Case study of CVS

According to the filed work results made by PSI team, we know that approximately one in four scripts experienced a problem at some point in fulfillment process. As we all know, the fulfillment process is critical for the transfer of the customer’s need into reality. An inefficient process would lead to a poor pharmacy service which would depress the recent customer. It’s certainly true that a better fulfillment process could prevent 60%-90% of the customer defection that were due to service.We know come up with solutions to deal with the problems now exist in the CVS fulfillment process. Improvement would never happen until changes are made. On the one hand, CVS should design a more efficient flow chat to reduce the inherent risks and inefficiency during the process. A proper flow chat should start with the analysis of the existing process situation in CVS and find out the bottle neck in the process. On the other hand, from the case, we know that a number of problems co uld occur in the part of Data entry.For example, customers pay the prescription and soon leaving the pharmacy, but the prescription may appear without drugs or the payment will not covered by their insurance. When they come back to pick drugs, they would be give nothing but dissatisfied. If things go on like this, customer satisfaction and customer loyalty will inevitably be effected . In order to reduce the defections in this part, changes should be made . CVS Pharmacy should build a comprehensive information system. The IT system should have enough function to support the operation.The doctor can upload the prescription after diagnosing, then the tech of pharmacy can check the prescription online and finish the remaining work. For the problem of no refill allowed, the IT system which contains prescription guidance by selecting the personal information of the patient in history. For the problem of DUR Hard Stop, IT at CVS should cut down the time for drug review. Since the possibil ity of different drug to drug interaction have the different time, IT system should have the ability to recognized the maximum time for major drug interaction which would absolutely improve the efficiency.Also the customers can login the system to check whether their prescription has been completed to decide when they go to take the drugs. After the above improvement, the most likely part to have problems is the situation at the pickup window at peak period. When customers came after work to pick up the prescriptions, most locations found it difficult to staff this time period simply because pharmacy employees did not want to work then. To address this problem, we feel that we can create some self-dispensary machines, just like ATM, so that the customers can take their prescriptions on the machine by themselves.Because of the establishment of the IT system, there will not be wooden boxes in use. If the system design is too complex, people will feel it is more efficient to use the or iginal method. The results may cause the failure of the changes. In order to prevent backsliding, the system must be easy to use so that both customers and staffs can use it conveniently. Pharmacy Service Initiative can greatly promote the customers’ pickup speed, save time, improve efficiency. Nothing could be better than that to be more attractive to consumers.Faster pickup-rate than other pharmacies can let CVS win more customers, increase customer loyalty, and attract new customers patronizing. Now most people complain about taking drugs,which is not only wasting long time to queue but also having complicated steps. If we can solve this problem, it will be a milepost of pharmaceutical service industry. This is a great opportunity for CVS companies to increase their market share, to defeat the competitor, and to become a leader in pharmacy.The economic benefits it brings to CVS is self-evident. Has the absolute authority is an absolute superiority on the pharmaceutical ind ustry, after that it will be hard to endanger the status and influence of CVS. In addition to economic benefits, the reform also brings many benefits to the internal stability of company. Not only reducing the customers’ complaints and churn rate, but also greatly improving the employee’s satisfaction and reducing turnover rate. These make CVS having more stable and rapid development.

Book List For Dialectical Journal 2 1 Essay

Quote Reply â€Å"War is peace, freedom is slavery, ignorance is strength† They are the Party slogans, and are wri? en in big le? ers on the white pyramid of the Ministry of Truth. â€Å"Who controls the past controls the future. Who controls the present controls the past. † The people controlling the present control everything and can ul! mately change the past and, therefore; the future. Big brother controls the present. The slogan is an example of the Party’s technique of using false history to  deteriorate the psychological independence of its people. To Kill A Mocking Bird Harper Lee Lord of the Flies William Golding An! gone Sophocles The Joy Luck Club Amy Tan Bless Me, Ul! ma Rudolfo Anaya Black Boy Richard Wright Of Mice and Men John Steinbeck Night Elie Weisel The Things They Carried Tim O’Brien Catcher in the Rye J. D. Salinger Odyssey Homer The Picture of Dorian Grey Oscar Wilde Julius Caesar William Shakespeare The Perks of Being a Wall7ower Stephen Chbosky.

Sicko by michael moore Essay Example | Topics and Well Written Essays - 1000 words

Sicko by michael moore - Essay Example Michael Moore has proficiently used ethos, pathos and logos to makes his argument stronger in the movie. (Thesis) The main technique used by Michael Moore to get attention of the people is Pathos. In the first few scenes of the movie, the director has shown a man who is sewing his own knee, a 79 year old man who is working still to pay his prescriptions and an old man who had to decide which finger he would use to pay for to get fixed. These scenes are emotionally charging and make the audience feel the pain and agony undergone by people. The audience gets connected with the people in the movie and sympathizes for them. These scenes project the pathetic health care situation in America and how people suffer despite they are in a rich country. The pathetic condition of people is the core pathos used by director in the movie. In this movie, the husband of a woman who works for a hospital gets denied for bone marrow transplantation because it not a mandatory surgery. He dies after few w eeks. Here the pathos is used in a great way as the viewers connects with the wife through the interview and gets attached and sympathize for her. Another major example in the movie is where a mother is interviewed on a playground; this is an emotional scene as she had lost her daughter. The reason why Michael Moore is instilling such scenes in movie is to portray the audience about the poor health care system in US. As per (Bradshaw) â€Å"This magnificent new film from Michael Moore is a timely reminder of the grotesque mess that Americans have made for themselves with healthcare, and how insidiously easy it would be for the same thing to happen to us, little by little†. The viewers feel disgusted and hate health insurance companies after the death of the man who was denied surgery. The movie has many interview instances and some people who have taken part in the interview have worked for treacherous heath insurance companies. These people have much knowledge about the comp anies and can be regarded as ethos of the argument. The people who are interviewed discuss and explain about the health insurance working system and principles. O ne good example of Michael Moore was when he interviewed a person who had the job of collecting history of clients to deny them claims. These instances make the audience understand the treacherous ways of health insurance companies. The author wants the public to understand how they are being fooled of money by the health insurance companies. This scene persuades the people to understand that ethics of health insurance companies are weak and the government is less concerned about this fact. The main aim of the director in making movie is to show the ignorance of public health in America. Michael Moore uses statistical information also to convey the pathetic health care situation in America. â€Å"Fifty million Americans do not have health insurance† (SICKO). This is opening statement of the movie. Right of the bat, Michael Moore announces a statistic that exclaims that there is something wrong with America’s health care. The use of statistics by Michael Moore is ideal because the movie is not only about statistics, but few of them prove his points. Another statistic that was impressive was â€Å"health care programs spent over 100 million dollars to beat Hilary and her view of socialized health care†. This shows the shrewd means of health care business and these statistics

So What Does This All Mean to me Assignment Example | Topics and Well Written Essays - 250 words

So What Does This All Mean to me - Assignment Example We may vary from the way we speak and our beliefs but still each of us has a unique characteristics that makes us interesting from each other. The stereotype role I play on my daily activities and decision making is the role of choosing and ending with the right decision and how this decision will entirely affect me and the people that surrounds me. I chose my current current is because this is something that will help me finish my studies and change my life in the future. My future career will be stereotyped based on what I am sowing today and I planned to be successful in different ways. I have learned to be more decisive, picky, and use my common sense from the American popular culture. I have also learned that it is still my own decision if I will get affected by the culture presented and that all that is happening around me; absorption is based on personal assumptions. Through this, I came to the point of not being so stereotype and I should always find a reason to justify things before concluding something. I believe that I can only maintain the values I have learn by practicing it and applying it daily relative to my decisions and how I think over into something and for me; values are something that you can acquire but hard to leave out in someone is applying it all to himself. Implementation of the values learned is somewhat similar to applying it to everyday activities. What I have learned today, Ill make sure that I get to apply it and through the application I know it will help me to go to the right path in terms of getting good career and most likely into business. Galupo, S. (2004). U.S. Pop culture seen as plague; damage, influence may be exaggerated: The Washington Times. Retrieved from

Levels in Undergraduate Family Nursing Education Personal Statement

Levels in Undergraduate Family Nursing Education - Personal Statement Example The district nurse, my mentor started talking to them, and what I observed was worth noting. The visible anxiety gradually calmed down. This was an effective communication, and this was essential in this scenario to pacify them. When I went back home that night and when things started settling down, I thought I would go over the whole incident and find out what was special about this incident, and how this incident can help me in any future incident in the professional practice (Ghaye and Lillyman, 2000, 53-87). This was a set of home health care, and from the incident, it was clear that the incident had considerable acuity. I was a student nurse, and therefore, it was a learning experience for me. The major goal of nursing care in this situation, given Mr. Xs advanced cancer, is palliation and restoration of maximum health function. I was entirely inexperienced, so I decided to observe what my mentor did in this situation (Ghaye, 2005, 7-37).  While reflecting, I gradually came to understand, well-developed communication skills are therefore essential tools for nurses. It was a face-to-face situation, and perhaps there is no substitute for it. I witnessed how effective and appropriate communication helped to establish a therapeutic helping relationship and enabled my mentor to determine their care needs and how it promoted trust and confidence and facilitated care appropriate for this situation. They were anxious and angry.  

The Book The Road and The Movie The Shop on Main Street Essay

The Book The Road and The Movie The Shop on Main Street - Essay Example In the book â€Å"The Road†, Cormac McCarthy writes of a period that had been established during the post-apocalyptic time and the setting is purely fictional to generate the mood that had been associated with failed determination at progress. These two tales predict the events within the universe using different approaches with the movie predicting actual events in relation to the Jewish treatment during the famous war and the book telling tragedy at the time the universe had been created to be linked to a fictional universe. The relationship had been accorded to the two tales to accord the needed incentive in delivering a stable plot development. The movie â€Å"The Shop on Main Street† and the book â€Å"The Road† have both been developed to indicate the nature that humanity may be subjected to the harsh conditions on both fictional and reality scale, and deliver means to find solutions of survival. The Shop on Main Street The movie depicts the plot placed to reflect the nature that the form fascism may be relayed towards innocent living to harm positive societal relations. The character Tono Briko who is depicted as a Czech carpenter is presented with the solution that would uplift his low stature. Tono establishes the relationship with an elderly Jewish woman in the attempt to offer security to her button shop business. Although he is depicted as a lazy individual without ambition, he is accorded the status of an assistant within the new business as a reward for the loyalty that he had portrayed (Crowther). The plot twist had been when he had been faced with the decision of protecting his friend or betraying her, as the Jewish citizens had to be transported and interdicted. Kadar and Klos had created the movie to bear the reflection of the subjections placed on the individuals who had witnessed the tyrannical rule of Hitler. The climax of the plot development had been seen when the tough decision had to be made concerning the human abi lity of relating between the virtues of presenting a saintly character to the evil personality that creates human relation. The plot had been developed to change the outlook issued from the developed theme of positive relation to the period that had been presented to acknowledge difficult decision of protecting the interest of the weak. The period favored the system implemented where the Jewish had been accorded the difficulty to exist during the Hitler regime. The story set had been developed to present the oppression theme on two individuals from both sides of justice. The elderly Jewish woman had been intentionally used in the plot development to relate to the Aryan co-worker to inform of the imbalance that had been inevitable. Although she fulfilled the demands that had been placed upon her to employ an Aryan, the difficulty presented had been noticed when the movie ended in the decision that Tono had to face. The theme of betrayal and oppression is played intricately within the development of the play to limit progress and peaceful relations needed to grant total closure. The time had been crucially related to the historical impact of the reign that Hitler had presented during his reign. The oppressed during the time had composed of Jewish who had been subjected to difficult presentation during the rule of the Nazi. The Road McCarthy’

