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What is Watanabe’s mental state throughout chapter 10? Give an example from the text. Why do you think he is feeling this way?

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Reading Response 6 Norwegian Wood Chapters 9-10 Directions: Please answer the following questions in complete sentences, and write at minimum 4-5 sentences per question. In order to receive full credit for a question you must answer ALL components of the question. Please type your answers and print them out to bring to class for discussion, and to be collected. 1) In Chapter 9, Midori and Watanabe spend a lot of time together. Describe their relationship at this point in the book. Do you think Midori is best for Watanabe? Explain your reasoning.
2) Describe Naoko’s state of mind in her letters at the end of Chapter 9 and during Watanabe’s visit in chapter 10. How is Naoko’s recovery going? What is she experiencing at night when she goes to sleep?
3) What is Watanabe’s mental state throughout chapter 10? Give an example from the text. Why do you think he is feeling this way?
4) Why does Midori get upset with Watanabe? What does she say in her letter to him? Do you think it was fair that Midori was so upset with him? Explain your reasoning. What does Watanabe later realize about his feelings for Midori?

In the Katavic and Butkovic (2016) reading, assess if the authors identified the internal strengths and weaknesses.

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Readings to help for part 1

(Retrieved from ProQuest Central database in the Touro library):

Katavic, M., & Butkovic, L. L. (2016). MBA knowledge transfer in construction. In 15th International Scientific Conference on Economic and Social Development – Human Resources Development (pp. 263-271). Varazdin, Coratia: Varazdin Development and Entrepreneurship Agency (VADEA).

Stakic, A. J., Zakic, K., & Jurcic, A. (2015). The process of internalization in higher education and its impact on efficiency of working force. In 11th International Scientific Conference on Economic and Social Development – Building Resilient Society (pp. 186-194). Varazdin, Croatia: Varazdin Development and Entrepreneurship Agency (VADEA). Retrieved from the Presentations section of the course under Module 2

Required videos:

Riley, J. (2015, June 3). Topic briefing – Porter’s five forces model of industry competition [Video file]. Retrieved from https://www.youtube.com/watch?v=cm9SsMa56r4 (21:32)

Riley, J. (2016, May 25). PESTLE analysis [Video file]. Retrieved from https://www.youtube.com/watch?v=sP2sDw5waEU (8:42)

Part 1

  1. In the Katavic and Butkovic (2016) reading, assess if the authors identified the internal strengths and weaknesses.

Properly cite your source(s)

  1. According to Stakic, Zakic, and Jurcic (2015), how  can the John Naisbitt University convert their (a) weaknesses into strengths, and (b) threats into opportunities?
Reading and Background Material for part 2
 Required Readings (Retrieved from ProQuest Central database in the Touro library):

Gill, A. (2016). Floundering in a deregulated market: an energy company seeks new strategies. Journal of Business Strategy, 37(2), 27-35.

Synthesis writing:

Dowell, J. A. (n.d.). Introduction to synthesis. Retrieved from https://msu.edu/~jdowell/135/Synthesis.html#anchor48017

Clarke, L. W. (2011, September 11). Writing an article synthesis. Retrieved from https://www.youtube.com/watch?time_continue=33&v=PqJ6lQimP3k (6:18)

Required videos:

Olsen, E. (2016, September 19). How to perform a SWOT analysis [Video file]. Retrieved from https://www.youtube.com/watch?v=I_6AVRGLXGA (7:02)

Riley, J. (2016, May 25). SWOT analysis [Video file]. Retrieved from https://www.youtube.com/watch?v=7JmDXDZYx0s (8:27)

 

 

Explain the background of the mentioned topic, using appropriate references. Clearly explain the objectives of your case study. This should include the details of which types of performance and risk you choose to study.

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6FNCE001W Banking Theory and Practice 2019-20Individual Coursework

To be submitted before 1pm on Thursday, 19th March 2020

The assignment is a case study. The length of the essay is 1000 words (+/- 10%) excluding cover page, table of contents, abstract, references and appendices.

