursing profession. We use communication to exchange information between patients, co-workers and all the people around us (Kozier et Erb 2004). No matter the form of communication we are constantly presenting and interpreting people’s ideas and thoughts. Communication is a method we utilize to connect the gap between knowledge and comprehension (Kozier et Erb 2004).This paper will discuss an observation of the personal care home environment, modes of communication such as; verbal and non-verbal, effective communication methods and barriers to communications. Observation Of Personal Care Home Environment. I visited an urban personal care home in the inner city. I will be identifying this personal care home as PCH â€Å"X†. I walked into the facility and it was very clean and spacious. I conducted my observation during lunch time in the dining room. This area was poorly lit and the temperature was very humid. There was also music playing in the background during mealtime. This personal care facility was very respectful, kind and caring to the residents in their care. The communication I observed in general was very clear and concise. Verbal and non-verbal communication. Verbal communication is a mode of communication that uses both written and spoken words (Kozier et Erb 2004). Here is an example of verbal communication: At PCH â€Å"X†, a nurse was giving medication to a resident and he introduced himself. The resident did not respond to the nurse so the nurse approached him in a different manner. He crouched down to the resident’s level and spoke to him again in a calm voice and lightly touched his shoulder. The resident later complied with his directions to take his medication. The nurse took a different approach with his verbal communication by speaking softly. Verbal communication is largely used due to the fact that people usually chose the words they use (Kozier et Erb  2004). Another mode of communication is non-verbal communication. Non-verbal communication involves other forms of communication such as gestures, facial expressions, and touch (Kozier et Erb 2004, page 423). Most people who use verbal communication use various forms of non-verbal communication simultaneously. The nurse in the example above used non-verbal communication, when he crouched down to the resident’s level and lightly touched his shoulder. This second example involves non-verbal communication: A Health Care Aide was about to assist a resident with lunch. The resident was not aware of his environment and had difficulty feeding himself. The Health Care Aide asked the resident to open his mouth but he did not respond. As a result, the Health Care Aide opened his own mouth and the resident mimicked him and they were able to continue feeding. Effective communication methods. Effective communication is a very important aspect in a nursing career. Here is a summary of some effective communication strategies that I have observed at PCH â€Å"X†: *Health care workers appeared to be neat and tidy wearing uniforms. This will convey a non-verbal communication method of professionalism. Clothing and apparel can be a source of information about a person (Kozier et Erb 2004). *A staff member asked a resident how their lunch tasted. The staff member paraphrased what the client was saying and reinstated the resident’s feelings. This showed the resident that the staff member was actively listening (Kozier et Erb 2004). *Health care workers seemed interested in what clients had to say and differentiated the real from unreal (Kozier et Erb 2004). Health care workers talked to residents about daily activities. One client stated â€Å"I have to go to work; my daughter will be picking me up soon†. The nurse responded â€Å"your daughter will be here to visit but you are retired and you  do not have to work anymore.† These are a few effective communication strategies I have witnessed at PCH â€Å"X†. Communication promotes understanding and can build a constructive relationship with clients and co-workers. As nurses we must be aware of what we say and how we act towards others. Barriers to communication. It is critical to be aware of the good communication methods as well as the bad communications methods. This particular personal care home was very respectful to clients. However, here are some barriers to communication I observed when I was at PCH â€Å"X†: *One resident had a language deficit and had difficulty speaking. The resident was calling out and it seemed as though she wanted something. It was difficult for the staff member to understand what she was saying. He overcame this barrier by asking her yes and no questions until he finally solved what she was trying to say. *Residents were being talked to like children. The clients were often referred to as â€Å"dear, sweetheart, or darling†. During lunch, I also overhead someone saying â€Å"we have to change you diaper you made a pooh-pooh†. This may demean a client however; this communication barrier can be resolved by calling residents by their name and by respecting their dignity as a person. *Residents can also be hard of hearing. A nurse was talking to a resident with his back turned asking him questions and he did not reply back. She continued to speak louder and the resident later asked why she was yelling. The nurse should have faced the client while speaking to him so he could realize that he was being spoken to. Nurses need to recognize the barriers to effective communication. Barriers make communication become non-therapeutic. Non-therapeutic strategies to communication can be detrimental to a healing relationship. Conclusion. In conclusion, communication is extremely important especially to a nurse. To properly assess clients’ needs we must be able to communicate with them verbally and non-verbally. If we can identify the barriers to communication we can find effective strategies to resolve them. We have to be clear when we communicate to our patients. A misinterpretation of instructions, plans, and vital information can be harmful to a client’s health and well being. Caring and comforting is an important aspect of nursing and that can only be demonstrated through effective communication techniques. References Kozier & Erb, Barbara, et al. Fundamentals of Nursing. 7th ed. Upper Saddle River, New Jersey: Pearson Prentice Hall, 2004.

Cost of Ambition in Macbeth Essay

Human society burdens itself with generating organizational systems of rank to distinguish groups of people. Ambition — the quest for power — is a foremost drive embedded in the human spirit that motives men to better themselves. This quest is seen in Shakespeare’s tragic play Macbeth with the titular character who strives to achieve and maintain ultimate power. The central aspect of Macbeth lies with the title character’s desire to both follow and diverge from his destiny. After hearing of his future greatness from the seemingly omnipotent Weird Sisters, Macbeth comes to realize the latent ambition trapped within him (Act 1, Scene III). This initial realization of potential unbars him from his prior self (a life of both honor and prestige) to transcend his well-established morals. Macbeth yearns for power over his country and over his fellow man, ambitions that lead him down a dark and bloody path. Shakespeare uses this fall from good graces to demonstrate to readers the cost of being overambitious. Prophecy foretold of Macbeth’s future rule as king and alluded to his eventual fate with a message of warning. However, in contrast of the warning to be wary, it was also said that no man born of a woman — as every man is — held decisive power over Macbeth (Act 4, Scene I). This bold statement lends greatly to the expansion of Macbeth’s irrationality during his later tirades. His overly ambitious quest for power motivates him to prematurely end the life of the current king, an act he has no need to execute, for had the prophecy of his kingship really been true, he’d have been crowned sooner or later, but his lust for power blinds him to this fact (Act 1, Scene V). Given his reputation as a war hero, none surmount the treachery of suspecting Macbeth of committing such a crime, especially when the cover-up was so well planned. For this reason, Macbeth could work behind the scenes, plotting his takeover of the country and none would dare suspect malicious intentions from him. In this way, his ambition was unchecked. As mentioned, Macbeth entirely disregards the prophecy warning that certain dangers threaten his prosperity as king. He does this not due to a lack of superstition; he clearly believes in the Weird Sisters’ words of praise and success. He does so because he holds the premonition of fortune on higher grounds that that of misfortune. Thus, that men are blinded by ambition is another message Shakespeare hoped to convey. The very same ambition — rather, the fear of losing the product of that ambition — led Macbeth to challenge the same prophecy that granted him the throne. He sought victory over all, took up arms against fate, and marched towards an undefeatable destiny by slaughtering any kinsmen with a possibility of stealing the throne away from him (Act 3, Scene I). These repeated ventures into meaningless manslaughter lead him further down a destructive path laid out for him by his desire for power. The desire corrupts him, and greater forces rise in opposition. Shakespeare’s powerful storytelling shines here as Macbeth’s obsession with power is met by the force of balance. Macbeth oversteps his bounds to prematurely attain a rank already in his possession; as a reaction, the righteous force of Macduff, a man seeking only the best for the country, rose to oppose him. Herein we discover the most important of messages: ambition void of righteousness leads nowhere. Macduff also sought power, power over those who would bring forth the destruction of his beloved country. Ina conflict between two opposing power-seekers, as Shakespeare makes evident by the death of Macbeth by the hands of Macduff, the more righteous force is destined to prevail (Act V, Scene VII). Macbeth suffered from a devastating internal conflict: coming to terms with the idea that one lived with strength to usurp his power. Swollen with pride, he denied that any such being existed and thus became further susceptible to Macduff’s greater strength. Shakespeare conveys how the quest for power is a truly crippling experience when taken outside the bounds of rational thought. His character Macbeth actively seeks what is owed to by by the passage of time and ultimately pays the price for his misjudgment. Had Macbeth rationalized the situations presented to him by the Weird Sisters, he’d have taken their words as the prophecy of a reward for his national pride, not as instruments of corruption.

Pirates of the Caribbean Essay

There dynamic personalities of the many characters in Pirates of the Caribbean are a huge part of what made the movie so successful. Among those characters, there are some who contribute more to the plot by their actions and some who affect the other characters by their mere presence. Captain Barbosa and the Commodore have some obvious differences that divide them in the movie, but their similarities are much more important. As a pair of comic alazons, Barbosa and the Commodore play an important role in providing basis for comparison against Captain Jack Sparrow and further complicate the love story in the movie. Captain Barbosa is interesting character in that his actions are often represented in an amateur light. It is important remember the introduction of Barbosa if one is to understand his character. It is important to note that he is originally Jack Sparrow’s first mate, which immediately relegates Barbosa to a subordinate and thus, amateur position. He never really grows out of that and through the rest of the movie and there is never much indication that he is capable, either. One such example where this is evident occurs when Barbosa makes the mistake of thinking that Elizabeth is the daughter of Bootstrap Bill Turner. By attempting this important blood ritual using the wrong person, Barbosa shows just how much of an impostor he actually is. In addition to that, one of the primary characteristics of a comic alazon is their unique ability to get in the way of the primary love scene in the movie. In this case, Barbosa’s constant meddling with Elizabeth, Jack, and William spurns a host of different love-filled possibilities in the film. Like Captain Barbosa, the Commodore is an interesting character who has a big role in the film. His primary role as impostor comes from his relationship with Elizabeth. He sets out to marry her and the film allows him to get very close, but ultimately she settles on Will Turner as her true love. This sets up the Commodore as something of a joke from the very beginning. In addition, he can be seen as a comic alazon because of his failed methods in finding Elizabeth when she has been captured by Barbosa. It is interesting to note that the Commodore is completely against piracy, which is something of a strange idea considering how common it was during the movie’s time. It was almost as if he was on a mission to stop something that he had absolutely no ability to stop. The commodore is similar to Barbosa in many ways and the movie adeptly points this out. These two are similar in that they serve as a foil for Will Turner in his relationship with Elizabeth. In addition, both are seen as something of jokes, and they are not taken seriously by the other characters even though the one thing they want more than anything is to be taken seriously. In a way, Jack Sparrow just toys with both the Commodore and with Barbosa and though he is always in reach of them, he manages to make them look foolish and escape at the same time. This is the one reason why they are important to the plot. The basic characteristics of the two characters make them very different simply based upon the fact that Barbosa is a pirate who is hurting Elizabeth, while the Commodore is against piracy and loves Barbosa. Those things are purely superfluous to the story, though, as the more important theme has to be drawn both characters’ abilities to look foolish and completely inept at the same time. All in all, these characters are incredibly important to the story’s development. Though their differences are pronounced, their similarities are even more important. On both sides of the spectrum, they serve as something to laugh at and people for the main characters to constantly toy with for the entirety of the film.