Analysis of the Origin of the marriage rituals, traditions, practices Research Paper

Analysis of the Origin of the marriage rituals, traditions, practices of Jewish weddings in Orthodox communities - Research Paper Example Marriage is a social institution in which two individuals are united in holy matrimony. The institution of marriage, as we see it today, has grown over many centuries. Traditionally viewed as the union of a man and a woman, this concept has become more complex today owing to the increased sophistication and civilisation of modern societies. Thoroughly immersed in customs, traditions, religion and civil regulations, many of the conventional rites have perished over time to yield place for new ones. The rituals, traditions and practices of marriage differ greatly across diverse cultures, religions, countries, ethnic communities and social strata. Majority of the traditional marriage ceremonies comprise an exchange of nuptial vows by the couple, offering of gifts and a public announcement of the marriage by an authority figure. Some other commonly incorporated elements in a wedding ceremony are traditional music, recital of poetry, chanting of prayers or readings from religious texts. A ll of these marriage customs have their roots firmly embedded in the beliefs and customs of the society in which they are conceived. In Judaism, marriage is regarded as the ultimate state of mankind and a man without a wife or a woman without a husband are regarded as incomplete. As Isaac Klein quotes from Leviticus 34a in his book "A man who does not marry is not a complete person." (Klein, 1979, p. 381) It is also believed that "Any man who has no wife lives without joy, without blessing, and without goodness." (Garland, 2003, p.276) In Jewish literature, the term that denotes marriage is â€Å"kiddushin†, which in English means "sanctification".

Theories of Constructivism and Rational Choice Essay

Theories of Constructivism and Rational Choice - Essay Example This essay stresses that in both constructivism and rationalism, a lot of attention is paid to the interaction between the individual and the social structure but the notion is viewed from different lenses by the school of the thoughts. Constructivism has also tended to give more attention to the traditions and mutual understandings of legitimate behavior. On the other hand, this comes into clash with the perceptions propagated by rationalists who believe that the actors try to do the right thing rather instead of working for and reaping the most benefits from their given set of preferences. Constructivists do not give preference to structure over an agency or vice versa. However, this theory does not accept the notion of individualism which is widely accepted by rationalizing theorists. Constructivists have presented arguments against the individualistic ontology of rationalizing theorists; instead, constructivism has placed stress on social ontology. As the report highlights the aim of positivist theories is to imitate and reproduce in a similar form the procedures undertaken by natural sciences. This is done by reflecting upon and evaluating the effect of material sciences. Positivist theories are characterized by their capacity to take into account various features of international relations like the nature of interactions amongst states, the size of the army put into order by governments, the clash and balance of the authorities and the control of the states. On the same hand, the role of post-positivist epistemology comes into limelight. This epistemology refutes the notion that the social world can be investigated and studies upon for the purpose of gaining more insight into the dynamics of international relations by taking an  unbiased and value-free  approach. The concepts of neo-liberalism and neo-realism, as promoted by a number of theorists, are not granted credibility and substance for study of the social world. Th is follows that the rational choice theory and other theories that fall under the category of neo-liberalism and neo-realism are not a viable approach for knowing more about the social world in an academic way. Post-positivist epistemology  regards that these theories are not applicable for this purpose because the scientific method cannot be used for analyzing the interactions being carried out in social setups, and therefore a science relating to the international relations can never be established. One of the main differences between the two sets of theories is that while positivist theories, like neo-realism, present simple explanations, e.g. the rationales as for why and how power is to be used; post-positivist theories instead center on constitutive questions, like what exactly is meant by power, what builds it up, how it is experienced and reproduced. The rational choice theory   Evolution of Rational Choice Theory The rational choice theory is based on the views and conc epts of a man named Cesare Beccaria from the 1700s. Cruelty and harsh punishments were common in the period of the nineteenth century but Beccaria’s dedication to the field aided in eliminating such unjust practices. He believed

Othello Essay Example | Topics and Well Written Essays - 1000 words - 11

Othello - Essay Example The first impressions of these characters are, on the one hand, Othello is good, but he is susceptible to manipulation because of his naivetà ©, whereas Iago, on the other hand, is in control as the evil mastermind of Othello’s doom. Othello is a good man because he is honorable and has, to some extent, the respect of his wife, troops and masters. He is a respectable, honorable man. He does not have an illicit affair with Desdemona, and instead, he marries her and makes her his legal wife. The way he looks at her shows his great devotion to her in the movie. He looks at her as if the world is Desdemona and she is his happiness and life. In addition, even when some people judge Othello because he is black, he remains noble in actions and words. For example, he respects Desdemona’s father, even when he calls him something that she fears â€Å"to look on† (Parker, Othello) as if he is some beast. Instead of ridiculing Senator Brabantio who has openly condemned him in public as someone who used â€Å"witchcraft† to charm his daughter, Othello stays respectful and tells the Duke and the rest of the people that the Senator â€Å"loved† him and his stories (Parker, Othello). In other words, he sees Brabantio as his own father. Furthermore, other people respect Othello, including his troops and masters. Cassio is faithful to Othello until the end. As an illustration of his devotion to his general, Cassio is heartbroken when he thinks he has failed Othello because of what he did when he was drunk. Cassio wants to serve and please Othello because he respects him as a general. Other troops and Venetian people also show respect to Othello by following his orders. For instance, when he breaks the brawl between Cassio and others, no one questions him. These people respect his authority, most probably because he is a noble person to follow. Even the Duke values Othello for his contributions to the Venetian army. The Duke tells Brabantio: â€Å"†¦your

About Shakespeare Essay Example for Free

About Shakespeare Essay Hamlet is Shakespeare’s longest and most tragic play. It was first published in 1603, from a draft published several years earlier. The play begins two months after the death of King Hamlet of Denmark. The country is in a state of unrest. Young Fortinbras of Norway is preparing for war. After the King’s death, his brother Claudius takes over the throne, and marries the widowed Queen Gertrude. Young Hamlet, the late king’s son is incensed. He is told by the ghost of his father, that Claudius had poisoned him, to become the King of Denmark. Hamlet starts acting like a madman rousing concern. Polonius, an advisor to King Claudius is also worried by Hamlet’s strange â€Å"transformation. † The two, along with Queen Gertrude instruct Rosencrantz and Guildenstern, Hamlet’s childhood friends to spy on him. Hamlet is also increasingly hostile towards his love, Ophelia, Polonius’ daughter. Out of fear, the King orders Hamlet to be sent to England. King Claudius and Polonius both feel that Hamlet is dangerous. To ensure who the culprit was, Hamlet cleverly changes the lines in a play which is performed before the king and the queen. See more: Is the Importance of being earnest a satirical play essay The King’s reaction convinces Hamlet that it was indeed he who poisoned his father. Alone, King Claudius reveals his crime, and confesses that he cannot escape divine judgment. After the play, Queen Gertrude scolds her son, but he instead scolds his mother for her wrong actions. Polonius is spying on the two, from behind a curtain. Hamlet hears Polonius, and kills him thinking he is Claudius. Anxious and scared, the king orders Hamlet to be sent to England, along with Rosencrantz and Guildenstern. The King wants Hamlet killed as soon as he arrives in England. Hamlet had the spies Rosencrantz and Guildenstern put to death instead. Meanwhile, Young Fortinbras has brought his army to Denmark. Hamlet admires Young Fortinbras, for his courage to fight for honor. The death of Polonius has a profound impact on Ophelia, who in her depression and apathy kills herself by drowning. Laertes, Polonius’ son is enraged. The king tells him that it was Hamlet who murdered Polonius. The two decide to get rid of Hamlet, their common enemy. Claudius and Laertes arrange a duel, in which Laertes will fight Hamlet. To ensure Hamlet’s death, Laertes poisons the tip of his sword. In the course of the duel, Laertes, Hamlet and the King are poisoned by the same sword. Queen Gertrude drinks a poisoned drink meant for Hamlet, and is killed. Dying, Hamlet tells Horatio to tell the world of his story and recommends Young Fortinbras the next king of Denmark. Hamlet – Prince of Denmark is a play that deals with the main subjects of honor, revenge and suicide. Hamlet is not our typical hero. Born in a royal family, he is a refined young man with noble attributes, but he has his weaknesses. After his father’s murder, he is driven mad by anger when his mother marries Claudius. His love for Ophelia too turned into a strange confusion and mix of emotions. He distrusts all those around him, and starts dwelling in a melancholy state of mind. Even those he thought were his friends turn out to be spies sent by the king and queen. This also explain Hamlets â€Å"insanity† to a great extent. But even so, Hamlet is a disturbed individual. The way he treats Ophelia is obvious evidence. He is cruel to her, in spite of her efforts to try and understand him. He is also impulsive – he kills Polonius without thinking twice. Justice and revenge form major themes of the play, with Claudius, at the Head of a country, having killed his own brother, and Hamlet, avenging his father’s death. Suicide also forms an essential theme in the play. Ophelia kills herself by drowning. Hamlet too is prompted to kill himself. † But should he, or not; â€Å"To be or not to be, that is the question. † Shakespeare portrays all the characters with great ingenuity. He analyses human psyche, and how eventually, everyone’s destiny is controlled by fate. References: About Shakespeare, Hamlet Study Guide, http://absoluteshakespeare. com/guides/hamlet/hamlet. htm