Required:

Conduct a case study on how Brexit and uncertainty of Brexit plan have affected a chosen UK commercial bank so far, in the context of performance and risk level. Your case study needs to include the following elements:

  1. Explain the background of the mentioned topic, using appropriate references.
  2. Clearly explain the objectives of your case study. This should include the details of which types of performance and risk you choose to study.
  3. Collect financial data of your chosen UK commercial bank from a reliable source.
  4. Carefully evaluate financial ratios/measures which meet the objectives of the case study.
  5. Analysis the financial ratios/measures, with the support of appropriate diagrams.
  6. Critically argue whether the bank’s performance and risk were affected by Brexit.
  7. Your essay has to include a cover page (with the title of essay, do NOT include your student ID), a list of reference, and the required appendix.
  8. The referencing format should be Harvard referencing style.

This essay should be submitted via the module blackboard site. You are expected to understand the university regulation on academic offence. The rules on late submission and plagiarism are applied and fully enforced by the school.

Key Marking Criteria:

  • Explanation on the topic
  • Quality of data collected
  • Choice and evaluation of financial ratios/measures for bank analysis
  • Analysis of the chosen financial ratios/measures
  • Validity and insightfulness in discussion and arguments

Extra Notes 

This Link is for the UK banks that you should chose one from

https://www.bankofengland.co.uk/-/media/boe/files/prudential-regulation/authorisations/which-firms-does-the-pra-regulate/2019/list-of-banks/banks_1219.pdf

It has to be one from the list in the link above.

You should measure data for risk and Performance and risk ratio. Just for one bank. And an old established bank as you will need data from 2014.

You should only write 100 words about Brexit not more.

These should be before June 2016 when Brexit was announced. So, you should analyze from 2014-2016 as the before period. Then from 2016-2019 to analyze the after effect. To see any impact from Brexit. You should analyze any impact on performance and risk.

Performance can be from profitability using ratio using return on equity ratio. And special measurements from net interest margins. And also, the market share of the bank. Credit risk and interest risk also.

SO there has to be two ratios for performance and two ratios for risk they should be used to show the before and the after. And their financial reports can show why they have made a loss for example. And mention the bank name.

What expectations did you have coming into this course? Do you feel this course failed to meet your expectations; met your expectations; or exceeded your expectations. Explain.

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Personal Reflection Statement
Assignment Guidelines: In a 1-2 page double spaced paper, please answer the following questions:

Reflecting on this course please share something significant that you learned that is valuable to you and why.
What would you like to see changed or added to this course and why?
What expectations did you have coming into this course? Do you feel this course failed to meet your expectations; met your expectations; or exceeded your expectations. Explain.

Method of Assessment: ‘Met’ or ‘Not Met’ based on above criteria

Analyze inter-professional and collaborative working strategies that may be used to overcome boundaries between professions.

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INSTRUCTION FOR THE ESSAY
This essay is for my third year 6 level interprofessional education module.In this essay you need to talk about social work but in the context of interprofessional boundaries. Make sure you answered the question and answer the question according to learning outcome. This essay is about THE UK ,so make sure you know about the role of social workers in the UK. The essay must be written for the UNITED KINGDOM.
Our tutor asked as to read this articles: Human Factors:The Dirty dozen in CTG misinterpretation. From the Global Journal of Reproductive medicine.
https://juniperpublishers.com/gjorm/pdf/GJORM.MS.ID.555683.pdf to have an idea about what to write about on essay. Can you please read it? she also asked to watch on you tube Safe Administration of Intrathecal Chemotherapy and Conjoined Twins an impossible decision to understand the essay. This essay is about working with different professionals collaboratively in clinical setting and in community as a social worker. Go and watch in you tube “CONJOINED TWINS AN IMPOSSIBLE DECISION” to have little idea about what social workers does. And this video is recommended to us to write this essay. She asked us to choose 2 human factors (dirty dozen) and focus on them out of 12 human factors. You need to come out with all learning outcome and skill and attributes. Make sure you evidence your essay with references and use citation through out the essay when you claim something. And make sure that you write DIO when you use journal at the reference page. I do not want to ask review for it. this essay about interprofessional practice, interprofessional collaboration.
Module Content
1. The module will address: Inter-professional and collaborative working strategies including overcoming boundaries between professions;
2. Current Government policies impacting on health and social care  provision; Health and social care initiatives, strategies and developments  related to service delivery and service improvement;