Fruit content of fruit juice and apple juice content of cider using Literature review - 3

Fruit content of fruit juice and apple juice content of cider using DNA methodology - Literature review Example The PCR –RFLP method was used for the analysis of the different fruits in the fruit juice. The PCR heteroduplex system was successfully applied to the LOC and was found to show greater sensitivity for the identification of the fruit juices. After this process, random reannealing of the amplified DNA was done based on Hardy- Weinberg law. The heteroduplexes obtained from these studies have proved that the heteroduplexes were underestimated at the lab-on-a-chip method. The differential data interpretation is done to obtain better results. (Scott and Knight 2009). DNA profiling method was developed for the fruit samples. Different DNA extraction methods were practiced for the isolation of the genomic DNA from the fresh fruits. Some of the DNA extraction methods are CTAB- based DNA extraction method and some kits such as Nucleon Phytopure plant DNA Extraction kit, DNeasy Plant mini kit and G2 buffer & Genomic –tip 20/G kits can be used for the extraction of the DNA from the given fruit juices. SSR markers are used for the identification of the DNA from the given samples. The SSR analysis was able to reveal that the genotypes were the same for the dried fruits and the fresh juices. The DNA samples obtained from the canned and processes foods will be very small of 500 bp. (Yamamoto et al. 2006). These DNA samples can be easily amplified using the high quality primers. In the pear fruit DNA sequence there are 15 SSR sequences and among them 9 SSR markers were obtained from the fruit juice containing pear. The reason for this could be that the DNA obtained from the fruit juices were around 150 base pairs and they were very small for amplification. The DNA profiling and the cultivar methods were found to be very useful for the identification of the DNA of the fruits from the fruit juices. (Yamamoto et al. 2006). Orange juice is one of the most

Professional Development- Reflective Statement Essay

Professional Development- Reflective Statement - Essay Example tand the complex range of knowledge, skills and understanding they have and to develop and use the intellectual and emotional power within themselves to try and improve their situation†(Ghaye and Ghaye 1998). A few years ago, I had absolutely no experience when it came to the topic of childcare. Hence my previous reluctance to delve headlong into the studies pertaining to it. But over the years, situations developed that allowed me to put what I had been learning in class into practice. would never have developed the skills necessary to complete my class requirements. Eventually, I was thrust into the middle of working with children in 3 different setting which motivated me to further challenge myself to learn more about child care. The decision about what my college degree would be was now clear to myself and my family. Although I was anxious about my classes and had some jiiters about enrolling, my family members did their best to allay my fears and encourage me to succeed. Rmeinding me that I had to challenge myself in order to become the best person that I could be and ensure that I would eventually achieve all my dreams and ambitions. However, their encouragement and pep talks were being outweighted at every turn by my fear of making the wrong career decision. I needed to be reassured about my degree choice so I began to research the job market for my course. Little did I know that I was not helping myself by doing that.As Dwyer and Wynn argued; ‘Young adults are often disappointed when they do eventually enter the labour market, and experience uncertainties previously associated with the end of compulsory schooling.’ (p.334) I began to wonder if I would be wasting my time by further pursuing my degree. Afterall, I may still have made the wrong career decision and end-up with a useless degree. As usual, my family was there to support me during my time of doubt. I was reminded that the course that I decided upon was more of a calling than a lucrative

The impact of Japanisation, lean production and high performance work Essay

The impact of Japanisation, lean production and high performance work practices in the UK Workplace - Essay Example The effectiveness of these techniques in practice has led many managers internationally to adopt these techniques; in this way the so-called ‘japanisation’ has become a common phenomenon within modern firms (referring to the management styles used throughout modern organizations). In most cases, the effectiveness of Japanese management techniques is based on the radical increase of employees’ performance; lean production as developed primarily by Toyota is extensively used by firms within the modern market in order to support the improvement of organizational performance: a target that is being achieved in most cases. On the other hand, because there are cases where the adaptation of Japanese management techniques do not lead to the increase of the employees’ performance (and the following increase of the firm’s profitability) it is necessary to identify the key elements of the Japanese techniques’ potential failure ensuring at the same time t hat alternative management techniques – effective ones – will be available to managers worldwide. The design and the development of management practices in workplace should be decided taking into account the cultural and social characteristics of the specific region. The culture of the particular organization should be also taken into consideration. The specific issue was examined by Soutar et al. (1999, 203) who noticed that ‘culture is an important idea as it deals with the way people live and approach problem solving in a social and organizational context’. In accordance with the above view, management practices in countries around the world are expected to present significant differences; however it has been proved in the literature and the empirical research that in modern workplace the practices followed by managers are similar; it’s just the fact that this similarity is further increased when referring to firms established in the same country.

Animal Products From Cloned Animals in the Food Production-Consumption Research Paper

Animal Products From Cloned Animals in the Food Production-Consumption Industry - Research Paper Example Food production, of course, should have corresponding safety to ensure that mankind will not suffer from the technologically based production of foods from animal products. There are differing and contrasting debates regarding the safety of the food products from scientifically cloned animals versus the conventionally and naturally produced animals. One published article cited that animal products from cloned animals do not pose food safety risks compared to conventional livestock produced animals (Prigg). But safety standards will have to be established well since the use of cloned animals is just on the verge of introduction in to the mainstream food market and will be flooded with multiple reactions from consumers worldwide based on issues people heard about the animal cloning controversy even without in the depth knowledge of what is really going on. On the same context, animal cloning is deemed good on the view that it will give producers and consumers the highest quality of ani mal products. Cloning provides producers with the option of having the best quality of animal products since cloning can produce offspring animals with the suited traits for animal product production (DeLancey et al.). Cloning gives the best produce of the best animal offspring since the cloned animal is from well-selected donor animals with the favourable characteristics or traits giving a highly qualified breed and stock for products. For example, a cloned pig from donors with the characteristic of having more lean meat rather than fat will produce the same quality from donor animals and meets the best quality for meat products, thus having the best chance of being sold and utilized.

History of ISIS Essay Example | Topics and Well Written Essays - 500 words - 1

History of ISIS - Essay Example The group’s origin dates back in 1999-2003 during the Iraq war, and a time when Sadam was under scrutiny by the US Government. The group was formed to promote the existing war in Iraq between Sunnis and Shiites, where Shiites were supposed to die because it was heretic. In addition, the group wanted to expand its control over Iraq and Syria. It emerged from Al-Qaeda in Iraq (AQI), which was a major character in Sunni insurgency. The group was then under the leadership of Musab al-Zarqawi then. However, after his death, the group merged with other extremist groups to form the Islamic State of Iraq (ISI). However, in 2007, things lost balance in the group after many Iraq Sunni groups differed with ISI because of boundary disagreements. In 2011, the group emerged after foreign troops withdrew from Iraq and when Abu bakr al-Baghdadi was appointed the group’s new leader, who chose former Ba’athist military and intelligence officials as his personal assistants. However, in 2012, it adopted a new Moniker and branded itself the Islamic State of Iraq and al-Sham (ISIS). The group has 7,000 members, 3,000 of whom are foreigners mainly from Britain and Belgium. According to reports published on CBS News website, ISIL (S) uses social media to recruit most of its members, especially from the west. In addition, it has a multilingual media group called Al Hayat, which specializes in printing and distributing glossy magazines and videos that aim at influencing people into being part of the group. Its main sources of finance are smuggling, extortion, and outlawed crimes. It is estimated that the group can make up to $8 million per month. The group’s organizational structure is composed of a supreme leader, wh o currently is Al-Baghdadi, who has two deputies, one in charge of Syria, and the other in charge of Iraq.  

Hist up 10 1877 Essay Example | Topics and Well Written Essays - 250 words

Hist up 10 1877 - Essay Example The way in which he established a policy to expand westward was to first slash the minimum amount of land that a farmer had to purchase. Originally a farmer had to purchase 640 acres, by 1832 a farmer only had to purchase 40 acres and the price per acre was slashed substantially. This made a strong financial incentive for settlers to steadily move west. In regards to how Jefferson viewed the West as being crucial to the well being of the republic, it is the case that he believed that scores of in small scale farmers that would be active participants in the American democracy. These people would help contribute to both the economic health of the country but also contribute to democratic health of the American Republic. #2-A) In regards to the first statement I am inclined to agree overall. Whilst there may have been an original plan to settle the west it may also be the case that Jefferson’s plan had been altered over time. With British colonial expansion in the Pacific North W est it may be the case that Westward settlement would have been seen as a defensive expansion. There was a significant increase in population across the Eastern seaboard and expansion would be a natural means to alleviate these pressures.

What Spiritual Issues Surrounding A Disaster Can Arise For Essay

What Spiritual Issues Surrounding A Disaster Can Arise For Individuals, Communities, And Health Care Providers - Essay Example It has been observed that due to particular disaster people primarily get emotionally affected. The approach of disaster management most of the time, fails to assist people in overcoming the losses including emotional trauma and other kinds of emotional distress due to high level of disaster (Act alliances, n.d). In this context, people need the support of spiritual care to overcome the aftereffects of any particular disaster. It has been observed that during any particular disaster, several communities of people and diverse cross sectional individual are seeking the assistance of spiritual care. It will be worth mentioning that these faith based organizations are showing an additional contribution towards providing spiritual care to those people who are in need of the same. Spirituality also refers to the aspect where one individual requires support of extra ordinary human care. Spirituality is believed to help people in ensuring early recovery from any kind of mental trauma (National Disaster Interfaith Network, n.d.).

Compare and contrast the planning functions of the Japanese and Research Paper

Compare and contrast the planning functions of the Japanese and Chinese economic models - Research Paper Example The economic models perform two basic functions, which include selection of information on the basis of econometric study and simplification of the gathered information. Economic models can be classified as stochastic models, non-stochastic models, qualitative models, quantitative models, equilibrium, and non-equilibrium models. If we talk about some of the benefits of having the economic models, we can say that economic models are widely used for a variety of purposes in the economic environment of every country. Some of main uses of economic models include guiding resource allocation decisions, forecasting the economic activities, planning the functions of economy, and making appropriate decisions related to the economy. All of these uses make economic model one of the most important models for the development of any country. Let us now discuss planning functions of the economic models of China and Japan, which are two of the most progressive and well-established economies of the w orld. Comparison between Planning Functions of Chinese and Japanese Economic Models Chinese economy has seen significant success and development over the last decade. The communist government of the People Republic of China has been successful in developing a strong Chinese economy, which has started developing its roots in most of the Asian, European, and American markets. â€Å"Although the politics of China remains communist, the economics might be called Advanced Mercantilist† (SNS 2010). Chinese economists have analyzed the perfects ways to deal with the west by considering the cases of South Korea and Japan and have come up with a well-designed economic modal, which has the ability to make the Chinese economy one of the most stable economies of the future world. If we talk about the Japanese model of economy, we can say that Japanese economic model has proved to be a very useful tool not only for the analysis of the current economic situation of Japan but also for the p rojection of its future economic situation. Japanese economy has faced various shocks after the World War II but the responses of the Japanese economic model to the shocks provide us with a very good approximation of the current economy of Japan. The planning functions of the Japanese economic model also depend on the types of consumers. Unlike Chinese economic model, the Japanese economic model considers consumers to be of two types, which include permanent-income-hypothesis consumers and rule-of thumb consumers. The response to shocks becomes very realistic and effective due to identification of types of the consumers. If we analyze the most recent economic recession and the affect of that economic recession on the economies of China and Japan, we come to know that china was one of those countries, which survived the economic recession up to a large extent. It is due to the implementation of an appropriate economic model that Chinese economy did not shake as the result of recent e conomic recession. Various analyses and reports show that the countries like Germany, Japan, America, and the United Arab Emirates were affected heavily due to the recent economic recession but the economy of china was so stable that the recession could not affect it up to a large extent. Japanese economy, which is currently the world’s second largest economy, also slipped into the economic rece