Independent Prescribing | Supplementary Prescribing

Independent Prescribing | Supplementary Prescribing Introduction This portfolio has been compiled in order to complete the non-medical prescribing qualification through the University of Central Lancashire. Throughout the portfolio, the author has analysed situations encountered whilst working along a designated medical practitioner (DMP). The author is a mental health nurse and is employed in a community mental health team, offering support to individuals who suffer with severe and enduring mental health problems. In the practice area, new ways of working (Department of Health (DH), 2007) is beginning to take effect which has enabled expansion of current roles, including non medical prescribing. The portfolio is organised into sections, with an index page for navigation. Two consultations are presented; the first involving an individual with a neurotic illness, where independent prescribing was deemed appropriate in the absence of co-morbid illness or significant risk. The second consultation pertains to an individual with severe and enduring mental health problems who has suffered adverse reactions to medication previously and for whom supplementary prescribing appeared to be the safest prescribing option. The consultations are followed by an evidence section and appendices. Completion of the portfolio has facilitated extensive development of knowledge in terms of pharmacology, including physiological variance (evidence 15). Knowledge of psychotropic medicines has also greatly improved and the importance of physical health monitoring for service users has since become a priority. The author believes that becoming a non-medical prescriber will provide an ideal opportunity to have a direct effect on public health targets such as reducing avoidable death from suicide and offering quicker, more appropriate treatment options to people with mental illness. The author also feels confident that non-medical prescribing in mental health will lead to increased concordance and better service user satisfaction. The required practice hours of the course have been achieved (evidence 1) through working with members of the prescribing team (evidence 2a, 2b, 2c, 2d, 2e). Throughout the portfolio, the author has ensured protection of confidential information, as directed by the Nursing and Midwifery Council (NMC) (2008) by referring to the service users by pseudonyms i.e. Alexander and by anonymising information related to the Trust for which the author works. Furthermore, consent forms have been obtained for named professionals and user perspectives Independent Prescribing Independent prescribing is defined as prescribing by a practitioner (e.g. doctor, dentist, nurse, pharmacist) responsible and accountable for the assessment of patients with undiagnosed and diagnosed conditions and for decisions about the clinical management required, including prescribing (DH, 2006 p2). The author will critically analyse an independent prescribing situation, addressing learning outcomes 1,2,3,4 and 5 in doing so. Reference to the stages of the prescribing pyramid will be made as this is a useful model to ensure appropriate prescribing (National Prescribing Centre (NPC), 1999). The patient will be referred to as Anne Knowles. Anne was a 28-year-old woman with a history of depression, referred by her General Practitioner who suspected a relapse. In order to confirm this, a full assessment was undertaken. Fortunately in mental health, adequate time is allocated for practitioners to gather information. Prescribers are encouraged to approach consultations in a structured way (NPC, 2003) therefore the Calgary-Cambridge model (Silverman, Kurtz and Draper 1998) was used alongside a structured tool in support of this approach. Health authorities have formulated unique Care Programme Approach (CPA) assessment tools based on the original guidance in Caring for People (DH, 1990) to accomplish a holistic assessment and this is what is advocated by the NPC (1999), as the first element of good prescribing practice. The author used the tool designed by the local health authority in the assessment of Anne (evidence 3). While the CPA assessment is comprehensive, the author elected to enhance it with additional tools to better inform prescribing practice. Incorporating Mortons (1992) symptom analysis tool a thorough assessment of Annes presenting symptom was facilitated. Furthermore, an individualised report obtained using a solution-focused approach (de Shazer, 1988), gave the author an appreciation of what was currently happening and how improvement would be detected (evidence 3, page 13). The author also utilised Becks Depression Inventory-II (BDI-II) (Beck, Steer and Brown, 1996) (evidence 4). Although routinely used in the practice environment due to its ease and speed of completion, it has been criticised due to the gender and cultural bias (female, Caucasian), which it represents (Hagen, 2007). This is something with which the author would agree and plans to use the Montgomery-Asberg Depression rating scale (Montgomery and Asperg, 1979) in the future as this has a broader reflection than the BDI-II. The remainder of the assessment, including a full medical, social and medication history, allergy status and exploration of Annes beliefs about her illness and future treatment were also included in the assessment. It is commonplace in clinical practice for staff to present assessments to the medical team where discussion of differential diagnosis occurs. Such discussion facilitates accurate diagnosis and debate of treatment options; however it is reliant on a precise initial assessment and effective presentation of the case. Following this a diagnosis of moderate depression was agreed under section F32.1 of the International Classification of Disease (World Health Organization (WHO), 1992). Considering the prescribing pyramid, the second step requires deliberation of the appropriate strategy to use. As the diagnosis of moderate depression was established, the author knew that a prescription was needed. Guidance from the National Institute of Clinical Excellence (NICE) (2004) suggests that individuals diagnosed with moderate to severe depression should routinely be offered a pharmacological intervention before psychological interventions. When considering choice of products, the third step of the prescribing pyramid, prescribers have available various antidepressants from diverse groups, namely Monoamine-oxidase Inhibitors (MAOIs), Tricyclic Antidepressants (TCAs), and Selective Serotonin Reuptake Inhibitors (SSRIs). There are also listings in the British National Formulary (Royal Pharmaceutical Society (RPS) British Medical Association (BMA), 2007) for other antidepressant drugs that cannot be classified into specific groups due to their unique pharmacology i.e. Mirtazapine and Reboxetine. In choosing between the agents, the author consulted national guidelines (NICE, 2004) which examine the effectiveness, appropriateness, safety and cost-effectiveness of drugs. NICE (2004) favours use of SSRIs to other antidepressant groups. This is because they are as effective as TCAs but concordance is higher because of the better side effect profile (NICE, 2004). Barbui and Hotopf (2001) reported that Amitriptyline, a TCA was more effective than SSRIs however conceded that use of SSRIs was higher because of their enhanced tolerability. SSRIs are less likely to cause sedation and cause much fewer anti-muscarinic effects than TCAs (RPS BMA, 2007). The other major distinction is that should they be used in overdose, SSRIs are considered less toxic than TCAs. Use of an MAOI was not considered as first-line treatment for Anne. Although once viewed as less effective than other antidepressants, when used in adequate doses, MAOIs are as efficacious (Riederer, Lachenmayer and Laux, 2004). However MAOIs are generally better in treating atypical depression (Riederer et al, 2004) and are associated with dangerous dietary and drug interactions (Nash and Nutt, 2007). SSRIs are the agents of choice in the practice area (evidence 5), in line with national guidelines. The common pharmacology of SSRIs is the prevention of reuptake of the neurotransmitter serotonin into the pre-synaptic cell, leaving increased amounts of serotonin available to bind to post-synaptic receptors (Carrasco and Sandner, 2005). Although the central nervous system is the desired site of action, SSRIs also exert their effect throughout the body, which explains their side effects. Aside from the primary pharmacology of the SSRIs, each has diverse properties, knowledge of which assists prescribers to choose the most appropriate agent. NICE (2004) directs prescribers to opt for Fluoxetine or Citalopram due to their ease of discontinuation as with other SSRIs, users have reported distressing discontinuation symptoms. A review by Haddad (2001) found as many as fifty different discontinuation symptoms, ranging in severity from mild to severely disabling. These included dizziness, nausea, lethargy, headache, electric shock like sensations, insomnia and nightmares. An understanding of the physiological mechanisms underlying the syndrome has yet to be realised. Theorists such as Tamam and Ozpoyraz (2003) and Blier and Tremblay (2006) speculate that the readaptation of the neurotransmitter systems, which rapidly increase reuptake of serotonin and subsequently decrease the amount of serotonin able to bind to post-synaptic receptors, are the likely triggers. Drugs with shorter half lives i.e. Paroxetine are the most problematic and those with longer half-lives and active metabolites i.e. Citalopram and Fluoxetine appear to fair better (Taylor, Paton and Kerwin, 2007). In terms of appropriateness, all SSRIs share identical cautions and contraindications and research has shown that Citalopram is just as effective as Fluoxetine in treating depressive symptoms (Patris, Bouchard, Bougerol, Charbonnier, Chevalier, Clerc, Cyran, Van Amerongen, Lemming and Hopfner Petersen, 1996). Consideration of patient-specific factors during the history taking identified that Anne found previous success with Citalopram. The medical history had not highlighted any conditions where cautions apply such as epilepsy, cardiac disease, diabetes mellitus, allergies etc and the author was aware that use of all antidepressants was contra-indicated in mania (RPS BMA, 2007). The choice of product was made in discussion with Anne. She had a preference for Citalopram and after reviewing the available evidence, the author concurred with this choice and prescribed Citalopram (evidence 6). See evidence 7 for a profile of Citalopram. Next, it was necessary to negotiate a contract with Anne, stage four of the prescribing pyramid. Anne understood Citalopram from previous use, however education regarding what the prescription was for and how long it would take to work (evidence 7) was given. Anne did not have a preference in terms of formulation and therefore tablets were prescribed, as this was the cheapest option. The side effects and red flag concerns of the medication were then identified to Anne (evidence 1, section 6). All antidepressants have been linked with a possible increased risk of suicidality. Research into SSRIs and suicidality demonstrates conflicting findings in that Healey (2003) found increased risk in early treatment and Isacsson, Holmgren and Ahlner (2005) reported a reduction. The Medicines and Healthcare products Regulatory Agency maintain that prescribers of SSRIs should monitor and assess for this regularly. Due to the possibility of suicidality occurring as a red flag, a prescription for treatment to last seven days was given and the rationale explained to Anne and her partner. In the practice area, service users are given information from the United Kingdom Psychiatric Pharmacy Group (UKPPG), available via the Trust intranet; the data regarding Citalopram was given to Anne (Appendix 1). Furthermore, Anne was encouraged to refer to the patient information leaflet, dispensed with the product from the chemist. Annes partner expressed concerns about media reports questioning the efficacy of antidepressant medication; this was addressed by giving him a copy of the Trusts response to the information (Appendix 2). This information was successful in reassuring him (evidence 8), along with the arrangements for reviewing Anne on a regular basis. In terms of reviewing Anne, stage five of the prescribing pyramid, a further appointment was made for seven days, in line with NICE (2004) guidance due to her higher background risk of suicide as an individual under the age of thirty years. Based on the evidence that SSRIs can increase risk of suicide, planning to see any patient commenced on antidepressants within a week would better ensure safety and professional accountability, in addition to addressing the public health target to reducing suicide. Although increased energy and motivation is apparent a week into treatment, the antidepressant effect is not, therefore the individual may continue to experience depressive symptoms and have the impetus to act on suicidal thoughts (NICE, 2004). Frequent monitoring thereafter is recommended by NICE (2004) who suggest professionals look for signs of akathisia, suicidal ideas and increased anxiety and agitation, which can occur with all antidepressants, including Citalopram. The author elected to give Anne and her partner the contact details for the Crisis Team in the local area, should support be needed out of working hours, explaining that they could be contacted if her mental health further deteriorated or she began to suffer with suicidal thoughts. It was indicated to Anne that she would be unlikely to feel the full benefit from the treatment for approximately two weeks due to the pharmacology of the drug (evidence 7) and that once the depression had lifted; guidelines suggest treatment should continue for at least six months after this marker. Geddes, Carney, Davies, Furukawa, Kupfer, Frank and Goodwin (2003) found that treatment continued for this time frame reduces the risk of relapse. In terms of keeping records, stage six of the prescribing pyramid, Annes progress was recorded using the electronic Care Programme Approach (eCPA) system. Use of eCPA in the practice area is a new development, intended to replace the paper-record system, allowing immediate access to relevant mental health staff. It is currently inaccessible to other health professionals; therefore duplication of work is necessary in order to ensure effective communication. Currently, professionals involved in the care of an individual seen by psychiatric services are identified as part of the initial assessment (evidence 1, section 19) and are advised of their treatment plan and progress via separate letters (Appendix 3). Working in this manner ensures safe, ethical practice by good communication with members of the multi-disciplinary team (NMC, 2008). In line with the NMC standards for recordkeeping (NMC, 2005) the author recorded and disseminated the information in a timely manner, using the same format as her DMP. In the future, the author plans to work with the non-medical prescribing lead to develop an appropriate format for her practice, which should enhance professional accountability. The seventh and final principle of the prescribing pyramid encourages reflection on prescribing practice. The author was confident that a prescription was necessary and therefore did not feel pressured by the patient to issue treatment against better judgement as can be the case (Britten, Ukoumunne and Boulton, 2002). Neither did the advertising activities of the relevant drug company influence the choice of product. Reliance on independent research was used to inform prescribing practice. Supplementary Prescribing Supplementary prescribing is described as a voluntary partnership between an independent prescriber (a doctor or a dentist) and a supplementary prescriber to implement an agreed patient-specific Clinical Management Plan with the patients agreement (DH, 2005a paragraph 8). A critical analysis of a supplementary prescribing scenario will follow, addressing learning outcomes 1, 2, 3, 4 and 5. As in the IP scenario, reference will be made to the prescribing pyramid (NPC, 1999). The patient will be referred to as Alexander Stewart. Alexanders General Practitioner (GP) had been managing his care; however he had been referred to the service following discontinuation of antipsychotic medication Risperidone, due to sexual dysfunction. Alexander was under the care of a consultant psychiatrist who had diagnosed Schizophrenia of the paranoid type, under Section F20.0 of the International Classification of Disease 10 (WHO, 1992). At the time of meeting Alexander, early warning signs of relapse were evident in that he believed others were against him and were sending messages via media sources. Alexander had sufficient insight to be able to recognise that his mental health was declining and had attended the appointment in the hope that an alternative treatment could be prescribed. The independent prescriber (IP), Dr Gater, felt that Alexander was a suitable candidate for a supplementary prescribing arrangement as there were no issues of substance misuse, no co-morbid illnesses and he had a good history of engagement. It is recommended that these factors be considered before contemplating supplementary prescribing in mental health care (DH, 2005b). New Ways of Working in Mental Health (DH, 2005c) dictate that individuals with highly complex needs, including those with dual diagnosis, history of poor engagement, co-morbid physical illness and assessed high risk of harm to self or others are seen by more advanced, highly trained professionals such as consultants. Dr Gater discussed with Alexander the possibility of supplementary prescribing and he agreed to work in this way, with the author as the supplementary prescriber (SP), who also took on the role of care co-ordinator. The IP set the parameters of the Clinical Management Plan (CMP) and this was then drawn up and signed, (evidence 9) indicating agreement by the IP, SP and Alexander as is mandatory for supplementary prescribing situations (DH, 2005a). The IP and SP had shared access to the patient record. The CMP in this instance was broad and permitted prescription of antipsychotic medication from a wide choice of agents, however CMPs can be specific, for example, only allowing the SP to make dose or frequency of dose changes to an identified medicine (DH 2005b). In such cases, if a patient were to develop adverse side-effects from the medicine, a new CMP would have to be developed, leading to increased workload and time delays for treatment. In this instance, because of the knowledge and experience of the SP, the close working relationship of the IP and SP and the accessibility of comprehensive guidance regarding the management of Schizophrenia (NICE, 2002b) a broad CMP was considered appropriate. The author used the prescribing pyramid to aid practice (NPC, 1999) and adhering to the first principle, considered a holistic assessment. The IP had already taken a thorough history and made a diagnosis, however the history taking was repeated by the SP to ensure that Alexanders presentation had not changed. Difficulties can arise if this occurs (evidence 2d). A CPA assessment was carried out (evidence 10), supplemented by a symptom analysis tool, namely Morton (1992). The assessment confirmed the original diagnosis. The National Service Framework for Mental Health (DH 1999a) reported that individuals suffering with this illness are nine times more likely than the general population to commit suicide and that the risk of death from other violent incidents is over twice as high. Government policy since this time has aimed to ensure that people with mental health problems are better able to access services and appropriate treatments in a timely manner, to prevent the aforementioned likelihoods. The author was keen to uphold these principles and treat accordingly. Theorists such as Wyatt (1991) and McGlashan and Hoffman (2000) have speculated that prolonged non-treatment of Schizophrenia can result in brain-damaging neurotoxicity and synaptic plasticity, respectively; however there is limited research into these theories (McGlashan, 2006). Findings from duration of untreated psychosis studies have lead to the recent development of Early Intervention Services which aim to ensure that people with mental illness receive timely treatment in order to prevent biological, psychological and social decline (Whitwell, 2001). Personal experience has further demonstrated that non-treatment of the illness results in further loss of insight, increased distortions of judgement and the possibility that the active phase will last indefinitely. This knowledge meant that the second principle of the prescribing pyramid was satisfied since the appropriate strategy was to issue a prescription. Alongside this, the author, working as care co-ordinator for Alexander highlighted interventions to address issues relevant to his quality of life and well-being including housing, finance and employment support etc as suggested by government policy (DH 1999a, DH 1999b). The third principle, consideration of product choice, was initially agreed via the CMP. This indicated use of antipsychotic medication; however the selection of agents was open for discussion between Alexander and myself. To aid the decision, referral was made to the NICE guidance for treatments in Schizophrenia (NICE 2002a). The guidance recommends use of atypical antipsychotics in the treatment of Schizophrenia. Evidence 12 explains typical versus atypical antipsychotics in further detail. Alexander previously had a good response to an atypical drug, namely Risperidone, however stopped it due to the adverse drug reaction (ADR) he suffered. Alexander developed retrograde ejaculation, a reasonably high reported adverse effect of this drug (Taylor et al, 2007). Alexanders G.P had been satisfied that the symptom was not caused by other conditions such as diabetes mellitus or multiple sclerosis; and as the symptom ceased following discontinuation of Risperidone, was satisfied that it was an ADR. Although evidence suggests that this effect is dose related (Raja 1999, Loh, Leckband, Meyer and Turner 2004), Alexander did not wish to recommence this treatment. In choosing the most appropriate treatment, the criteria was therefore further simplified to an atypical agent, where possible, with a low affinity for alpha1 adrenergic antagonism since this is thought to be the cause of retrograde ejaculation with Risperidone (Loh at al, 2004). From the atypical agents listed in the current British National Formulary (RPS BMA, 2007), the two with the lowest affinity for alpha1 adrenergic antagonism are Aripiprazole and Quetiapine (Loh et al, 2004). Alexander was also presented with information comparing antipsychotics in terms of other commonly experienced side effects (Appendix 4) and then given the opportunity to ask questions. Finally, Alexander and I agreed on Aripiprazole and a prescription was issued (evidence 11). In addition to the importance of the positive side effect profile, Aripiprazole also rated as less expensive than comparable treatment with Quetiapine (Taylor et al, 2007) and this is a factor which prescribers are directed to pay attention to (NPC 1999, NICE 2002). In terms of preparations, Aripiprazole is manufactured in tablet form, orodispersible tablets and as an oral solution. As Alexander was happy to take tablets, this was the preparation prescribed. Aripiprazole is described as having a uniquely robust pharmacology (Davies, Sheffler and Roth 2004), centred on it being a partial agonist at Dopamine D2 receptors. Evidence 12 provides a profile for Aripiprazole, which explains this in further detail. It is distinctive from the other atypical agents as it stabilises the spread of dopamine in two of the four major pathways (mesolimbic and mescortical) where the neurotransmitter Dopamine is found, as opposed to purely blocking dopamine receptors or working as an antagonist at D2 receptors. Despite this difference, a recent systematic review of Aripiprazole actually found that it did not have significant advantages over other atypical medicines, neither did it demonstrate increased efficacy over typical drugs (El-Sayeh and Morganti, 2004). Coupled with this, Aripiprazole was shown to instigate similar adverse effects as treatment with typical agents, with the exception of akathisia, which lead to improved compliance (El-Sayeh and Morganti, 2004). Aripiprazole has not been shown to cause elevation of prolactin levels, nor is it associated with the development of impaired glucose tolerance or weight gain, therefore in theory, monitoring of these factors is not required (Travis, Burns, Dursun, Fahy, Frangou, Gray, Haddad, Hunter, Taylor and Young, 2005). In fact, Travis et al (2005) purport that no specific monitoring is required outside of the basic screening advocated in NICE (2002b) i.e. monitoring for endocrine disorders and cardiovascular risk factors etc. Despite this, the NHS Trust for which the author works recommends extensive monitoring (Appendix 5). The author would therefore be compelled to work within the guidance of the employing authority. In negotiating a contract (stage four), because Alexander and I shared the decision to try Aripiprazole, it was hoped that concordance would be achieved. Evidence 14 highlights the implications of excluding service users from the decision making process. Delivering the choice agenda in mental health is considered key to an effective prescribing value base for nurses (Jones and Jones, 2007), however it must be identified that issues of capacity for individuals with mental health problems can jeopardise this. For individuals lacking capacity during an acute Schizophrenic episode, guidance recommends the use of oral atypical medications, prescribed after consultation with the individuals carer or advocate (NICE, 2002a). Government policy has stated that service users should be encouraged to compile an Advanced Directive (AD) as part of their care plan, highlighting their treatment choices (NICE 2002b), although in practice, the author has limited experience of this happening (evidence 13) and does not feel it is something that the Trust encourages. Concerns have been expressed that service users might draw up unrealistic and illogical plans, refusing all forms of treatment, however a recent study found evidence to the contrary of this (Papageorgiou, Mohamed, King, Davidson and Dawson, 2004). It is the opinion of the author that where possible ADs should be formulated, allowing the patient to be autonomous, however the author also acknowledges that there may come a point where decision-making is replaced by that of the prescriber. At present ADs can be over-ridden if the patient is subject to compulsory treatment under the Mental Health Act (1983). In Alexanders case, an AD was offered but refused. Alexander was considered capable of providing informed consent and therefore, following the principles of good practice (United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1996), the author communicated to Alexander, various details about the prescription. These included information on what the prescription was for, how long the drug would take to work, how long to take it for, what dose to take and the possible side effects. The UKPPG data regarding Aripiprazole was given to Alexander (Appendix 6). The fifth principle of the prescribing pyramid, review of the patient was dictated by the CMP. Weekly review was carried out in order to ensure that the treatment was effective, safe and acceptable. Had it not been, the broad CMP permitted use of alternative agents. The IP and SP reassessed Alexander as planned three months later. In this time however the IP and SP met frequently to discuss the progress of Alexander and record keeping was kept up-to-date using the eCPA system. At present, GPs are advised of supplementary prescribing arrangements and changes in these via Trust devised letters (see Appendices 7 and 8). In this instance the letters were compiled and sent within 24-48 hours in line with local policy. The author reflected on her prescribing decision as recommended by the final stage of the pyramid and is confident that neither patient pressure nor the action of pharmaceutical companies affected decision-making. In practice, the author has experience of nursing individuals on a range of antipsychotics and is aware that this may affect choice of drug in the future Conclusion The author has described and analysed an independent and supplementary prescribing experience and has attempted to meet the module learning outcomes in doing so. The author is confident that her rationale for prescribing decisions is based on sound comprehensive guidelines and practice experience. The author plans to base future decisions on the prescribing pyramid model, making a conscious effort to see outside of the prescriptive toolkit so as to remember the importance of other nursing interventions. It is the intention of the author to utilise the support and clinical supervision available in the practice area, including discussion about differential diagnosis and treatment options with the medical team following assessments. This will ensure safe practice, professional development and recognition of the contribution of non-medical prescribers within the team. Evidence 16 details the authors plans for continuing professional development in prescribing practice, both as an independent and a supplementary prescriber. These goals are important to ensure competency in prescribing practice is maintained. By ensuring that practice is updated, monitored and evaluated, service user experience is hopefully improved leading to increased concordance and better health outcomes