3. Evidence-informed practice in light of service user experience.

Learning Outcomes Level 6

1. Analyze inter-professional and collaborative working strategies that may be used to overcome boundaries between professions;

2. Evaluate service delivery in relation to their professional role;

3. Apply and evaluate the extent to which their specialist knowledge contributes to
patient/service-user experience.

Skills and Attributes;
• Demonstrate the skills of autonomy and be able to interact effectively in inter-
professional discussion.
Also, please do not put subheading throughout the essay. just write as normal essay.
Also, can you read all of the file completely, thoughtfully I have uploaded to be able to write this essay as each of them explain something else. which is necessary for this essay

Discuss the intent of the sculptor, craft person, and architect in relation to function.

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Write a five-page, double spaced paper that addresses concepts of function, materials, elements and principles of design. For your essay, choose:

  • one craftwork
  • one sculpture
  • one architectural structure

about which to write. Be sure to cite the URLs where these works can be viewed. Choose visual examples other than those cited in our text, lesson overviews, or bulletin board questions. Use your text, suggested URLs, Internet searches, and library resources.

Discuss the intent of the sculptor, craft person, and architect in relation to function.

Consider the role of form, materials, and concept for the sculpture, the craft piece and the architectural structure.

Specifically address how the resulting elements and principles of design of each of the three works support the content of the that work and the maker or designer’s intent.

Check for correct spelling and grammar

Using a formal systems diagramming approach, analyze Baria’s performance and develop a robust “effect-cause-effect logic” tree diagram using the 5-Whys tool, as in Part One.

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SP004 Directions

Read the scenario as well as the Introduction and Chapter 1 of the Meadows text, the Cathon article on the Learning Organization, the Zemke article on Systems Thinking, and the other material required, and then respond to the prompts that follow.

Scenario

As an expert in systems analysis, you’ve received an e-mail from the chief financial officer (CFO) of XYZ Manufacturers to discuss a potential consulting project. The CFO is vaguely familiar with the concept of systems thinking but isn’t sure it could be successfully applied to her fast-paced, global business.

  • Based on your knowledge of systems thinking and the learning organization, reply to the CFO’s enquiry by explaining at least three challenges of managing complex organizations and how and why effective systems thinking can help improve their performance. Support your response and reasoning with explicit and appropriate references to the readings and with at least two other theoretical frameworks or academic references about systems thinking and practice. (2 -3 paragraphs)
  • Having learned about systems thinking and the learning organization, and reviewed at least one other theoretical framework or academic reference about general systems thinking and practice, give at least two examples, from your experiences in organizations, in which the application of systems thinking could have helped the organization become more effective. Be clear in explaining which specific principles and concepts from systems thinking could have helped in the examples you choose, and explain how and why. (4 – 5 paragraphs)

Part II: Gap Analysis Using the 5-Whys

Read the “Opportunity Consultants, Inc., Case Study” and then respond to the following prompts:

  • Using a systems approach, analyze the performance of Opportunity Consultants, Inc. and develop a case-specific “effect-cause-effect logic” tree diagram using the 5-Whys analytic tool. See the Rubric for details on what this diagram should contain.
  • Write a summary description of your diagram with specific recommendations for improving the club’s performance that are linked to your diagram analysis. (1–2 pages)

Part III: Gap Analysis With Causal Loop Modeling

Read the “Baria Planning Solutions Case Study” and “Facilitating Systemic Thinking in Business Classes” documents, and then respond to the following prompts:

  • Using a formal systems diagramming approach, analyze Baria’s performance and develop a robust “effect-cause-effect logic” tree diagram using the 5-Whys tool, as in Part One.
  • Create an appropriate, simple causal loop diagram (CLD) that incorporates relevant and logical feedback loops to capture the fundamental system behaviors, outcomes, and causes in the “Baria Planning Solutions Case Study.” See the Rubric for details on what this diagram should contain.
  • Write a summary description, including specific recommendations, that links directly to your 5-Whys and CLD analyses for improving Baria’s sales support operations and organization as a whole. (1–2 pages)