Good for Another Essay Example for Free

Good for Another Essay We were in our final year in secondary school, and we were asked to pay for WAEC and NECO fees. Some paid for WAEC only, some paid for NECO only, while some paid for both. Three weeks before the closing date, me and my friend went out for break, though it was prohibited to eat your breakfast in the class but me and Ada often eat there. That day, when we went into class, we were surprise to see one of our classmate; Sarah crying. We asked her why she was crying and she told us her parent cannot afford to pay for her WAEC or NECO fees. I was touched by the way she was crying and I promise her I would pay for her, I told her I would tell my parents and I was sure they will pay for her. Me and Ada told her to wipe her tears before the rest of the student came in from break. That day, when I reached home I told my mother about it and she promised to pay for her WAEC only, that she would give me the money in two days. We all graduated from secondary school and we all made our result and almost all of us furthered our education to Universities of various types. I lost contact with Ada and Sarah since then but, you know; Life have to go on. I was at the school cafà © one day when I saw Sarah, oh my God! I can’t believe I was seeing her, we were so happy to see each other again after our life in secondary school. We talked for so long, and through our chatting I discovered her Dad was now rich, and she was studying Law. We exchanged phone numbers and hostel Numbers. We became friends again. At the end of second semester in school, I went home only to find out my father was dead, he was hit by a bus the night before the day I came home. I wept, oh my God! I did not only wept because I lost my father, I also wept that my education might stop, I wept that all my years in school might be wasted. I wept that I fell sick and was admitted at the hospital for a week. A week after I was discharged from the hospital, I heard registration for next semester will be closing in one week. I told my mother, but she told me she cannot afford the fee. I was devastated, I was afraid that my greatest fear is coming to reality. I decided to go to Sarah for help, but to my greatest surprise, she told me she wanted to use the money she had for something else. It hurts me so much that I wept right in front of her. All she could tell me was she can’t give me the money. I wept home and told my mother what Sarah told me, she could not believe this, she could not believe this was the girl she helped some years back. She told me to wipe my tears, and that life goes on. I was dropped out of school and I started apprenticeship in a salon shop not far from our house. After two years, I invested my own salon and with more effort and the help and support of my mother, my shop grew up. My salon became one of the best of the well known salon. I was in my salon one day when Ada came in, I did not even notice her. I was busy working when I heard someone call my name, I turned and saw Ada, I shouted and hugged her. Oh Goodness, I was seeing Ada again after so many years. We chatted for a while and she told me she saw Sarah, she told me Sarah was dropped out of school and arrested by the Police, that she was caught with Cocaine. I told her what happened to me, how I was dropped out of school, she was surprise that Sarah could do such a thing to me, me of all people. I told her I was well over it, and Sarah deserved all that happened to her. Though I am successful in life but, I will never forget how I was dropped out of school. I may forgive Sarah but, I will never forget what she did to me.

Diagnosis of Systemic Lupus Erythematosus (SLE)