Human Maturity in The Human Comedy by William Saroyan :: Maturity Mature Literature Essays

Human Maturity in The Human Comedy by William Saroyan William Saroyan's The Human Comedy, deals with ravages of life. Due to these trials, Homer is forced to mature. How he matures is a result of facing the challenges. Two very import themes that help homer mature are family and death. Homer represents the men of the house because he works and earns money for the family. For example, he goes to school until three o'clock, then goes to work until midnight. Going to school and working is very hard but it needs to be done for the family to survive. In addition, Homer needs to be both a father and a big brother for Ulysses. Homer loves and cares for Ulysses, and he teaches Ulysses about life, and physical appearance. Finally, Homer said, 'Any work that has to be done around here, men can do. Girls belong in homes, taking care of men.'; (Pg. 157) Homer is rewarded for being the man of the house by getting love and shelter from his family. Love is needed from the family to keep Homer supporting the family. Homer becomes mature by working, but looses his one and only childhood. Death is a very important theme, because delivering death messages is what made Homer mature. For example, Homer told his mother 'All of a sudden I feel different—not like I ever felt before.'; (Pg. 33) Delivering telegram message changed everything for Homer because he was no longer a child. Furthermore, delivering death telegrams made Homer sick. At the age of fourteen, when Homer had to deliver death messages, this made him realize that one day he is going to die himself. At the end when Homer realizes his brother's death, Homer said, 'What's a man supposed to do? I don't know who to hate. I don't know what to do.'; (Pg. 186) This showed being a teenager moreover a man, did not solve the problem about death.

Latin American Change Essay -- Colonialism Spanish Latin American Essa

Over the course of the past half-millennium, the 33 countries that now comprise Latin America and the Caribbean have gone through drastic change. Since the discovery of the New World in 1492, each country has gone through some level of colonization by a European power and transition to its current state. During this period the regions have seen political, social, religious and economic transformations of various degrees. Nevertheless, many scholars argue that regardless of the changes encountered, many are merely on the surface with little to no meaningful change instilled. A Variety of leaders have attempted to improve their country by both conservative and liberal means. Despite these attempts, though, the underlying foundation of colonial ideals remains. The colonial period began with the discovery of Hispaniola by Christopher Columbus in 1492 and most Latin American countries gained their independence in the nineteenth century. The colonization of Latin America and the Caribbean was dominated by the Iberian countries with small colonies established by the French, English and Dutch. Regardless of the nationality of the colonizers, almost all of the colonies shared basic characteristics, which have persevered over time in some way or another. It is possible to organize the traits of these colonies into four distinct categories: economic development, religious and social mixing, racial and ethnic mixing and political structures. There were two basic industries found in the New World that shaped their economies: agriculture and mining. Both of these required tremendous labor input to match the demand of continental Europe. Goods such as sugar, cotton, coffee, indigo, tobacco, silver and copper were produced and exported in great quantities. At a very early point in the development of the colonies it was understood that the European settlers weren’t willing to do the physical labor themselves; instead African slaves were brought to the New World in order to work on the plantations. When the situation arose that African slaves didn’t adapt to the conditions properly, Native Indians were forced to labor. This subjugation of Africans and the indigenous populations has had dramatic effects on society. As most regions emancipated the slaves sometime in the mid eighteenth century, a social pyramid developed where white elite’s at the top, mulatto landown... ...d of colonialism has permeated through every aspect of society leaving a legacy with recognizable origins and characteristics regardless of the changes instilled by any specific government. As revisions to the economy, political structure, racial and gender situation and national identity are made it is impossible to escape the similarities of the past. Only drastic, social upheaval can cause the type of change activists dream about. Maybe the Spanish inadvertently left a trait that has hindered growth across their history, the concept of Manana (â€Å"tomorrow†), thus putting important policy decisions for another day. We can find examples in the histories of these countries where significant change is found, but it never has a contagious element allowing it to spread across the region, and it is rarely going to affect more then one aspect of society for any extended amount of time. Regardless, of the actual results we have witnessed in the past, there is one constant: a desire for improvement and the ever increasing number of leaders willing to take unorthodox steps to achieve these goals. As long as these characteristics remain, transitions to desired ideals will eventually occur.

The Man I Killed, By Tim O’Brien Essay -- Vietnam War

Usually when someone is murdered, people expect the murderer to feel culpable. This though, is not the case in war. When in war, a soldier is taught that the enemy deserves to die, for no other reason than that they are the nation’s enemy. When Tim O’Brien kills a man during the Vietnam War, he is shocked that the man is not the buff, wicked, and terrifying enemy he was expecting. This realization overwhelms him in guilt. O’Brien’s guilt has him so fixated on the life of his victim that his own presence in the story—as protagonist and narrator—fades to the black. Since he doesn’t use the first person to explain his guilt and confusion, he negotiates his feelings by operating in fantasy—by imagining an entire life for his victim, from his boyhood and his family to his feeling about the war and about the Americans. In The Man I Killed, Tim O’Brien explores the truth of The Vietnam War by vividly describing the dead body an d the imagined life of the man he has killed to question the morality of killing in a war that seems to have no point to him. The detailed descriptions of the dead man’s body show the terrible costs of the war in a physical aspect. O’Brien’s guilt almost takes on its own rhythm in the repetition of ideas, phrases, and observations about the man’s body. Some of the ideas here, especially the notion of the victim being a â€Å"slim, young, dainty man,† help emphasize O’Brien’s fixation on the effects of his action—that he killed someone who was innocent and not meant to be fighting in the war. At the same time, his focus on these physical characteristics, rather than on his own feelings, betrays his attempt to keep some distance in order to dull the pain. The long, unending sentences force the reader to read the deta... ... big deal than in helping him work through his emotions. In between the remarks from the others, O’Brien sits in the inevitable silence of Vietnam—a stillness that forces one to confront the realities of war. Behind every war there is supposed to be a moral—some reason for fighting. Unfortunately, this is often not the case. O’Brien relays to the readers the truth of the Vietnam War through the graphic descriptions of the man that he killed. After killing the man O’Brien was supposed to feel relief, even victory, but instead he feels grief of killing a man that was not what he had expected. O’Brien is supposed to be the winner, but ends up feeling like the loser. Ironically, the moral or lesson in The Things They Carried is that there is no morality in war. War is vague and illogical because it forces humans into extreme situations that have no obvious solutions.

Peak Oil and Global Warming Essay

There is now much debate regarding whether the remaining oil supply can last to realize the worst of the negative effects of global warming. According to one controversial analysis done by scientists at the University of Uppsala based in Sweden, all fuel will be burned even before temperature levels become exceedingly hot (Coghlan, 2003). Although estimates on the remaining oil reserves are not the same, it is believed that oil will reach its peak by as early as 2010. The scientists say that combined oil and gas reserves amount to only 3,500 barrels which is less than the very optimistic figures from the Intergovernmental Panel on Climate Change (IPCC) (Coghlan, 2003). On the other hand, IPCC scientists defended that even if the oil reserves is not enough to constitute the more devastating effects of global warming, the burning of coal will more than make up for the deficiency. Nonetheless, both sides agree that burning coal is even more harmful (Coghlan, 2003). In a worst-case scenario, it is depicted that there is still 18,000 billion barrels of oil left but according to University of Uppsala geologist Kjell Aleklett that claim is â€Å"completely unrealistic† and that even the expected 8,000 billion barrels is more than double the remaining amount estimated by Sweden. The IPCC, however still argues that their predictions still has grounds using â€Å"a much broader and internationally accepted range of oil and gas estimates† and even if reserves of oil and gas do run out, there is still huge reserves of coal that may be burned for fuel or be converted into gasoline notwithstanding the fact that coal is much more harmful to the environment because it produces more emissions and particulates (Coghlan, 2003). Peak oil and global warming are two related problems and solving these two problems requires the same measures which is by reducing reliance on fossil hydrocarbon fuels. For America, coal, oil, and natural should be eliminated as a primary source of energy (Holson, 2007). Aside from being an energy source, oil is also being used as feedstock, particularly for the manufacturing of â€Å"plastics, pharmaceuticals, synthetic rubber, asphalt, lubricants, nitrogenous fertilizers, pesticides, and insecticides†. It is also an important resource for the military especially during periods of war (Holson, 2007). There are many other alternative sources of energy that produce basically no emissions and are renewable. Such energy sources include solar energy, wind energy, hydroelectric energy, and geothermal energy. These forms of energy sources have already proved efficient and effective yet many refuse to market it because of greater profit earned from oil and other exhaustible fossil fuels. Nuclear energy is another efficient energy source but this should be given much thought because nuclear power provides all sorts of other risks. The Kyoto Protocol is also a good recourse as it will aggregately reduce greenhouse gas emissions of countries that have committed to the protocol. Being one of the top producers of greenhouse gases, the US should also ratify the protocol, as currently, it is the only country that refuses to ratify the protocol after Australia agreed last year. US President George W. Bush that said reducing emissions would be bad for the US economy. However, failure of the US to do so will be bad for the rest of the world. Be it peak oil or global warming. The best recourse would be finding alternative energy sources. This would reduce oil consumption rate and oil will be available for a longer time avoiding the possibility of an extreme energy crisis. Alternative energy sources that literally produce no emissions would also be more beneficial to the environment.

Indus River Essay

World History India (Indus River) Source: Lake Mansarovar Length: 1,900 mi (3,060) km Coverage: Tibet, Ladakh, Zanskar Valley, and Pakistan Tributaries: Zanskar, Sutlej, Jhelum, Ravi, Beas, and Chenab It is a river of south-central Asia rising in southwest Xizang (Tibet) and flowing 3,060 km northwest through northern India and southwest through Pakistan to the Arabian Sea. In Pakistan the Indus is considered the Chief River and in India known as King River. In its days the valley was the site of an advanced civilization that lasted from 2500 to 1500 b.c. In the western edge of the river near central Pakistan lies the twin peaks of Takht-I-Sulaiman (Persian, throne of Solomon). One of them is at 11,295 ft (3,443m) and the other 11,085 ft (3,379m) high, at the northern end are the highest points around. There is a Muslim shrine on the top of one of them. The upper Indus is fed by snow and glacial melt water from the Karakorum, Hindu Kush, and the Himalayan Mountains, flow through deep gorges and scenic valleys. It is not easy to navigate due to the bad turbulence inside. It receives the combined waters of the five rivers of the Punjab (Chenab, Hjelum, Ravi, Beas, and Sutlej), its chief affluent. From here the river then flows onto the dry Punjab plains of Pakistan and becomes a broad, slow moving, silt-laden stream. In ancient times people considered it (Sanskrit, syand to flow) and the Vedans called it â€Å"sindhu†. Sindhu is the oldest name in Indian history. Alexander the Great built a fleet and used the Indus River to get to an unknown route towards the Persian Gulf. Which lead him to another triumphant victory.