Diagnosis of Systemic Lupus Erythematosus (SLE) Systemic lupus erythematosus is a multi-systemic autoimmune disease that was first described in 1941, by Klemperer and colleagues (Gonzalez-Buitrago and Gonzalez, 2006). It is a disease that can attack almost any organ or system in the body, where imbalances in self tolerance create an abnormal immune response to self proteins resulting in autoimmunity (Male et al, 2006). SLE is a disease that has a strong correlation to defects in apoptosis; however no specific cause of the disease is known (Arbuckle et al, 2003). The prevalence of the disease is worldwide; however it commonly affects people of African descent, particularly in Europe and Northern America (Kumar et al, 2009). Environmental triggers are known to contribute to the disease manifestation; although genetic links have also shown association with all HLA classes (I, II, III) on chromosome 6. Other transcription factors such as IRF5, STAT and proteins such as PTPN22 have also been seen to contribute to the manifestation (Mal e et al, 2006). SLE is particularly common between the ages of 15-50, where patients present with positive antinuclear antibodies (ANA). ANA are a group of heterogenous antibodies that are capable of binding to components of the nucleus, resulting in damage of DNA. The initial screening method for patients with AIDs such as SLE is via the ANA test. 80-90% of patients with SLE present with a positive ANA (Bonilla et al, 2007), however other AID such as Sjà ¶grens syndrome, Rheumatoid arthritis, Autoimmune hepatitis, Scleroderma and Polymyositis Dermatomyositis, also see positive results. Antigen specific assays such as extractable nuclear antigen (ENA) and double stranded DNA (dsDNA) must then be performed to confirm a diagnosis, as approximately 70% of patients with SLE have antibodies to dsDNA (Rahman Isenberg, 2008). Positive results can be seen within the aging population as the immune system begins to deteriorate. Nilsson et al, (2006) supports this and found that positive ANA results were fo und particularly in elderly patients over 85 years. 90% of patients with SLE are women, suggesting a hormonal link (Rahman et al, 2008). Hormonal imbalances are seen in women with SLE, thus it becomes difficult to maintain immune tolerance. Increased oestrogen levels result in increased antibody production and Th2 response, whilst decreased levels of androgens depress the response resulting in an abnormal immune response (Danchenko et al, 2006). 1.2 The clinical significance of ANA testing The diagnosis of SLE is dependent on a variety of factors including clinical details, family history, age, race, sex, medication and infection (Stinton Fritzler, 2007). The classical symptom for SLE is a butterfly-shaped rash which is commonly seen on the face (Figure 1.1). In 1982 the American College of Rheumatology (ACR) described a set criterion (Table 1) (updated in 1997), for the diagnosis of SLE aiding clinicians to correctly diagnose patients. Four points of the criteria must be met, for a definite diagnosis of SLE. The criterion for SLE includes symptoms, immunological and haematological tests. Points 10 and 11 are of particular importance, as they are confirmatory of SLE. A study by Arbuckle et al, (2003) examined the onset of SLE in 130 patients and found that 115 patients had positive indirect immunofluorescence (IIF) ANA, before diagnosis. 1. Malar Rash A butterfly rash usually seen on the face 2. Discoid rash red, scaly patches on skin that cause scarring 3. Photosensitivity Skin rash as a result of unusual reaction to sunlight 4. Oral ulcers Oral or nasopharyngeal ulceration 5. Nonerosive Arthritis tenderness or swelling of joints 6. Pleuritis or Pericarditis Pleuritis inflammation of the pleura, the lining of the pleural cavity surrounding the lungs Pericarditis small amount of fluid builds up between the two layers of the pericardium. 7. Renal Disorder Persistent proteinuria Cellular castsmay be red cell, hemoglobin, granular, tubular, or mixed 8. Neurologic Disorder Seizures 9. Hematologic Disorder Hemolytic anemiawith reticulocytosis Leukopenia Lyphopenia Thrombocytopenia 10. Immunologic Disorder Anti-DNA: antibody to native DNA in abnormal titer Anti-Sm: presence of antibody to Sm nuclear antigen Positive finding of antiphospholipid antibodies on: 11. Positive Antinuclear Antibody An abnormal antinuclear antibody by immunofluorescence Once a positive ANA test has been performed there is no reason to repeat the test, however if clinicians have a strong suspicion of an evolving connective tissue disease (CTD) negative ANAs should be re-requested (Blerk et al, 2008). Other immunological tests such as complement components (C3 and C4), C-reactive protein, anti-phospholipid antibodies and anti-histone can also be tested to investigate SLE; however these may not always aid all patients (Egner, 2000). 1.3 History of ANA testing and how the diagnosis of SLE evolved The ANA test has been around for over 40 years and is the most widely performed autoantibody test, worldwide. The test is commonly performed within Immunology laboratories and has evolved very little over the years. ANAs originated from lupus erythrocytosms, also known as the LE cell phenomenon. LE cells were discovered in 1948 by Hargrave, who saw that patients with SLE have polymorphonuclear leukocytes, which had phagocytosed nuclei, within the bone marrow (Hepburn, 2001). Following the discovery, Lee et al, (1957) showed that the LE cells were formed by gamma proteins in leukocytes which were thought to be antibody. Fluorescent labels were also introduced in 1957, to show homogenous patterns on human tissue (Hughes et al, 2008). By 1961 rat sections substrates were introduced, enabling patterns such as homogenous, speckled and nucleolar to be seen in patients with rheumatic diseases. The use of rat substrates brought about a new discovery, which saw that washing cells in saline, c aused alterations to cells within slides, thus altering patterns seen, thus the precursor of the ENA screen was introduced. By the 1970-80s Human epithelioma type 2 cells: CCL-23 (HEp-2) substrates were widespread and National quality assurance schemes began to establish. 1.4 Techniques implemented in laboratories for ANA detection There are many techniques available for the testing of ANAs; these can be seen in the UK National External Quality Assessment Service (UKNEQAS) report found in Appendix 1. 1.4.1 Indirect immunoflourescent (IIF)-ANA Indirect immunoflourescent (IIF) is a general screening technique performed to identify patients with autoantibodies. It enables scientist to link autoantibody patterns present within a patient sera, to help diagnose and monitor their progress during treatment. ANA testing using IIF was developed by George Friou in 1957, where initially substrates such as chicken erythrocytes were used (Kumar et al, 2009). ANA substrates were traditionally prepared in-house using rodent tissue where thin layers of tissue were sliced using a cryostat. However as demand for the screening of autoantibodies increased (Figure 1.2), preparing slides was no longer feasible, as it was time consuming and laboratories could no longer manage rodent houses as they required expert attention. Commercial companies then began to produce ready to use tissues substrates, offering a greater sensitivity. However as many commercial substrates are now available, variability between kits, manufactures, substrate, conjugate and the degree of cellularity (good monolayer of cells and a number of mitotic spindles), make it difficult to standardise methods of detection and reporting. In order to produce accurate results, substrates must be present in the correct phase of the cell cycle (Figure 1.3). Identification of IIF-ANA patterns is dependant on the true state of chromosome. Most autoantibodies are directed against antigens expressed during interphase. Interphase is divided into 3 stages: G1, S and G2, where cytoplasmic organelles and fibres structure are most visible and the nucleoli appear well differentiated. A mix of mitotic and non mitotic forms of cells are needed in the metaphase stage as it is influential in interpreting IIF-ANA patterns, especially centromeres and homogenous patterns (Sacks et al, 2009). The HEp-2 substrate is commonly used in ANA detection and was introduced commercially in 1975 (Kavanaugh et al, 2000). HEp-2 provided a greater sensitivity for the testing of SLE as they were composed of human laryngeal squamous cell carcinoma, allowing the recognition of over 30 nuclear and cytoplasmic antigens (Gonzalez-Buitrego Gonzalez, 2006). HEp-2 substrate contains various organelles (Figure 1.4) allowing uniform distribution of cells, showing large nucleolus, meaning no interference of the intercellular matrix is seen (Gonzalez et al, 2002). The introduction of the HEp-2 substrate was a big step forward in identifying patients with the ribonucleoprotein complex (anti-Ro). The anti-Ro antigen is particularly significant in patients with SLE as it offers a poor prognosis. However this antigen is seen to overlap between different autoimmune diseases such as Sjà ¶grens syndrome, thus the detection of the antigen must be precise. The Ro (SS-A) antibody is seen to target protein antigens associated with small RNA molecules known as hY-RNAs11, 12 and are of unknown function (Cozzani et al, 2008). HEp-2 cells were seen to destroy the Ro antigens during fixation, so commercial companies began to devise ways around this. To overcome this problem, HEp-2 cells were genetically modified to produce extra Ro antigen and this substrate was known as HEp-2000. HEp-2000 substrate is uniquely produced by ImmunoConcepts (Sacramento CA, USA). The slides have 10-25% mitotic human epithelia and offer a greater sensitivity (Table 2) in the diag nosis of SLE. They have aided in reducing the number of ANA negative SLE patients; however detection of Ro is dependent on the stability of actin, as it can denature easily. Although HEp-2000 substrates were seen to be more beneficial in detection of Ro antigen, they limit the identification of the different epitopes of the Ro antigen. At present HEp-2000 substrate can only identify the 60kDA Ro antigen; but since the 52kDA Ro antigen also exists, patients with this epitope are missed. A study by Cozzani and colleagues (2008) looked at 5,949 people over a 5 year period. All participants were photosensitive and 2,315 of these had connective tissue disease (CTD) such as SLE. The study found that the anti-Ro was easy to identify on HEp-2000 slides with a sensitivity of 81% according to the Altman test, of accuracy. However a study by Bossuyt and Luyckx (2005) compared IIF to EIA and saw that patients with anti-Ro antibodies were missed using HEp-2000 slides, as the undetected patients contained the Ro 52 antibody; although they reported a sensitivity of 82.9%. One patient in this study was negative for IIF-ANA, but was shown to have a positive Ro antigen by EIA. A study by Dahle et al, (2004), looked at HEp-2 and compared three ANA methods; Enzyme immunoassay (EIA), double radial immunodiffusion (DRID) and IIF. 3,079 patients were examined and overlapping results between IIF and DRID were seen and 60% of IIF-ANA gave a positive homogenous pattern. However results for EIA showed that positive IIF results appeared negative by EIA. In 2006 the LGI performed a study looking at 18,320 samples, requesting ANA tests by IIF. The study found that 1 in 5 patients, identified as negative or weak positive by IIF, showed positive for anti-Ro via EIA. This proved that Hep2000 cells cant detect the different epitope of Ro, thus concludes that antigen-specific testing is required following the ANA test. This agrees with Morozzi et al, (2000), who suggest that a combination of 2 or more methods are required for the detection of the anti-Ro antibody in patients. This study looked at 64 people with connective tissue disorders and tested them by IIF, EIA and DRID. Results showed that 54 people were positive by at least one method and the specificity of each technique was good, whilst sensitivity varied. Sensitivity for IIF-ANA via HEp-2000 was 89%, EIA (Ro60) was 89%, EIA (Ro52) was 67% and DRID presented with a sensitivity of 76%. Although the NEQAS report shows that DRID is no longer used within laboratories, results from thi s study suggest that EIA has the ability to detect the different epitopes, preventing misreading of the anti-Ro antigen. Thus to ensure that all SLE patients are identified antigen-specific tests such as extractable nuclear antigen (ENA) should be used to detect the various epitopes (Cozzani et al, 2008). Conjugates play a significant role in the determination of IIF and EIA results. Fluorescein-conjugated antibodies produced from goat, sheep or rabbit are commonly used. These are usually bought from commercial companies, which produce pre-diluted conjugate, raised against mouse or human, which aims to achieve optimal sensitivity and reactivity. Immunoglobulin fraction can be also be used; however fluorescein conjugates such as fluorescein isothiocyanate (FITC) are preferred as they produce less background staining. A fluorescein/protein (FP) molar ratio is employed, with in-house diluted conjugates. The ratio varies between kits, however a 1:3 dilution with phosphate buffered saline (PBS) is usually used (Egner, 2000). At LGI the conjugate used for detection of ANAs is IgG, as it allows accurate diagnosis and monitoring of diseases such as SLE. IgM-ANA can also be employed, although this indicates milder or non-specific diseases, whilst IgA-ANA gives little information so arent used. Due to the use of fluorescence conjugate, slides fade overtime, thus it is particularly important to determine results as soon as possible as photographs are not taken. As IIF varies daily due to slides and condition of the microscope, it would be appropriate to carry out daily checkerboards to see which working dilution is best for the conjugate, improving consistency; however this is no longer feasible in high-throughput laboratories. When reporting ANA three factors require evaluation: the pattern observed; substrate used and the titre of the positive test. Experienced scientist can interpret ANA slides and distinguish titre levels; however this takes years of experience. The screening dilution is important in patients presenting with positive results, as it helps determine an individuals severity of disease and can prove beneficial to clinicians. Serial dilutions at 1:10, 1:20, 1:40, 1:80, 1:160 and 1:320 can be performed, where the titre value is the one at which positive sample becomes negative. 5% of a healthy population can present with a positive low ANA titre, with no disease activity and are commonly women aged over 60 (Shmerling, 2003). Peterson et al, (2009) found that beside patients with SLE patients, other diseases also present with positive ANA titres. 