Assignment 3 Essay

In the rapidly evolving global marketplace in which outsourcing is ubiquitous, organizations need to be vigilant in their management of risk. Enterprise Risk Management (ERM) is a growing paradigm in which business leaders seek to effectively identify, mitigate, and manage risks across all aspects of the business as a whole. The ERM model classifies business risk into seven distinct, but inter-related categories: 1) strategic market risks, 2) operating risks, 3) finance risks, 4) human capital risks, 5) Information Technology (IT) risks, 6) legal risks, and 7) reputation risks. (Beasley, Bradford, and Pagach, 2004) A proposed outsourcing of any business process needs to carefully evaluate how the proposed change may create, increase, or reduce risks in each of these business areas. This paper will examine a proposed change from a legacy payroll system to an outsourced solution and evaluate the costs, benefits, and risks of the proposed change. Additionally, it will suggest how to effectively manage such a transition. COSTS AND BENEFITS When considering the costs versus benefits of a business decision, both costs and benefits can be categorized as either direct or indirect. Direct costs refers to those activities that require a quantifiable and foreseeable outlay of the organization’s assets. Indirect costs, however, refer to potential costs that may arise. Direct benefits refers to those activities that either increase revenue or reduce cost. As with direct costs, direct benefits can be easily quantified. Likewise, indirect benefits are more difficult to foresee and quantify. Following is a cost-benefits analysis matrix representative of the proposed payroll outsourcing project. Direct Indirect Benefits Revenue Enhancements Cost Reductions Reduction in man-hours Increased efficiency Avoidance of noncompliance fines and penalties Costs Implementation costs Vendor fees Service agreement fees Disruption to payroll activity during transition ENTERPRISE RISK MAMAGEMENT Using the ERM model as a guide, we can identify risks associated with the proposed transition across multiple business areas. Outsourcing the organization payroll functions has the potential to expose it to finance, human capital, and legal risks. A single vendor mistake, such as miscalculation of tax deductions has the potential for an exponentially negative effect on the organization’s bottom line, the morale, and potential loss of, the employee workforce, and legal compliance with local, state and federal regulations. Tim Stuhldreher stresses that extreme care must be given when choosing a payroll vendor. (Stuhldreher, 2012) Not only should potential vendors be thoroughly researched and vetted, a continuous process evaluation should be put into force to identify, limit, and guard against unintended risk. PROJECT MANAGEMENT There are many tools which project managers have at their disposal to ensure that a project stays on schedule, within budget, and within scope as well as produces intended outcomes. Common among these management tools are the Gantt chart, the performance evaluation and review technique (or PERT), and the critical path method (or CPM). Each of these scheduling and management techniques has a unique focus as well as certain limitations. A Gantt chart is a horizontal bar chart which identifies the tasks which are to be completed within the project and provides a timeline for their completion. A Gantt chart for the proposed payroll outsourcing project would have as it individual tasks formation of a vendor selection committee, selection of a payroll vendor, development of a data transfer protocol, system testing, and personnel training, and establishing a go live date. These individual milestones provide the parameters of the project’s scope, and the Gantt chart develops a schedule for completion of these milestones. One significant advantage of a Gantt chart is its simplicity. By providing a graphical representation of the tasks and timelines, management can easily understand, and gauge, the scheduling and completion rate of the project. A Gantt chart, however, is limited in that its primary focus is the project’s scheduling, and it is inflexible to developing changes that may evolve during the project. Also, while it does identify the tasks that are milestones within the project, it does not illustrate any interdependencies among those tasks. The PERT technique attempts to deal with the uncertainties to which Gantt charts are inflexible, and allowing for uncertainty is the major advantage of PERT. (Davis, 1966) PERT also identifies dependencies among project tasks, thus provide for a more efficient estimation of project completion time. PERT relies on multiple estimates to factor in scheduling variations due to uncertainty. In doing so, the thing that makes it advantageous over Gantt charts also is the cause for its disadvantage. PERT charts are significantly more complex than Gantt charts so managers may have difficulty interpreting and understanding them in the context of the entire project. The critical path method (CPM) also illustrates dependencies within project activities, but CPM seeks to identify the significance of the activities and their inter-relatedness. CPM seeks to compress completion time and mitigate risks inherent in the relation of tasks to each other. In addition to the advantage of showing dependencies, CPM more clearly illustrates the impacts of scheduling revisions. As with PERT, though, the added level of detail also presents disadvantages. The larger the project, and the more tasks, the more convoluted CPM becomes with dependency paths. CPM is also a bit myopic – it has a narrow focus on the dependency paths within the project, and it does not address resource allocation. The aforementioned project management tools all are useful for managing the scheduling and duration of a project. Project managers must also evaluate whether the project is delivering the intended outcome. Such evaluation should not only occur at the terminal end of a project, it should be a continued process throughout the life of the project. (Zofi, 2012) Additionally, employee morale and perception needs to be taken into consideration when implementing a change. This is especially true when it comes to outsourcing business functions. Elmuti, Grunewald, and Abebe observed that, consequent to outsourcing strategies, employees report lower levels of job satisfaction, lower levels of organizational commitment, and higher intentions to quit. (Elmuti, Grunewald, and Abebe, 2010) It is human, and organizational, nature to resist and be skeptical of change, particularly when a major business function that had previous been done in-house is outsourced. A proactive project management plan will anticipate and address employee resistance. Organizations considering an outsourcing strategy would be well served to openly and actively communicate with their employees the reasons for, and impact of the potential change while welcoming and encouraging questions and feedback from them. The more the employee base can be involved in affecting, and buy into change, the less their resistance may be. References Beasley, Mark, Bradford, Marianne, and Pagach, Don â€Å"Outsourcing? At Your Own Risk† Strategic Finance (July 2004), pp. 23-29 Davis, P. M. â€Å"From Scientific Management to Pert-An Evolution† Nebraska Journal of Economics and Business (1966), pp. 34-45 Elmuti, Dean, Grunewald, Julian, and Abebe, Dereje â€Å"Consequences of Outsourcing Strategies on Employee Quality of Work Life, Attitudes, and Performance† Journal of Business Strategies vol. 27, no. 2 (2010), pp. 178-203 Stuhldreher, Tim â€Å"Payroll complexity leads to outsourcing† Central Penn Business Journal (June 22, 2012), pp. 17-18 Zofi, Yael â€Å"Getting Deliverables Out the Door† Industrial Engineer (July 2012), pp. 35-40