1:20 healthy people presented with a positive ANA and the number of positives increased to 1:3, with a dilution of 1:40. To reduce the number of fals e positives, titres are commonly performed at 1:80. At LGI titres were performed on all positive samples and pregnant women, regardless of whether they are positive or negative. Pregnant women are closely monitored as a precaution as IgG antibodies cross the placenta, thus anti-Ro/La antigen is capable of causing fetal heart block (Rahman Isenberg, 2008). Patients who presented with symptoms for SLE were also titrated; however lots of weak positive results were seen as a dilution of 1:40 was employed. As workload increased titrations became laborious and impractical, thus performing titres routinely was abolished and titres are now only performed upon request. Cut-offs exist, however these are modified around the local population, to give a better sensitivity (Stinton Fritzler, 2007). Shmerling, (2003) has suggested that ANA titres can correlate with disease activity, but as positive samples undergo antigen specific testing via EIA, titres should be abolished, unless there are specifically requested by the clinicians to monitor changes to disease. Wieser et al, (2001) found that there was a lack of correlation between the clinical features of patients and laboratory results obtained. The study looked at 3 cases with varying antibody titres and established algorithms seen in Figure 1.5. Similarly Hanley et al, (2009) suggested algorithms help in diagnostics (Appendix 2). As a small number of cases were analyses, it appears that there is not sufficient evidence to develop an algorithm; however both the studies have been adapted in Europe as they were seen to prevent patients with detectable antibodies being missed and to avoid the unnecessary testing and time of laboratory staff. Slide processors are available to prepare IIF slides. They first appeared in the late 1990s and include platforms such as ASP1200 and AFT from Binding Site (Figure 1.6). These slide processors ensure that all samples are prepared quickly, reliably and accurately, avoiding cross reactivity in sample preparation. Slide processors perform IIF via indirect antibody reactions as seen in Figure 1.7. Patient serum is incubated with a substrate, followed by washing to remove any unbound protein. A second antibody, FITC is added and this reacts with immunoglobulins which have combined with the substrate. Another washing stage is performed and slides are ready to be mounted and interpreted manually, however this causes subjectiveness. IIF-ANA result interpretation is dependent on the operators setup of the microscope, type and number of hours the bulb (mercury) has been used, type of objective lens, filters and most importantly magnification. At the LGI the Leica DMRB mercury microscope is employed and allows cells to magnify at X200, X400 and X500. Positive results fluoresce an apple-green colour (Table 3), whilst negative samples have little fluorescence. Two independent observers interpret the slides to prevent reading errors and any conflicting results are followed by an anti-ENA and anti-DNA screen. Automated commercial slide readers are now available to allow interpretation of ANAs. Images are automatically scanned and stored within computer systems, where positive and negative ANA results are determined by the amount of flourenscene emitted. The operator can then scan through positive ANAs, identifying their patterns. This aims to improve the subjectiveness seen between scientists and aims to improve accuracy; however these are not robust so not widely used. The advantage of IIF-ANA is that it is easy, inexpensive, available from a wide range of commercial companies, sensitive, reliable and has reduced cross reactivity and background fluorescence. The disadvantages of IIF-ANA are that it is laborious and requires a high degree of technical expertise. Within most Immunology laboratories the ANA test is not linked to the pathology computer systems, so tests cannot be picked up via an interface. This can be problematic as wrong samples can be analysed and reported. The use of barcode readers can overcome this problem. Homogenous Homogenous Pattern is the most common pattern seen in 60% of Systemic Lupus Erythematosus (SLE) patients. However it can be seen in drug induced lupus, Rheumatoid Arthritis. Positive patients are then further evaluated against: Anti-dsDNA, Anti-Smith Speckled Speckled Pattern can exist as coarse expressing is Sm, U1-RNP antigen or fine expressing Ro or La. Sm positive is seen in 4-40% of SLE patients, whilst RNP is seen in high titres in patients with Mixed Connective Tissue Disease (MCTD). Patients with Scleroderma and Sjogrens Syndrome also present with positive results. Centromere Centromere pattern is seen in 57-82% of patients with CREST syndrome and Raynauds. The suspected antigen is CENP A, CENP B, CENP C. Nucleolar Nucleolar Pattern seen in patients with Scleroderma. There are multiple nuclear antigens, such as fibrilliarin. Positive patients are then further tested against Scl-70 (Anti-Topoisomerase I). Table 3: Shows the various ANA patterns seen by IIF on the HEp-2000 substrate (Produced by Nisha Lad, 2010) As different laboratories use different substrates and conjugates, IIF-ANA lacks standardisation worldwide (Bonilla, 2009). A study by Blerk et al, (2008) showed that if laboratories employed the same cells, substrate and conjugate they were able to report the same staining patterns. Over 157 laboratories across Belgium participated and each looked at 9 different samples. Looking at the results it is clear that after considering the variable factors, participants that employed the same HEp-2 slide substrates (Medica, USA) and method of detection were able to produce consistant results, suggesting standardization can be achieved. Although IIF-ANA is subjective, replacement with EIA or bead technology is suggested to increase sensitivity. Bonilla et al (2007) performed a study in the USA suggesting that IIF had a sensitivity of 90.6%, whilst bead technology had a sensitivity of 41.9% and the specificity of IIF was lower at 76%; however for bead technology was 87%. Having tested 385 patients a conclusion was made saying IIF was a better technique for diagnosis of patients with SLE. Olaussen and Rekvig (1999) also produced similar results, where two commercial IIF assays and two commercial ELISA kits consisting of a range of antigens, significant in the diagnosis of SLE were used. The study showed correlation between IIF and ELISA, where sensitivity for IIF was 88%, whilst that for ELISA was 86%. Specificity however varied with 67% for IIF and 60% for ELISA. Another study by Gonzalez et al, (2002), analysed 709 samples comparing IIF and EIA for the diagnosis of ANA. Results showed good reproducibility in both as says, but found that the antibodies which produced a homogenous and speckled IIF patterns were best detected via EIA. On the other hand a study by Nifli et al, (2006) compared routine technology in a selection of Clinical Immunology laboratories and analyzed 11088 samples, using IIF and ELISA at the University Hospital of Heraklion in Greece. Results showed a highly significant correlation for ANA performed by ELISA; however it suggested that as IIF had a low sensitivity of 58%, this could be replaced by multiplex technology, allowing multiple antigen measurement. Looking at these studies closely it appears that although there were similarities between technologies, different kits and manufacturers were used, producing variable results. 1.4.2 Antigen-specific assays for the detection of ANA Many different patterns can be seen by IIF-ANA, however to determine autoantibody specificity further antigen-specific assays are needed. Antibodies against Sm, native dsDNA and chromatin are used in the diagnosis of patients with SLE (Hanley et al, 2009). Currently ANAs are categorised into two main groups; ANA to DNA and histones (dsDNA) and ANA to extractable nuclear antigens (ENA). Enzyme-linked immunosorbent assay (ELISA), also known as an enzyme immunoassay (EIA) are now available for antigen specific testing, providing a new horizon for SLE testing, as they are able to identify individual antigens. ELISA/EIA is the most commonly performed technique, implemented in laboratories today. In the past, ELISA plates were assembled in-house, however as a successful assay requires careful assembly of the different layers, this soon became difficult to achieve, thus commercial ELISA kits were developed in the 1980s to overcome assay failure and to overcome the subjectiveness of IIF-ANA. The ELISA assay can be performed either manually or via automated technologies. 96 well plates coated with the same antigens are commonly used, however Phadia produce an EIA platform, whereby pens containing singles wells with individual antigens can be used, allowing multiple antigen recognition and analysis. Both ELISA/EIA operate via immunometric methods of detection for anti-ENAs and anti-DNAs. The principle (Figure 1.8) of this technique is via microplates which are coated with purified antigens of interest. Patient serum is incubated in the wells and unbound antibody is then washed away, followed by the addition of a conjugate such as alkaline phosphotase (AP) or horseradish peroxidase (HRP). Another wash stage is performed and colorimetric results develop, which are proportional to the initial concentration of antibody in the patients sample. Results are dependant on kit standards, which produce a calibration curve and then the optical density of the wells is taken to give a q uantitative result (Branda et al, 2009). ELISA are a versatile assay, where the amplification of the signal, increases the overall sensitivity of the assay, as it uses an antibody which are specific to the type of antigen/protein being measured. Studies suggest that ELISA is a sensitive assay, however lacks specificity so false positives results are detected (Castro and Gourley, 2009). The advantage of ELISA is that it can be performed both manually and via automation. Analysers can also be linked to the pathology computer systems, preventing transcription errors in result interpretation. However disadvantages for ELISA are that purified antigens need to be prepared via HPLC, meaning assays are not cost effective and can be time-consuming. As microtitre plates are now purchased with one antigen, there is a limited dynamic range of detection; however EIA pens now overcome this problem. To produce successful assays, instrumental conditions need to be carefully considered. Washing errors, contamination of substrate or inadequa te incubation times may produce little signal amplification resulting in false negative results (Castro and Gourley, 2010). 1.4.2.1 Anti-dsDNA Anti-dsDNA were first described in 1957, by Ceppelini and colleagues. Anti-dsDNA are found in patients with SLE and are mainly found in the form of nucleosomes. Nucleosomes are fragments of chromatin that cells release during apoptosis. dsDNA antibodies bind to the nucleosome to form complexes which settle in the glomeruli, resulting in glomerulonephritis and increasing the risk of lupus nephritis flare, thus detection is crucial as it helps to determine the therapy required for treatment. à ¯Ã‚ Ã‚ ¡-actinin (100kDA) is a microfilament skeletal muscle protein, which aids in maintaining the function of podocytes in the kidney. This protein is not specific for SLE, although it can act as a marker for renal involvement (Raheman et al, 2008). The dsDNA assay can be performed via (Figure 1.9); IIF with Crithidia luciliae substrate (CLIF), Farr assay also known as radioimmunoassay (RIA), however the most commonly used technique is EIA/ELISA as described in 1.4.2. The Farr assay is regarded as the gold standard technique for the detection of dsDNA (Launey et al, 2010). It uses cultured cells labelled with thymidine and idocythidine, which act as radioactive DNA. In the assay bound and free DNA is separated by precipitating immuglobulins and ammonium sulphate. Although this method is good, it misses low avidity anti-DNA antibodies due to a nitrocellular filter, which allows the passage of free DNA and however double stranded DNA (dsDNA) cannot be filtered. Thus the radioactivity is said to be proportional to serum anti-DNA (Isenberg Smeenk, 2002). The Farr assay can detect high affinity antibodies, with relatively high specificity; however it requires precision in pipetting as there must be sufficient labelled DNA to bind to samples in order to reach an endpoint. Although the use of radiolabels within the Farr assay provides highly reproducible results, it becomes very costly, dangerous and difficult to dispose of the radioactive isotopes. Other limitations with this assay are that it only detects IgG and cannot determine any other immunoglobulin isotopes (IgA/IgM), thus patients presenting with dsDNA antibodies to IgA/IgM can be missed (Egner 2000). UK NEQAS shows that the Farr assay is still being used (Figure 1.9), as it is a more accurate confirmatory test that can be used in the diagnosis of SLE. The accuracy of the Farr assay can be seen in many studies. A study by Launey and colleagues (2010) compared the Farr radioimmunoassay to three commercial enzyme immuoassays and CLIF staining. The study looked at 99 patients with SLE and found that the Farr assay was the best assay, offering greater sensitivity and specificity of 95%, than the three other ELIA and CLIF assays. Derksen et al, (2002) also showed similar results. He compared the Fa rr assay with the Varelisa EIA assay and found that the Farr assay was superior to the EIA assay as it presented with a specificity of 95% and a sensitivity of 72%, whilst in EIA specificity corresponded to sensitivities at 44%. Many laboratories also perform follow-up DNA tests by EIA, using CLIF to determine the avidity of anti-dsDNA antibodies. However CLIF can also be used alongside IIF to measure anti-DNA (IIF-DNA) and this does not requiring any specialist equipment, other than a fluorescence microscope. The CLIF assay allows detection of high affinity antibodies through titrations, however this requires precise pipetting. CLIF detects antibodies to kinetoplast of organisms, which consists of circular dsDNA and allows both IgG-anti-dsDNA and IgM-anti-dsDNA to be tested (Gonzalez-Buiterego Gonzalez, 2006). The test is highly reproducible and is particularly suitable for a limited number of samples. Although the assay offers the highest specificity for ANA testing, it has a relatively low diagnostic sensitivity for SLE. Due to the degree of accuracy of the Farr assay, it is undoubtedly the best assay for the detection of dsDNA and so has been approved by the World Health Organisation (WHO) and operates under the WHO80-IRP standard. However due to the risk of handling radioactive substance and the cost of the assay; this is not routinely used within Immunology. 1.4.2.2 Anti-ENA Positive IIF-ANA are typically followed up by extractable nuclear antigens (ENA). ENAs were discovered in 1966 by Smith and colleagues, offering a greater specificity, to allow a more accurate disease diagnosis, in correlation to the initial IIF-ANA screen. Originally ENAs referred to proteins found in a saline extract of cell nuclei, however since then the components have been identified and these consist of cytoplasmic molecules. A whole spectrum of approximately 100 antigens can be screened; however most have no clinical significance. In order to cover the majority of inflammatory autoimmune diseases 6 clinically significant antigens (Table 4); Ro, La, Sm, RNP, Scl-70 and Jo1 are used within most laboratories across the UK. It can be seen that SLE is associated with many of the antigens in the screen. Although ENAs are commonly performed via EIA (Figure 1.10), other methods such as qualitative gel precipitation assays, passive haemagglutination, immunoblotting, counter current immunoelectrophoresis (CIE) and antigen microarray can also be used (Kumar et al, 2009). Sceening of ENAs is expensive in comparison to IIF-ANA as it allows specific antigen detection, offering a greater sensitivity as approximately 90% of positive IIF-ANA produce negative results via EIA (Dahle et al, 2004). Gel precipitation assays such as double immunodiffusion (DID) and counter current immunoelectrophoresis (CIE) are still being used within laboratories; however these were discovered over 5 decades ago. CIE uses an electric current to accelerate the migration of antibody

Bilingualism and the effects of third language acquisition

Bilingualism and the effects of third language acquisition Since the early 1920s, much research has been done on bilingualism, with the earliest investigations finding mainly negative cognitive effects attributed to bilingualism (Pintner Keller, 1922; Saer, 1923). However, ever since Peal Lambert (1962) counter-claimed that bilinguals actually do perform better in certain cognitive tasks (e.g. symbolic manipulation types of non-verbal tasks), more recent studies have solidified the current view that bilingualism enhances ones cognitive flexibility and metalinguistic awareness. Yet, most research on language acquisition only focuses on one target language and neglects other languages already acquired or are being acquired by the learner. Research on third language acquisition (TLA) or the acquisition of additional languages (AAL), which attempts to fill this gap by bringing together the two traditionally detached fields of bilingualism and language acquisition, has only begun to accelerate during the late 1990s (Cenoz, 2008; Falk Bardel 20 10). The effect of bilingualism on TLA is one of the main areas of interest in research concerning third language (L3) studies. In order to sufficiently answer this question, we would have to define what we mean by bilingualism and third language acquisition. Different linguists define bilingualism differently over a broad spectrum, from the maximalist view of equal native-like competency in two languages to the minimalist interpretation of a minimal competency in two languages. For the purpose of this paper, we will define bilingualism as the ability to communicate effectively in two languages. Similarly, henceforth, third language acquisition will be defined as the process of learning and acquiring of a non-native language in a secondary context (i.e. language is acquired in a structured setting) by a learner who have already acquired two other languages previously. General consensus today prescribes to the notion that bilingualism brings about various cognitive benefits. It can be postulated that third language learners have a distinct advantage over second language learners due to their enhanced cognitive capabilities brought about by their bilingualism. Hakuta Bialystok (1994) wrote that the knowledge of two languages is greater than the sum of its parts. Most studies tend to indicate advantages in bilinguals over monolinguals in language acquisition, especially when the learners bilingualism is additive rather than subtractive (Cenoz, 2003). While there are numerous other factors affecting TLA including language similarity, L1/L2 influences, L1/L2 proficiency, recency of use, language status, role of Universal Grammar, cross-linguistic influences, early multilingualism and age of TLA (De Angelis 2007; Cenoz, 2008), we will be focusing solely on the effects of bilingualism on TLA. In particular, we will be discussing the effects of meta-ling uistic and meta-procedural gains on TLA due to bilingualism. Bilinguals have shown to display cognitive flexibility and enhanced metalinguistic awareness over monolinguals, and this in turn enhances bilinguals TLA (McLaughlin Nayak, 1989; Cenoz, 2003). Studies of bilingual children have shown bilinguals to have higher scores in tests targeting creative or divergent thinking. Research has also shown bilinguals to possess better abilities to control and utilise linguistic knowledge and to have an overall predisposition in word awareness tasks (Cummins, 1991; Bialystok, 2001). Furthermore, in Cummins (1991), the interdependence hypothesis was proposed which suggested that skill transfers take place from a bilinguals L1 into L2. One can only assume that these enhanced cognitive and metalinguistic abilities would have a positive effect in a bilinguals acquisition of a L3. It can also be logically deduced that the skill transfers from L1 into L2 based on the interdependence hypothesis can also occur from a L3 learners L1 and L2 into the L3. In an e ffort to further this hypothesis, De Angelis (2007) wrote that TLA differ significantly from second language acquisition (SLA) due to the fact that L3 learners can transfer linguistic elements from their prior knowledge in both L1 and L2, and this gives L3 learners an advantage over L2 learners. Studies have also shown that L3 learners often leverage upon their access to two different linguistic systems during the process of TLA (Herdina Jessner, 2002). All these suggested that the enhanced cognitive and metalinguistic abilities a bilingual possesses positively affects the acquisition of a L3. Enhanced cognitive abilities are not the only skills transferable during TLA. Syntactic transfers have also been shown to occur in L3 leaners. Different languages have different syntactic rules, and most bilinguals would have had access to the different syntactic rules governing the different languages they know (assuming that the two languages are syntactically dissimilar). This knowledge of two different sets of syntactic rules would assist a bilingual in the learning of a L3. Flynn, Foley Vinnitskaya (2004) proposed that language learning is cumulative in the Cumulative-Enhancement Model, suggesting that each language learned previously influences and enhances subsequent language learning, adding to a cumulative advantage for third and additional language learners. However, a more recent study by Bardel Falk (2007) on Swedish and Dutch L3 learners found only positive transfers of syntactic properties from L2 but not L1 in the learning of a L3. It was additionally proposed that i n L3 acquisition, the L2 acts like a filter, making the L1 inaccessible. If the above researches holds true, bilingualism could have either a positive or negative effect on third language acquisition depending on the learners L2. If the L2 is syntactically similar to the L3, the L3 learner would experience positive transfers of the syntactic properties of L2 into L3, aiding the learners acquisition of L3. Conversely, if the L1 but not the L2 is syntactically similar to the L3, the L3 learner would not be able to access the benefits of his knowledge in his L1 that he would otherwise have been able to reap had there not existed an L2 to act as a filter. Nevertheless, both studies while disagreeing on the existence of syntactic transfer from a L3 learners L1, agreed that they both found no negative (only positive or neutral) transfers regardless of the similarity or dissimilarity of the L3 learners L2. Therefore, irrespective of the fact that syntactic transfer from L1 occurs or not, bilinguals would have an advantage (or at least no disadvantage) in languag e learning as compared to monolinguals. Similarly, studies have also proved that transfers in the bilinguals knowledge of different orthographic systems give the bilingual an advantage in TLA. While numerous languages in the world are similar orthographically, many written languages have vastly different orthographic systems. In many cases, a learner of an additional language would need to learn a new orthographic system. Abu-Rabia Sanitsky (2010) compared students with knowledge in two orthographies (Hebrew and Russian) against students with knowledge in only one (Hebrew) in the acquisition of English as an additional language. While the results found that transfers of orthographic skills occurred in both groups of students, the learners who were familiar with two orthographic types outperformed those with knowledge in only one type of orthography. It was also noted that the rich orthographic experience in different orthographies is an advantage for trilingual speakers. However, numerous studies have found limited orthog raphic transfers when two vastly different orthographic systems were involved (e.g. Wang, Perfetti Liu, 2005 on Chinese-English; Wang, Park Lee, 2006 on Korean-English). In particular, Bialystok, Luk Kwan (2005) compared Spanish-English, Hebrew-English and Chinese-English bilinguals with monolinguals, and found that all three groups of bilinguals obtained higher levels of literacy than the monolinguals. They also found that Spanish-English and Hebrew-English bilinguals had a greater advantage than Chinese-English bilinguals (Spanish and Hebrew are both written alphabetically albeit in different scripts; Chinese is written logographically). While evidence shows that bilinguals would have an advantage in TLA due to orthographic transfers, the magnitude of such gains would be dependent on the similarities (if any) of the orthographies involved. It can be assumed that as the benefits of orthographic transfers exist due to the bilinguals enhanced awareness of different orthographic and script systems, bilinguals who use the same orthography and script in both L1 and L2 would find little or no advantage over monolinguals in the acquisition of an additional language which uses a different orthographic system. The same bilingual would however experience benefits in learning a L3 which uses the same or similar orthography and script as both the L1 and L2. However, what remains to be researched is the amount of orthographic transfer when the L3 is orthographically similar to either but not both the L1 and L2. It would also be interesting to find out if the filtering effect as proposed earlier by Bardel Falk (2007) on blocking o f syntactic transfers from the L1 by the L2 likewise holds true for orthographic transfers. TLA is similar to SLA in many ways, but yet it has been reported that language learners benefit from not only meta-linguistic gains but also from meta-procedural gains from prior language learning experiences. A study by McLaughin Nayak (1989) speculated that expert learners use different information-processing strategies and techniques than do more novice learners, and noted that multilinguals use a wider range of strategies and are more flexible in language learning than monolinguals. Similarly, Kemp (2007) showed that multilinguals experience in language learning helps them formulate better learning strategies which speeds acquisition through freeing up working memory. Kemp further noted that the number and frequency of strategies used in language learning is positively related to the number of languages the language learner already knows. From this, we can conclude that the more languages a person knows, the easier it will be for him to acquire an additional language. We can thu s deduce that bilingualism gives the bilingual an advantage in L3 acquisition brought about by the prior language learning experience. However, most studies on L3 learners meta-procedural gains have compared L3 learners with L2 learners, neglecting the differences between L3 learners who are simultaneous or sequential bilinguals. For L3 learners to reap the benefits from meta-procedural gains, logically, the learner must have had prior textbook learning of a language. Simultaneous bilinguals who grew up learning two languages simultaneously in a naturalist setting would not have had prior language learning experiences to tap upon. Further studies on TLA comparing simultaneous and sequential bilinguals would fill this gap and offer additional evidence of such meta-procedural gains if results prove that sequential bilinguals perform better in TLA over simultaneous bilinguals. During the course of this paper, we have discussed how, more often than not, bilingualism has shown to exhibit positive effects on the acquisition of a L3 be it meta-linguistically or meta-procedurally. It has to be noted that while most studies conducted on the effects of bilingualism on TLA tend to claim advantages for bilinguals, not all reports on the effects of bilingualism on third language acquisition is positive. Some studies have instead shown no significant advantages in TLA by bilinguals (Soler, 2008). Cenoz (2003) further pointed out that even if bilingualism has an effect on third language acquisition, it does not have to affect all aspects of third language proficiency in the same way, and different conclusions can be drawn depending on the dimension of language proficiency taken into consideration. Moreover, in Del Puerto (2007), it was pointed out that balanced bilinguals tend to perform better than less balanced bilinguals in third language learning. In other words, the degree of proficiency in L1 and L2 must also be taken into account when evaluating the effects of bilingualism on third language acquisition. Logical reasoning would direct that a bilingual who is less proficient in or is suffering from language attrition in either of his languages would perform less impressively than a balanced bilingual. As Del Puerto (2007) aptly sums it, third language acquisition is an exceedingly complex process and a multicausal phenomenon than can be affected by multifarious factors. We have but discussed some of the effects of bilingualism on third language acquisition, but the multitude of causal factors involved in third language acquisition means that much more can be discussed on this subject.

Macbeth Essay -- essays research papers

Does the statement "Fair is foul, and foul is fair" thoroughly expresses the many themes of Shakespeare’s ‘Macbeth’? The first time we hear the statement is very early in the play when the witches say the exact line "Fair is foul, and foul is fair" only for Macbeth himself to repeat it very closely two scenes later. This repetition of the lines shows me that the characters themselves believe that there are many foul events taking place. In this essay I will endeavour to prove that the above statement doesn’t express ‘Macbeth’ thoroughly. Firstly I will show the fair Macbeth himself degrading into a foul inhuman monster. Secondly, I will compare the witches to Macbeth to demonstrate the real foulness in these characters. I will then show why I believe that there simply isn’t any fairness existing in ‘Macbeth’. Then I will point out that there are simply too many themes in Shakespeare’s ‘Macbeth’ to be summed up in one line. Macbeth, in the beginning, is a man of valour, honour and nobility. By his loyal traits he helps maintain Scotland’s stability. Macbeth, on the outside, seems to be the fairest man in all Scotland, however we know better. Under the cloaking shadows of his skin, Macbeth hides his one weakness - that is ambition. His wife knows of his ambition and stirs him to act on it. Macbeth struggles with a choice; should he let the witches prophecies realise themself, or should he take steps to the achieve them. He knows that the latte...

English Language Learners: Families and Schools Essay examples -- ELL

Diverse cultures within the United States are rapidly developing and growing and the educational sector is the number one target to ensure that English –learners are receiving adequate education. Within the educational sector there are administrators and teachers who are involved in students lives on a daily basis to ensure that education is equal. In order to achieve the vital objective of equality, socio-cultural influences on ELL students, bilingualism and home language use, parental and community resources, and partnerships between families and schools all have to be considered to provide an opportunity for equal education. The American society has a vast influence on students who are English learners. In this case it is prominent for educators to provide the best knowledge, creative strategies for learning and classroom management skills that are reliable to give these students the best education. Becoming more perceptive and analytic observers as educators enables teachers to detect aspects of children's everyday learning experience from home that could be adapted for use in school (Leighton, Hightower, Wrigley, 1995). In order to understand the most important aspect about ELL students it is significant that the teacher become knowledgeable about the students’ cultural background. One way to accomplish this task is to become familiar with a student’s background by reading multicultural literature on the students’ culture, tradition, religion, and beliefs. Engage with the parents and family members to get the most important information about the student to know how the student lea rns. Once the educator has learned the students’ cultural background it will be easier to instruct the student and for student to learn. An ELL... ...education and students to flourish academically. References Academic Writing Tips. Org. (2011). ELL families and schools. Retrieved April 5, 2012 from, http://academicwritingtips.org/component/k2/item/640-ell-families-and-schools.html?tmpl=component&print=1 Cummins (1994). Knowledge, power, and identity in teaching English as a second language: Educating second language children. Cambridge, England: Cambridge University Press. Leighton, M. S., Hightower, A. M., & Wrigley, P. (1995). Funds of knowledge for teaching [Electronic version]. In Model strategies in bilingual education: Professional development. Washington, DC: U.S. Department of Education. Retrieved April 5, from http://www.ed.gov/pubs/ModStrat/pt3i.html Robertson, K. (2007). Bilingual family night for ELL families. Retrieved April 5, 2012 from, http://www.colorincolorado.org/article/18800/