Reality of Teaching and Learning Pronunciation Essay

Rationale of the study Nowadays, with the rapid pace of integration and globalization, English becomes a golden key to open the door of many fields such as commerce, communication, science and technology throughout the world. Therefore, to meet the demand of the society, it is very necessary to teach English in schools at all levels. And the highest target is to get well in communication. If one wants to get successful in communication, he must be good at pronunciation: â€Å"a threshold level of pronunciation in English such that if a given non-native speaker’s pronunciation falls below this level, he or she will not be able to communicate orally no matter how good his or her control of English grammar and vocabulary might be† (Celce-Murcia, 1987:5). In the field of language teaching, the role of pronunciation has varied widely from having virtually no role in the grammar-translation method to being the central focus in the audio-lingual method where emphasis is on the traditional notions of pronunciation, minimal pairs, drills and short conversations. The growing emphasis on communicative approaches for the teaching of English has placed higher demands for correct pronunciation. Despite this fact, at the upper-secondary school level in Vietnam, in language teaching and learning, compared with vocabulary, grammar and language skills, pronunciation has so far been paid less attention to. In the official textbooks used for teaching English at high school level, there are a few exercises for pronunciation practice. To make the matter worse, all important English exams at schools as well as the entrance exam to universities are always in written form so most teachers as well as students have little motivation to teach and to learn pronunciation. As a result, students are often shy and unconfident to speak in English. And that is the reason why the effectiveness of teaching pronunciation still remains one of the most widely problematic subjects in the field of language teaching. Coping with this pressing fact, as a language teacher teaching English at Quynh Coi high school (QCHS), the author always thinks of some burning questions: in language teaching and learning, what is the present situation of teaching and learning pronunciation at high school level in QCHS? What are the problems teachers and students face in teaching and learning pronunciation? How to find suitable methods to teach pronunciation? What should teachers do to teach pronunciation effectively? How should teachers make students become interested in learning pronunciation? The answers to these questions will help language teachers improve their students’ pronunciation as well as help them make progress in effective communication. For the above reasons, the author decides to carry out the study entitled: â€Å"The reality of teaching and learning pronunciation at Quynh Coi high school: problems and solutions†. 1. 2 Aims of the study The main purpose of this study is to discover the reality of teaching and learning pronunciation at Quynh Coi high school, especially to find out problems that teachers and students often have in pronunciation lessons. The writer also hopes to make some feasible solutions that can help the English teachers overcome those problems and improve students’ pronunciation. 1. 3 Research questions The above aims of the study can be realized by answering the following research questions: (1) What is the present situation of teaching and learning pronunciation at QCHS? (2) Which problems do the teachers and students at QCHS face in pronunciation lessons? (3) What teaching techniques can be used to improve teaching pronunciation for students at QCHS? 1. 4 Scope of the study As a case study, this study focuses on the reality of teaching and learning two aspects of English pronunciation: stress and intonation for the 12th form students at Quynh Coi high school. The subjects of the study are 12th form students those are familiar with learning pronunciation for two years at high school. Moreover, stress and intonation are two major aspects of pronunciation introduced in the official textbook used by the 12th form students. Other characteristics of English pronunciation would not be deeply investigated in this research. . 5 Methods of the study In order to fulfill the tasks mentioned above, both qualitative and quantitative methods are selected for this case study, involving the following instruments: survey questionnaires, classroom observations and interviews. Firstly, the survey questionnaires were delivered to both teachers and students to investigate the reality of teaching and learning pronunciation at QCHS. Then, some classroom observations and interv iews with some English teachers have been also conducted to get supplementary information. Finally, the results obtained from questionnaires, observations and interviews have been discussed and analyzed to with a hope for providing language teacher with some feasible teaching techniques to work successfully with their students. 1. 6 Significance of the study This study hopes to make contribution to teaching pronunciation at high school level in Vietnam and the result of the study is considered to be useful for teachers and students at school. Thus, this study will be an interesting reference material for any high school language teachers in Vietnam, especially for those who are in favor of improving their students’ pronunciation. This research will help teachers and students identify their problems in teaching and learning pronunciation and self- improve their pronunciation. 1. 7 Design of the study This thesis consists of six main chapters: Chapter one is the INTRODUCTION including the rationales, the aims, the scope, the research questions, the methods, and the design of the research. In the book â€Å"Pronunciation† published in 1994, Christiane Dalton and Barbara Seidlhofer (1994:3) consider pronunciation â€Å"as the production of significant sound†. They look at the word in two senses. First, it is used as part of a code of a particular language. That is the reason why English sounds are distinguished from sounds of other languages. In this sense, pronunciation can be told as the production and reception of sounds of speech. Second, sound is used to achieve meaning in contexts of use. Here the code combines with other factors to make communication possible. In this sense pronunciation is referred with reference to acts of speaking. In the scope of this study, the concept of pronunciation can be described as â€Å"a way of speaking a word, especially a way that is accepted or generally understood† (American Heritage Dictionary, 1992) or â€Å"may be said to conclude the sounds of the language or phonology; stress and rhythm; intonation; combination sounds; linkage of sound† (Ur, 1996). 2. 2 Features of pronunciation Gerald Kelly (2000) points out main features of pronunciation including phonemes and suprasegmental features, in which consonants and vowels belong to phonemes, intonation and stress are two main parts of suprasegmental. Phonemes are units of sound, they are known as segments. Suprasegmental features are features of speech which apply to groups of segments, or phonemes. The features which are important in English are stress, intonation, and how sounds change in connected speech. The following diagram shows a breakdown of the main features of pronunciation: Features of pronunciation (Kelly, 2000:1) As seen from the diagram, pronunciation is a broad subject with the boundaries of various items such as consonants, vowels, stress, and intonation. This study is intended to focus on two major features of pronunciation: intonation and stress are deeply investigated. According to Quirk R. and Greenbaun S. (1973:450), stress is the prominence with one part of a word or of a longer utterance is distinguished from other parts. This can be understood like this: when an English word consists of more than one syllable, one of these syllables is made to stand out more than the others. This is done by saying the syllable louder. For instance, in such words as â€Å"English†, â€Å"teacher†, and â€Å"student† the first syllables are stressed. Intonation is an important part that most teachers have to deal with when teaching connected speech, it refers to the way the voice â€Å"goes up and down in pitch† (Kelly, 2000: 86) when we are speaking. It plays a vital role in helping people express their opinions, and understanding thought of others. In short, the word â€Å"pronunciation† is like a big umbrella covering various sub-items as consonants, vowels, intonations, stress, etc. With such big boundaries of items, language teachers and learners have to think of how to master these key aspects, especially stress and intonation, to be successful in teaching and learning pronunciation. 2. 3 Teaching pronunciation 2. 3. 1 The importance of teaching/ learning pronunciation and a â€Å"paradox† 2. 3. 1. 1 The importance of teaching and learning pronunciation Pronunciation is as important as any other aspects of language like syntax and vocabulary. Some people may argue that speech is obviously much more significant than pronunciation. However, speech cannot exist without pronunciation. Correct pronunciation, in fact, is considered to be a prerequisite to develop the speaking skill. That is why teaching pronunciation should occupy an important place in the study of any language. According to Gerald Kelly (2000), pronunciation â€Å"involves far more than individual sounds† including word stress, sentence stress, intonation, and word linking. All of these influence the sound of spoken English. Sound is the core of the language. When teaching a language, the first and foremost thing teachers should do is to let learners have chances to expose themselves to the sounds of that language. That is the reason why more and more teachers pay much attention to teaching pronunciation to their students. Considering the importance of communication in general and pronunciation in particular, Gerald Kelly confirms â€Å"a learner who constantly mispronounces a range of phonemes can be extremely difficult for a speaker from another language community to understand. A consideration of learners’ pronunciation errors and of how these can inhibit successful communication is a useful basis on which to assess why it is important to deal with pronunciation in the class† (2000:11). Sharing the same ideas with Kelly, Martin Hewings (2004:10) adds â€Å"difficulties with pronunciation might mean that students fail to get their message across, even when the correct words are being used, or they might fail to understand what is said to them. † The inaccurate use of suprasegmetal elements, such as tress or intonation, can also cause problems. Errors in pronunciation can lead to a problem of reception, or comprehension of the meaning or function of an utterance, even worse, they can affect the perceived tone or mood of an utterance. Moreover, it is obvious that good pronunciation serves as a strong motivation for language learners. Most language learners show considerable enthusiasm for pronunciation as they consider it as a good way to show that they are competent in the language. Once they have obtained adequate pronunciation competence, they gradually build up strong confidence for themselves and are ready to learn new things without hesitation. 2. 3. 1. 2 A â€Å"paradox† As the matter of fact, the role of pronunciation in English learning process could not be negated. Regrettably, teaching and learning pronunciation has not received appropriate attention as expected and Gerald Kelly call this fact a name â€Å"a paradox† (Kelly, 2000: 1). It tends to suffer from being neglected. This may not be teachers’ lack of interest or motivation in pronunciation. The main reason comes from their teaching experience and confidence, â€Å"feeling of doubt as to hoe to teach† (Kelly, 2000:13). In spite of the fact that both teacher and students are keen on pronunciation, they often take grammar or vocabulary precedence over pronunciation for granted. If it is not neglected, â€Å"it tends to be reactive to a particular problem that has arisen in the classroom rather than being strategically planned† (Kelly, 2000:13). This is the most popular problem is pronunciation lessons. Teachers only deal with pronunciation when it comes to be problematic. There is no lesson plan, no strategy in teaching and learning pronunciation. Most teachers often prepare lesson plan for teaching grammar, vocabulary, but pronunciation. Yet pronunciation work can, and should, be planned for, too. Teachers should regard features of pronunciation as integral to language analysis and lesson planning. This paradox arises from both the nature of pronunciation itself, from the teaching staff as well as from the learners themselves. However, to deal with this problem, as language teachers, teachers need to have a good grounding in theoretical knowledge. Furthermore, in order to teach pronunciation successfully, teachers should be practically skilled in classrooms, and they need to have good ideas, approaches, techniques, as well as classroom activities. 2. 3. 2 Teachers’ roles in teaching pronunciation Mastering a foreign language pronunciation is not something impossible as far as the student and the teacher participate together in the total learning process. Thus, to succeed in a pronunciation program, the teacher plays an essential role. Kenworthy (1987), Nguyen Bang and Nguyen Ba Ngoc (2001), and Hoang Van Van, et al. (2006) shared the similar ideas about teachers’ roles in the teaching and learning pronunciation process, in which, teachers are responsible for:†¢Helping learners to hear: The teacher has a mission to provide appropriate input of the target sounds for learners to hear. Teacher needs to check that their students are hearing sounds according to the appropriate categories and help them develop new categories if necessary. †¢Helping learners to make sounds: It is true that some English sounds do not exist in the learners’ mother tongue. Some learners may be able to imitate the target sounds if they are provided models. However, for those who lack such an ability, it is teachers’ duty to explain the way those difficult sounds are made and provide aids to help learners produce correct sounds. †¢Providing feedback: Students need to be told where they are standing, how much they have gained and what they need to improve because sometimes, students themselves can not know whether they are making mistakes or not. The teacher must provide them with feedbacks on their performance. †¢Pointing out what is going on: In many cases, learners fail to realize what and how they are speaking, as speaking is for most parts unconsciously controlled, learners may sometimes make mistakes in the way they produce a particular sequence of sounds, or put stress in an incorrect place, leading to misunderstanding. It is the teachers’ role to specify the area that learners have to pay attention to so as not to cause miscomprehension. †¢Establishing priorities: Native-like pronunciation is not easy to achieve. Therefore, learners need a guide to tell them about what aspects they should master, what aspects they not need to be â€Å"perfect†. Inevitably, when learning a foreign language, it is dealt if learners master every aspect of it. However, as this is somehow unrealistic, learners should learn to satisfy at an accepted level of those aspects which are not vital. The level at which learners can feel satisfied at depends on different situations for different individuals. †¢Devising activities: It is not easy for teachers to cover all activities in a limited time. Thus, teachers need to identify what exercises will be suitable for their learners, what activities would bring them the best effect. In devising them, however, it should be accepted that certain activities are more suitable to some students than others. †¢Assessing progress: An important role of teacher is to assess progress. Learners need to know at what level they are in pronunciation. Tests allocated at appropriate times will serve as a strong motivation for students. When they look at their marks, they have a clear sense of how much they have gained. Judging learners’ pronunciation performance is very complicated. However, this should be done accordingly. 2. 3. 3. Approaches, techniques and activities in teaching pronunciation2. 3. 3. 1 Approaches in teaching pronunciation In the book â€Å"Teaching pronunciation† (Celce-Murcia M. , et al.1996: 2), the authors point out two general approaches to the teaching of pronunciation in the modern time, namely intuitive-imitative approach and analytic-linguistic approach. An intuitive-imitative approach depends on â€Å"the learners’ ability to listen to and imitate the rhythms and sounds of the target language without the intervention of any explicit information†. This means the teaching of pronunciation depends largely on the teac her’s turning on and rewinding a cassette player (or another instrument), and the main activities in the class are listening and repeating. In this approach, the teacher has no responsibility to explain how sounds are formed or produced and the learners do their main task of listening and imitating, and it is expected that learners will gradually gain pronunciation competence. Meanwhile, an analytic-linguistic approach â€Å"utilizes information and tools such as a phonetic alphabet, articulator descriptions, charts of the vocal apparatus and other aids to supplement listening, imitation, and production† (Celce-Murcia M. , et al. , 1996: 2). In this approach, learners are given explanation as well as training on how to form particular sounds of the target language. Between these two approaches, there is no scale on whether which one is better. Choosing to apply which approach into teaching pronunciation depends on teachers themselves and the level of learners. To do well with these two approaches, it is a need for both teachers and learners to fulfill knowledge of articulator system such as consonants, vowels, stress, and intonation, etc. In this study, the author considers the use of both approaches to gain best effect in teaching and learning pronunciation. 2. 3. 3. 