Meeting Stakeholder Quality Needs Essay

Reflective Statement In this module I have had to think about how this company functions in a lot more detail than I have ever done before. It is easy to take for granted some of the work that is done on the quality side of the business. It was interesting to look at and audit my department and discuss with my manager areas where I believe we can improve. The skills I have been taught have given me a new view on the processes I complete and I am now considering alterations and improvements which I did not do before. The module has led me to question why things are done the way they are done, and if there is a better, more efficient way. Finally the concept of stakeholders, whilst not new, has been made more relevant. I am more aware of what I do and how it affects others within Allen Gears. I am more aware of how the company is viewed within the community and the importance that of the community as a stakeholder in the business. 1.1 Determine organisational stakeholders and their expectations Stakeholders can be categorised as any party that has a share or an interest in an undertaking. This could mean literal ownership and shares in a business or an actual interest in a business succeeding as its success is in some way tied to your own. This therefore includes customers, suppliers, employees and the local community. When considering Allen Gears, as an employee I would be considered a stakeholder. The Management team of Directors are stakeholders not only through being employed but not as owners. As a company that pays taxes the government are a stakeholder and as an employee of nearly 200 people the surrounding area would be considered a stakeholder. Another way of determining stakeholders is to identify those who are directly impacted by the project and those who may be indirectly affected. Examples of directly impacted stakeholders are the project team members or a customer who the project is being done f or. Those indirectly affected may include an adjacent organization or members of the local community. Directly affected stakeholders will usually have greater influence and impact of a project than those indirectly affected. Every stakeholder has their own needs and requirements. Each of their requirements will not be the same and may divert along different tangents. For example within Allen gears a concept to produce fewer gearboxes but at higher margin for more profits may sit well with government and shareholders, but if it comes at the cost of jobs and less revenue for suppliers then this would not be in their interests. It is therefore difficult to please all stakeholders at all times as their requirements may be at odds with each other, but awareness of your stakeholders and their expectations can help when you are making decisions that directly or indirectly impact on your stakeholders. 1.2 Discuss methods of meeting stakeholder expectations or requirements Stakeholders can b e defined as all entities that are impacted through a business running its operations and conducting other activities related to its existence. The impact can be direct in the case of the business’s customers and suppliers or indirect in the case of the communities in which the business chooses to place its locations. Businesses must consider the needs and expectations of its stakeholders, though it need not consider them to be of equal importance. Certain stakeholders such as owners and investors are more important than others. Once the business has identified its stakeholders and their importance to the business, it can begin to plan based on their needs and expectations. Each stakeholder has concerns that it expects to be met by the business. For example, the business’s owners expect it to be profitable and to distribute that profit to them while local and federal government agencies expect it to obey the law and pay its taxes on time. The importance of each stakeholder to the business determines the degree to which the business attempts to accommodate the stakeholder in the course of planning its actions. [ (Li, 2013) ] If identifying the stakeholders is the first step then the second step is to plan how you intend to communicate with them. If there is a two way method of communicating not only can you inform the stakeholders that you are meeting their expectations, more importantly they can inform you when you aren’t. These can be as easy as a brief conversation or a detailed as a monthly meeting with the chamber of Commerce. Within Allen Gears I attend several weekly meeting where stakeholder requirements are not only expressed but tracked to make sure we meet pre agreed targets and delivery dates. Any information gathered from communication needs to be disseminated throughout the company. This is so that all aspects of the company are aware of the stakeholder expectations. Once the relevant information is received it can be acted upon and the results can be reported to the stake holder. Within sales our key stakeholders are typically customers. We communicate via meeting, ov er the phone or by e-mail. Typically any requirements that are technical are e-mailed and upon receipt someone in our department is tasked with resolving any questions or requirements. The results are then feedback to the customer. 1.3 Identify methods of communicating stakeholders’ requirements with team members Communication Methods The method to communicate within Allen Gears should be based on: * The type of information to be distributed * The audience requirements * The timeline for a required response [ (Abudi, 2009-2013) ] Within Allen Gears the sales team all sit within speaking distance of one another so it is quite easy to express any immediate stakeholder requirements or issues. For formal clarifications or where a response needs to be documented e-mails are usually the preferred method. These are easy to store and handy to reference in complicated situations or where a large amount of information needs to be given. In sales we also regularly visit our customers who are our primary stakeholders. As we operate around the globe a cheaper alternative to this is conference calls. Any relevant information from these calls or meeting can then be fed back to team members via visit reports or one-to-one sessions. We also operate a database which holds all the latest information gathered or sent to our stakeholders. This is accessible by all members of the sales team. 1.4 Explain processes for updating information on stakeholder requirements Stakeholder requirements will change rarely stay fixed. Dependant on the nature of the stakeholder they can change due to your actions or their situation. Within sales our primary stakeholder is the customer. Part of our sales role is to review the status and satisfaction of the customer. Feedback may indicate that we need to change your approach to stakeholders. Within Allen Gears another key stakeholder is the projects management team. We regularly discuss how to improve and if we can prove a better quality of work. If an improvement is found it is implemented through team meetings and process change. There are a number of implications o f not responding quickly to a change in stakeholder requirements, including wasted resources, broken relationships, and damage to the organisation’s reputation. At Allen Gears one of the tools we employ to update stakeholder requirements is a tender database. This holds the latest information received from our stakeholders and is sorted by each tender or project. Against each entry is a section that records any necessary action to be taken with respect to the latest information received. This tool allows us to maintain a record of the latest information and encourages dialogue with our stakeholders to make sure we are meeting their expectations. 2.1 Discuss the meaning of quality to an organisation When discussing the meaning of quality to an organization it is important to define meaning of quality. For Allen Gears quality could be described as meeting the needs and expectations of our customers. What must also be considered is the cost of achieving that quality. The â€Å"cost of quality† isn’t the price of creating a quality product or service. It’s the cost of not creating a quality product or service. A useful tool to help recognise failures and re-work is the Cost of Quality (CoQ) Model. In this, every activity is classified either as Core Work, Failure, Appraisal or Prevention. The Cost of Quality is the sum of Failure, Appraisal and Prevention costs. This is a relevant way of thinking about waste and failure. Core Work| All work carried out directly for the benefit of a customer, done right the first time. These are real, value-adding activities. Customers would happily pay you good money to do these, on their behalf.| Examples: Delivering service to a customer, manufacturing a product, issuing an invoice, processing an order| Failure| Any activities associated with producing errors, or services that are not right the first time, or dealing with work that was not done right the first time. None of this is â€Å"good†.| Examples: Handling complaints, paying compensation for problem, dealing with queries, responding to help-desk calls, correcting errors, solving problems, repeating previously done work| Appraisal| Any activities carried out to check if work has been done right the first time. Some of these activities are â€Å"good†, if they lead to prevention activities that improve core work.| Examples (good): Audits that lead to improvement, staff performance appra isals Examples (bad): checking somebody else’s work, authorising, counter-signing, QC checks| Prevention| Any activities carried out to ensure other activities can be carried out right the first time. These are â€Å"good† things to do.| Examples: Training, coaching, developing standard operating procedures, identifying customers’ requirements, briefing staff on plans and requirements, developing error-proofed systems, establishing policies| The theory behind the Cost of Quality (CoQ) Model is that, the more time that is spent on Prevention activities, the less time will need to be spent on Appraisal and dealing with Failures. Prevention activities build quality in. Both Appraisal and Failure are â€Å"after the event†, and therefore are too late and add cost. (Seath, 2006) Examples within Allen Gears include: * The reworking of a manufactured item. * The retesting of an assembly. * The rebuilding of a tool. * The correction of a tendered document. In short, any cost that would not have been expended if quality were perfect contributes to the cost of quality. (Campanella, 1999) To reduce the cost of quality a business needs to employ a process that can be reviewed, maintained and assessed so that quality is not only always achieved but is done so in the most efficient manner. 2.2 Identify and apply organisational quality policies and procedures ISO 9001 (OE and Services) ISO 9001 is the internationally recognised standard for the quality management of businesses. It applies to the processes that create and control the products and services an organisation supplies, and prescribes systematic control of activities to ensure that the needs and expectations of customers are met. ISO 9001 is designed and intended to apply to virtually any product or service, made by any process anywhere in the world [ (ISOQAR Limited , 2013) ] There are 6 mandatory procedures required by the ISO 9001 standard. * Control of Documents * Control of Records * Internal audit * Control of non-conformance * Corrective action * Preventive action Within Allen Gears we adhere to all these procedures as standard. Documents are required to have an issue number. Records are controlled and stored by the quality department. Departments are internally audited every six months. As Allen Gears manufactures many parts any non conformance is highlighted and corrective and preventative action is taken as standard. This also happens in all areas of the business but this tends to occur more in manufacture due to the unique and complex nature of our products. ISO 14001 (OE and Services) ISO 14001 is an international standard that specifies a process for controlling and improving a company’s environmental performance. ISO 14001 consists of: * General requirements * Environmental policy * Planning * Implementation and operation * Checking and corrective action * Management review This means you: Identify elements of your business that impact on the environment and gain access to the relevant environmental legislation. Produce objectives for improvement and a management program to achieve them, with regular reviews for continual improvement. Primarily within Allen Gears this relates to the environmental consequences from the manufacture of our products. Allen Gears uses hazardous substances that must be controlled and managed in a safe and an environmental friendly way. Also within our office there is a recycling policy that is part of the overall environmental policy. [ (ISOQAR Limited , 2013) ] ISO 18001 (OE and Services) BS OHSAS 18001 is intended to help businesses control occupational Health and Safety risks. It was developed in response to a widespread demand for a recognised standard of certification, and actually works well with the ISO 14001 standard. It is a framework that allows a business to consistently identify and control its Health and Safety risks, reduce the potential for accidents and legal issues, and improve overall performance. (ISOQAR Limited , 2013) Within Allen Gears this standard requires the completion of risk assessments and risk control.This is especially important within a company that operates heavy machinery, which Allen Gears does. We also required to report all incidents and check for corrective and/or preventative action. 2.3 Determine how to encourage staff to contribute ideas to improve quality At Allen Gears due to the specialised nature of our gearboxes everything that we do is centred on providing a quality, bespoke product. To that end the ideas and practices of promoting quality are ingrained into the company structure. We are consistently looking at improving and checking that processes are as efficient as possible. We have several methods which we use to encourage staff to suggest ideas to improve quality. Allen Gears runs a suggestion box which looks for quality improvements and process improvements. This is reviewed weekly and there is a monthly cash prize for the best idea which promotes staff participation. Staff are appraised and performance is discussed. Key performance indicators are agreed and these relate to quality as well as productivity. The appraisals are a two-way dialogue therefore staff have a chance to highlight areas of concern and methods to improve quality. Staff are encouraged to participate, give their thoughts and are made to feel that it is a safe environment to make suggestions. Around the business there are information screens which give all member of the company the latest information on how we are performing as a company against agreed targets. This shows the parts of the business that are on target and the parts that are not. This helps the business to focus on the areas that need the most attention. Given the importance of quality, you can never have too many ways to encourage improvements. Using a â€Å"negative focus† is one of those methods. The rea lity is that when members of staff make errors or mistakes, someone has to do extra work to make up for the issues at hand. Typically this is at an extra cost or within a short time frame than the original work. When you link poor quality to extra work, you challenge employees to face reality for themselves and others. Mistakes and errors have a negative impact. The way to reverse this situation is to reduce or eliminate them and by highlighting the issues employees are motivated to think of solutions. 2.4 Conduct a quality audit and make recommendations for improvement One of the most important objectives of an internal quality audit is measuring the effectiveness of an organization’s quality management system. For this to happen, executive management must first meet its overriding responsibility of establishing and maintaining a system regarding quality policy, goals, resources, processes and effective performance–including monitoring and measuring the system’s effectiveness and efficiency. For example below is a portion the sales process for enquiries that is to be audited. Audits are conducted to verify whether processes are conducted in accordance with documented processes, BS EN ISO 9001, customer requirements, and legislation and for aerospace processes, subject to AS9100. Compliance against Rolls-Royce and customer specifications may also be audited. Audits shall be used to determine the effectiveness of the quality system and the results fed back to top The ultimate aim of the audit process is to identify weaknesses within the Allen Gears processes – as continuously improving these will prevent quality and delivery issues. Scheduled internal audits of compliance with company procedures and BS EN ISO 9001, AS9100 checklist covering all teams having an influence on the quality of the product or the environment. Unscheduled audits of any area, function or activity as deemed necessary. In instances of non-conformance to procedures, BS EN ISO 9001 or AS9100 an ‘Audit Failure Entry’ (Corrective Action Request) shall be raised for each clause or procedure contravened. Each Corrective Action Request will be given a unique number via the IBS system. The Auditor shall discuss non-conformities with the Manager and agree a mutually acceptable rectification plan and close out date. This shall be recorded on the GD233-2. Should t he auditor have difficulties in obtaining a commitment to rectify a non-compliance, then the Director or MD shall be consulted. It is the process owner’s responsibility to close down non-conformances with their area. A table listing the questions and corrective actions based on the Sales report can be seen below: Question| Y/N| Examples /documentation| Issues?| Corrective action/Recommendations for improvement| Have all members of the sales team got access to the standard practices and process?| Yes| On the desktop of every computer or laptop is a shortcut to Allen Gears Standard Procedures. Members of staff are made aware of this and part of the training is to go through this in detail| No issues| No corrective action required| Are all staff aware of the standard practices and processes for their job role?| Yes| From discussions all members of the sales team are aware of the standard practices. These practices require that documentation and databases are filled in. The staff completing these tasks is an example of their awareness| No Issues| No corrective action required| Are tenders highlighted as highly likely or unlikely?| Yes| Within the tender database there is a section for highlighting the likely hood. Part of the tendering process is to complete this.| On a few tenders this part of t he tender database has been left empty leaving it unclear whether the tender is likely or not.| A regular review of the database to make sure all aspects are fully completed and filled in.| Are the tender database and tender files kept updated| Partially| The tender database was reviewed and there were examples of recent correspondence with customers.| The tender database has a section that records actions and the date they are due to be completed by and there is evidence that this part of the database has not been updated for some tenders. A print out of files that have not been updated is issued but not acted upon| A regular review of the database to make sure all aspects are fully completed and filled in. Meetings to unsure that the information is up to date| Are customers contacted regularly for information?| Yes| Important e-mails are forwarded to management and are also recorded in the database. Phones and correspondence is recorded in the database. Weekly meetings are held to discuss ke y projects. This meetings are recorded in Outlook| No Issues| No corrective action required| Are bid no bid reviews completed?| Partially| Bid no bid reviews are recorded in outlook as a weekly Monday meeting.| If an enquiry comes in that requires immediate attention,(or needs resolution before the next Monday) there is no structure for impromptu bid no bid reviews| An alternative method of reviewing short term proposals and projects should be formulated.| Are Specification reviews completed?| Partially| There is evidence of specification reviews taking place for highly likely projects only| If a project that was not likely becomes likely it may not have been reviewed to a sufficient level and this will not be recorded.| Within the tender database there should be a section to record that a review has taken place. A tick box would suffice. It is not necessary to review all projects.| Are tender documents produced in accordance with the sales process?| Yes| There is evidence within th e tender files of General Arrangement drawings, tenders and datasheets. They are stored correctly and completed to the required standard.| No Issues| No corrective action required| Are tenders turned down and closed down in accordance with the sales process?| Partially| There is evidence of tenders that are dead, but they have not been closed out to a sufficient level| The major issue is that reports that are run will include incorrect data| The database and tender files need to be checked more regularly to ensure that data held is accurate| Is all order documentation completed correctly and within the minimum timescale?| Yes| There is evidence in the tender files of all the documentation in accordance with Allen Gears procedures being completed and examples and notes from the necessary pre order meetings. This shows that orders are completed to the required standard| No Issues| No corrective action required| 3.1 Discuss the concept of, and need for, continuous improvement A culture of continuous improvement is necessary to enhance productivity and free up the capacity that will provide manufacturers a stable foundation to pursue innovation and growth. (The National Institute of Standards and Technology , 2011 ) For a business it means that you are constantly and consistently improving your competitive position by improving efficiency, quality, innovation, or any other attribute that is vital to the system or process within the business. If you do not continuously improve any number of bad outcomes can occur. Customers stop buying, profitability declines and morale decreases. The plan–do–check–act cycle (Figure 1) is a four–step model for carrying out change. Just as a circle has no end, the PDCA cycle should be repeated again and again for continuous improvement. Figure 1: Plan-do-check-act cycle When to Use Plan–Do–Check–Act: * As a model for continuous improvement. * When starting a new improvement project. * When developing a new or improved design of a process, product or service. * When defining a repetitive work process. * When planning data collection and analysis in order to verify and prioritize problems or root causes. * When implementing any change. [ (American Society for Quality, 2004) ] Within Allen Gears we use the plan-do-check-act cycle. Typically on a quarterly basis we brainstorm and produce evaluation matrices based on areas where we believe we can bring about change and improvement. Recently we investigated reducing the total time spent in productivity meetings. As they involve several members of management and take 30-45 minutes, any time saved would be seen as a quantifiable improvement. Following the evaluation process we began the trialling of a new method for displaying productivity figures for our weekly meeting. This was a small scale test to see if time was saved. After a month there was agreement that this method made it easier to analyse where productivity was falling and where staff were not being utilised efficiently. This meant the meetings where shorter. This display method is now used in several other areas of the business to display their productivity figures on a monthly and quarterly basis. 3.2 Assess work activities and identify areas for improvement In my roles as a Sales Engineer my key deliverables and work activities are to: * Produce proposals in response to client’s enquiries. * Manage the interfaces of Engineering, procurement, Commercial and Tendering inputs to ensure all proposals are commercially and technically robust. * Manage and agree prioritisations of Engineering, procurement, Commercial and Tendering to ensure clients required dates are adhered too. * Communicate with customers throughout proposal preparation, post submission and ongoing, in order to develop long term customer relationships. * Undertake customer visits in support of the sales strategy. Producing proposals is an important part of informing the customer how the gearbox Allen Gears intends to produce is aligned with what they have requested. Currently there are parts of the proposal that are standardised. Whilst it would not be possible to standardise the whole proposal there are steps that could be taken to reduce the overall time to complete a proposal with standardisation. The management of the process by which parts of the business provide input for proposals is also not effici ent. Whilst communication is good it could be improved. The information received varies between members of staff and there is not a set process which details what should be received and the timescales. If this was implemented the process could be benchmarked and we would have a clearer understanding of the issues that cause delays when completing proposals. Customer communication is an important part of any business and at Allen Gears one of my key activities is to receive and act on any feedback from customers with regards to the proposals we are sending. Allen Gears currently has a very good method of collating this information and we use it as a benchmarking tool to review if we are meeting customer expectations. Whilst the tool is very effective there is always room for improvement. The tool should be reviewed for effectiveness. There is some data that is not captured within the system and on review some data that is captured but not relevant. By reviewing the tool Allen Gears can continually assess it for effectiveness and make sure it is always providing the most useful information. 3.3 Encourage staff to contribute ideas for continual improvement In these current times of austerity any competitive advantage must be realised as securing orders and making profit become increasingly difficult. By recognising the current climate and highlighting the situation within Allen Gears it is possible to get employees to suggest methods and processes which can cut costs and help the company win business. Allen Gears has tried to encourage its employees to look at processes that they are completing regularly and consider improvements. If you concentrate on nurturing the process, the results will come as a natural consequence. Everyone has processes and every process can be improved. Unintended variation in our processes leads to undesirable variation in the outcomes of our processes. If you discuss the process with process stakeholders they will be able to suggest ideas for process improvement. Another option is to provide incentives for employees who innovate. By creating a culture within Allen Gears where creative thinking and innovation is rewarded rather than frowned upon will help to constantly generate new ways that employees can function better individually and as teams, as well as improving the way the company operates as a whole. Throughout Allen Gears mangers should look for problems that need to be solved within the organisation. There is no such thing as a perfect company. A company that thinks it has nothing to improve on will certainly improve nothing. If Allen Gears or any company proactively looks for areas where your company could improve, it will give you targets to focus the energies of your employees on. Another idea is to promote the idea concept of experimentation. An organisation that is truly committed to continuous improvement is filled with people who are comfortable with learning from what doesn’t work. An organisation where people are afraid of consequences will never be successful at continuous improvement. At Allen Gears we have a research and development team where a large portion of what they produce is experimental. Bibliography Abudi, G. (2009-2013). Abudi Consulinting group. Retrieved March 6, 2013, from GinaAbudi.com: http://www.ginaabudi.com/methods-for-distributing-information-on-projects/ Ad Esse Consulting Ltd. (2008). Managing your Stakeholders. Retrieved March 6, 2013, from ad esse: http://www.ad-esse.com/resources/documents/Articles/managing_stakeholders.pdf American Society for Quality. (2004). Plan-Do-Check-Act (PDCA) Cycle . Retrieved March 2013, from American Society for Quality: http://asq.org/learn-about-quality/project-planning-tools/overview/pdca-cycle.html Campanella, J. (1999). Principles of Quality Costs: Principles, Implementation, and Use, Third Edition,. ASQ Quality Press. ISOQAR Limited . (2013). ISO 9001 (QMS). Retrieved from ISOQAR – Part of the Alcumus Group: http://www.alcumusgroup.com/isoqar/standards/iso9001-quality/ Li, A. (2013). How Do the Needs & Expectations of Stakeholders Influence a Program’s Plan? Retrieved March 6, 2013, from Demand Media: http://smallbu siness.chron.com/needs-expectations-stakeholders-influence-programs-plan-36119.html The National Institute of Standards and Technology . (2011 , April 10). U.S. Department of Commerce. Retrieved from The National Institute of Standards and Technology (NIST): http://www.nist.gov/mep/ngs-continuous-improvement.cfm Seath, I. J. (2006, October 19). Cost of Quality – the forgotten tool? Retrieved April 30, 2013, from http://www.performance-measurement.net/news-detail.asp?nID=222