2 Techniques and activities Pronunciation is never an end in itself, thus to receive expected result in teaching and learning pronunciation, teachers have made use of a great deal of techniques. It may be taught in isolation or in combination with language skills of speaking, listening, reading or writing. Supported by Kelly (2000:16); and Celce, et al (1996:8), some common techniques are:†¢Drilling: One of the main ways in which pronunciation is practiced in the classroom is through drilling. In its most basic form, drilling simply involves the teacher saying a word or a structure, and getting class to repeat it. †¢Listen and imitate† The pronunciation of the target language is provided by the teacher or tape recorders, language labs, etc. students are to listen to a sequence of sounds or sentences and repeat it. †¢Chaining: This can be used for sentences which prove difficult for students to pronounce, either because they are long, or because they include difficult words and sounds The above mentioned techniques are nearly similar; they usually take two forms, which are either all-class or individual. These two forms are actually the two phase of the same techniques. Normally, at first, the whole class repeats after certain sound and phrases. After a certain amount of class-drilling, individual students take turns and pronounce those items themselves. †¢Phonetic chaining: This technique makes use of articulator descriptions, articulator diagrams and a phonetic alphabet. Learners are provided with basic theoretical knowledge about how sounds are formed. They are also aided by the teacher to make genuine sound production. †¢Minimal pair drills: These relate to words which differ from each other only one phoneme. Normally, students are allowed to listen to the tape and distinguish between the two sounds. This type of activities is particularly useful to teach sounds which causes difficulties for learners or sounds that are mismatched. †¢Contextualized minimal pair: In this technique, the teacher establishes the setting and present key vocabulary; students are then trained to respond to a sentence stem with the appropriate meaningful response. When minimal pair drills seem a bit boring and too theoretical with separated sounds, the contextualization seems to be more useful because it is more practical. †¢Tongue Twisters: This technique rooted from speech correction strategies for native speakers. When other techniques look serious and sometimes put learners under pressure, tongue twisters provide a more delighting way to learn pronunciation. Sounds which are difficult to differentiate are put together to make meaningful sentences. †¢Reading aloud/recitation: Students are provided with a passage or scripts and then read aloud, focusing on stress, timing and intonation. This activity is often done with texts such as poems, rhymes, song lyrics, etc. †¢Recording of learners’ production. This technique can use audio-tape, video-tapes of rehearsed and spontaneous speeches, free conversations, and role plays. It needs the feedbacks of teachers as well as self-evaluation. †¢Practice of vowel shifts and stress shifts related by affixation: Base on rule of generative phonology, used with intermediate or advanced learners. The teachers point out the rule-based nature of vowel and stress shifts in etymologically related words to raise awareness; sentences and short texts that contain both number of a pair may be provide as oral practice materialsuch as:PHOtograph And phoTOgraphy 2. 4 Learning pronunciation 2. 4. 1 Factors affecting learning pronunciation According to Joane Kenworthy (1987), there are many factors affecting learning pronunciation, including the native language, the age factor, the amount of exposure, phonetic ability, attitude and identity. The native language: it is inevitable that learners’ native language has a great impact on their ability of pronouncing English. The â€Å"foreign accent† is therefore easy to identity. The age factor: it is often assumed that the younger a person starts learning a foreign language, the better he is at pronouncing it and he has a greater chance of having a native-like accent. The amount of exposure: people who live in the country where the target language is spoken and is surrounded by an English-speaking environment may have some advantages over some who do not. Phonetic ability: researches have shown that some people naturally have a â€Å"better ear† for a foreign language than others. Attitude and identity:results from many studies have shown that learners who have a positive attitude towards speakers of a foreign language tend to have a more native-like pronunciation. 2. 4. 2 Students’ roles in learning pronunciation It is essential that in order to learn a language, motivation plays a vital role. The same thing happens to learning pronunciation. If students really care much about their pronunciation, they will become more cautious about their speaking, and gradually build up good pronunciation. In teaching and learning pronunciation, if teachers play the roles of a â€Å"speech coach†, students themselves need to involve in this process as much as possible in order to get good results. According to Nguyen Bang and Nguyen Ba Ngoc (2001), students need to satisfy some demands. Firstly, they need to perceive the model as exactly as they can. Secondly, they need to response as much as and as well as possible to the recognition, the imitation and repetition activities. Lastly, beside the help of the teachers, students should do self-correction of their pronunciation mistakes. 2. 5 Teachers’ and students’ problems in teaching and learning pronunciation Both teachers and students encounter various problems in the process of teaching and learning pronunciation. These problems do not only arise from the nature of pronunciation itself, but from various subjective and objective factors. In the light of the previous and current studies, some major problems that teachers and learners face in teaching and learning pronunciation are:. The nature of pronunciation According to Nunan (1991), the problem of acquiring the phonology of a second or a foreign language presents a formidable challenge to any theory of second language acquisition. In teaching and learning pronunciation, the biggest problem that most of the English teachers and students complain come from nature of pronunciation. English pronunciation itself contains so many complicated factors and invisible rules. In the light of this problem, Doff A. (1988) listed some common problems that learners often make when they speak English. The first is difficulties in pronouncing sounds which do not exist in the students’ own language. The second is the problems with similar sounds that often cause learners’ confusion. The third is difficulties in pronouncing consonant clusters. And the last problem mainly comes from English stress and intonation. Students seem to have a tendency to give all syllables equal stress and â€Å"flat† intonation. Class setting A lot of problems in teaching and learning pronunciation come from class setting such as classroom size, quality of the teaching staff, teaching and learning equipment. Firstly, a large class causes difficulty in teaching pronunciation. At high school, on average, there are over 50 students per class. With such a high student-teacher ratio, it is impossible to make sure that the teacher could carry out successful teaching techniques and activities, and the learner is not able to listen and receive what the teacher is saying. The quality of teaching staff is also a big problem. Most teachers of English are non-native speakers, and a few of them can have a native-like pronunciation. As a result, the language input that students receive every day is from non-native people. Therefore, it is impossible to require students to achieve perfect pronunciation. Teaching model According to Kelly (2000), in the past, the model of teaching English pronunciation was â€Å"received pronunciation†, the pronounciation of people in the southwest England. Today, there are a vast number of English: American English, Australian English, etc. Thus, it is difficult for teachers to choose what model to teach. In fact, each teacher often cannot produce a â€Å"perfect† accent without being affected by his own language. This fact sometimes causes both teachers and students problems in teaching and learning pronunciation. Some teachers do not feel confident with their own voice and students do not know what input language is perfect to receive. Intelligibility Beside factors from the nature of pronunciation, class setting, etc, teaching and learning pronunciation involves in its own problem that Kenworthy (1987) calls it as â€Å"intelligibility†. He defines â€Å"intelligibility† as â€Å"being understood by a listener at a given time in a given situation†. This means that intelligibility is affected by a number of factors: the speaker, the listener, the time, and the situation. This also means that teaching and learning pronunciation depends on many factors, causing many problems for both teachers and students. In conclusion, in this chapter, some theoretical backgrounds relating to teaching and learning pronunciation have been pointed out. These factors are the pronunciation concepts and their features. Factors relating to pronunciation teaching and learning as the importance, the problems, techniques and activities have been also given. It cannot be denied that pronunciation and teaching pronunciation is an important part to conduct in any language course. It is even more important for those who are or will be teachers of the language. Methods of teaching pronunciation are various with different elements of pronunciation. What are the attitudes of teachers and learners towards teaching and learning pronunciation? The school has 36 classes with 90 teachers and 1,800 students. Each year, the school enrolls more than 600 new comers. 3. 1. 2 Description of the course At school, all students when pass the entrance exam to the school have to study English as one of the compulsory subjects. During the process of learning English at school, students use three English textbooks (English 10, English 11, English 12) focusing on four skills including reading, speaking, listening, writing and language focus part. The language focus comprises two major parts: pronunciation and grammar. Normally, students start learning pronunciation when they study English 10. However, at grade 10th, students only learn some vowels and simple consonants. At grade 11th, students continue to study complex consonants. And at grade 12th, students start to be familiar with stress and intonation exercises. That is the reason why stress and intonation are two major aspects of pronunciation chosen in this investigation. 3. 2 Subjects The subjects of this study comprised 10 teachers and 55 12th-form students at QCHS. All English teachers were invited to participate in this study. They are from 27 to 60 years old, and have taught English for more than 2 years. They graduated from both regular and in-service training. With those teachers who have taught English for many years, they have teaching experience, but were not well trained. They mainly graduated from colleges, even in-service training. With younger teachers, they graduated from many different universities: state and non-state universities. They are full of motivation, but lack of teaching experience. In general, these teachers are good at teaching grammar and do not feel confident to deal with speaking, listening, and pronunciation lessons. Thus, they often focus their lesson on grammar but the speaking and pronunciation. The class that the author chose to study consists of fifty-five 12th-form students. These students have had at least 6 years of academic English experience by the time they reach this course. However, their English proficiency is not good, especially at pronunciation. They may be good at grammar and can do these grammar exercises quickly, but can not speak fluently. Most of them do not feel confident to speak in class and express their ideas in English. These students have studied at high school for more than two years. Therefore, they have been getting similar with the teaching and studying methods, the conditions and the teaching environment, so it easy for the author to get their consent to participate in the research. 3. 3 Research methods As mentioned previously, the researcher chose a mixed-method approach to data collection, utilizing triangulation to measure a broad variety of variables in the research. Necessary data was gathered directly from the teachers and students participating in the research in several ways: Questionnaires: In order to collect reliable and comprehensive data, two questionnaires were designed: one for teachers and one for students. They are both open-ended and close-ended questions. Teacher questionnaire (Appendix 1): one survey questionnaire with 8 questions was designed for the teachers to get their ideas of pronunciation teaching and learning reality, problems faced by their students and some recommendations to improve learning pronunciation reality at school. To get this aim, the questionnaire is categorized into the following groups: †¢Teachers’ attitude towards present situation of teaching and learning pronunciation at QCHS; †¢Approaches, techniques and classroom activities used by teachers in teaching pronunciation;†¢Problems faced by teachers in teaching pronunciation; and †¢Teachers’ recommendations of techniques to improve students’ pronunciation. Student questionnaire Appendix 2): another survey questionnaire with 8 questions was designed for students including the following categories: †¢Students’ attitude towards learning pronunciation, especially stress and intonation; †¢Students’ problems in learning pronunciation; and †¢Students’ expectations in learning pronunciation. In-depth classroom observations: Six informal classroom observations during regular classroom sessions were used as an additional data source. The observations were carried out for two weeks during the course of the study to get more practical information about teachers’ and students’ attitudes towards teaching and learning pronunciation, and difficulties as well as techniques used in pronunciation lessons. During the process of observations, the author focused on some aspects taking in class as:†¢Teaching and learning materials used in class; †¢Students’ activities and their mistakes in producing pronunciation; and †¢Teachers’ approaches and techniques used in teaching pronunciation. Interviews and discussions (Appendix 3): after collecting data from the survey questionnaires and classroom observations, the author used the post interview in order to get the in-depth discussion about techniques used to improve students’ pronunciation. Because it is too difficult for the researcher to conduct long interviews with all teachers, the researcher randomly selected 5/10 teachers for interviews. They were willing to express deeply their opinions, and ideas about teaching techniques. 3. 2.Data collection procedures The study was conducted in the first term of the school year 2010-2011 (from September 2010 to December, 2010). At the beginning of the first term, two sets of questionnaires were given to the teachers and the students who agreed to participate in the research. After two days, these questionnaires were collected. The information from these questionnaires were then summarized and presented in the form of statistics. For the following two weeks, the author carried out some classroom observations. The observations during six English lessons including one in reading, one in writing, one in listening, one in speaking and two in language focus periods. At each session, the researcher took field notes on what happened when the students learned pronunciation. Finally, when the information from the survey questionnaires and classroom observations were collected and analyzed, structured interviews were carried out. The data collected from three different resources were read through to obtain a sense of the overall data. They were then analyzed both descriptively and interpretatively. The initial sorting-out process was writing findings in the form of reflective notes and summaries of field notes. The information was then displayed in forms of tables and figures while qualitative data from the open-ended questionnaire items, classroom observations and interviews were presented by quoting relevant responses from the respondents. CHAPTER FOUR: PRESENTATION OF THE DATA This part, the information from collected data was presented in accordance with the category of data collection instruments. 4. 1 Survey questionnaires 4. 1.Teachers’ and students’ attitudes towards teaching and learning pronunciation Assuming that the consideration of the teachers’ and students’ attitude towards teaching and learning pronunciation would be beneficial to the research, at the outset, these factors were surveyed. The results, shown in below, reflect that grammar is the most concerning aspect in learning English at high school. Surprisingly, only 10% of the tea chers think that pronunciation is the most necessary for their students. They always pay much attention and time and energy on grammar. In contrast, teaching and learning pronunciation as well as developing listening, speaking or reading skills do not receive enough attention to. 4. 1. 2 Students’ pronunciation level From the chart 2, we can see an optimistic reality of students’ level in learning pronunciation at Quynh Coi high school. Being asked about this, all the teachers said that students’ level is not equal, however; it is not good as expected. 60% teachers said that their students’ level at pronunciation is at average; and even 30% of the students get under average level. None of the teachers evaluate their students’ level at pronunciation is good or excellent. . 1. 3 Pronunciation teaching and learning time Chart 3 presents time that teachers and students spend on teaching and learning pronunciation. One more time teachers and students share the same ideas about the fact that too little time is on pronunciation. 80% of the teachers and 43% of the students said that they di d not have time to spend on teaching and learning pronunciation in one teaching session (45 minutes); 20% of the teachers and 32% of the students spend less than 20 minutes on teaching pronunciation. None of the teachers and a very small number of the students teach and learn pronunciation for more than 20 minutes. The overall results indicate that the reality of teaching and learning pronunciation at Quynh Coi high school is not positive as expected. Although both teachers and students are very optimistic towards teaching and learning pronunciation, students’ level is not good as well as time spent on teaching pronunciation is limited during one normal teaching session. 4. 1. 4 Teachers and students’ problems in teaching and learning pronunciation Chart 4 shows that both the teachers and the students face many problems during the process of teaching and learning pronunciation. The biggest problem that both teachers and students face comes from the nature of pronunciation. The next two factors preventing students from gaining good pronunciation are teaching time and students’ competence. 27% of the teachers and 22% of the students said that they do not have enough time on pronunciation. 20% of the teachers considered that their students’ competence in pronunciation is too low. 22% students also agreed with that idea. Class setting is the next factor that 20% teachers chose. It is clear that quality of teaching staff is not good enough to come over all the difficulties in teaching pronunciation. In contrast, only 1% of the students agreed with this. The smallest factor that both teachers and students think that causing problem in teaching and learning pronunciation is students’ motivation. 4. 1. 5 Teachers’ and students’ problems in teaching and learning intonation and stress From the chart above, most of the teachers (50%) and students (43%) think that stress is the most difficulty in teaching and learning pronunciation. the second is intonation: 30% of the teachers and 14% of the students think that intonation causes trouble. Meanwhile, none of the teachers meet any difficulties in teaching consonants and vowels. Particularly, chart 6 shows that 43% of the students cannot know the place of stress in a word; 20% said they cannot pronounce stress though they may be know place of stress in those words. Surprisingly, 27% of the students said that they do not know anything of stress. From the above chart, we can see that the reality of learning intonation is even worse than learning stress. 56% of all surveyed students understand nothing about intonation, causing a lot of difficulties in teaching and learning pronunciation.