Part IV: Robust Causal Loop Modeling

Read the “Bayonne Packaging, Inc., Case Study” and “The System Archetypes” documents, and then respond to the following prompts:

  • Using a formal systems diagramming approach, analyze Bayonne’s organizational performance and develop a robust “effect-cause-effect logic” tree diagram using the 5-Whys tool, as in Part One.
  • Create a robust causal loop diagram (CLD) that incorporates appropriate causal loop logic in the analysis and that also identifies common system archetype patterns within the diagram. This diagram should describe fundamental system behaviors and outcomes.
  • Write a summary description, including specific recommendations, that links directly to your CLD analysis (which includes embedded archetype relationships) for improving the packaging company’s operations and the organization as a whole. (1–2 pages)

What will be involved in getting your product from country of production to country of sale?

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Instructor Notes;

You provided some good info on why you selected McDonald’s and the Nigerian market. You did not have any headings or subheadings to identify some of the other parts of the final paper that are required. Eg. Strategy you will employ to launch your product.

• Organizational structure you select to support the launch. o Within the organizational structure you choose, explain how you will handle management, marketing, operations, finance, internal controls, etc…

• Sales and marketing aspects • Logistics aspects o What will be involved in getting your product from country of production to country of sale?

• Financial management considerations of the launch, etc. You should also discuss the different business environments that will need to be considered with a launch in Nigeria. Eg. Political, Fiscal, Cultural, etc.

 

Describe the circumstances of the following case study and recommend a course of action. Explain your approach to the problem, perform relevant calculations and analysis, and formulate a recommendation.

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Unit #5 – Reading

  1. Heisinger, K., & Hoyle, J. B. (n.d.). Accounting for Managers. Retrieved from https://2012books.lardbucket.org/books/accounting-for-managers/index.html
  • Chapter 9 – How Are Operational Budgets Created?
  • Chapter 10 – How Do Managers Evaluate Performance Using Cost Variance Analysis?

This text explains the budgeting process and how managers use budgets to evaluate performance. It describes flexible budgets and introduces standard costs, which are used to calculate budget variances. Illustrations using applied examples are also provided.

Optional Video

  1. Chegg. (2016, April 5). Static and Flexible Budgets[Video File].

Assignment – Case Study Unit #5

Submit a paper which is 2 pages in length (no more than 3-pages), exclusive of the reference page. Paper should be double spaced in Times New Roman (or its equivalent) font which is no greater than 12 points in size. The paper should cite at least three sources in APA format.  One source can be your textbook.

Describe the circumstances of the following case study and recommend a course of action. Explain your approach to the problem, perform relevant calculations and analysis, and formulate a recommendation. Ensure your work and recommendation are thoroughly supported.

Case Study:

Papaya Partners is a distributor of papayas. They purchase papayas from individual growers and package them in 10-pound cartons for delivery to their various customers, generally supermarkets. Last month, they budgeted to sell $500,000 worth of cartons at a price of $25 each. Actual sales met a budget of $500,000 at $25 per carton.

Management has received cost information based on actual performance and needs to understand the drivers of the overall variance from the budget. They have asked you, as an analyst in their management accounting department, to calculate and explain the variances. The following data has been provided:

Budget
Cost of fruit @ 10 pounds per carton    $      200,000
Cost of packaging @ 1 pound per carton    $        10,000
Labor costs @ .5 hours per carton    $        90,000
Total Cost    $      300,000
   
Actual 
Cost of fruit @ 10 pounds per carton    $      244,200
Cost of packaging @ .55 pound per carton    $        11,000
Labor costs @ .75 hours per carton    $      150,000
Total Cost    $      405,200
   
Unfavorable variance    $105,200.00

 

Specifically, management needs to know the:

  • Standard cost per unit (carton)
  • Actual cost per unit
  • Direct materials price variances
  • Direct materials usage variances
  • Direct labor rate variance
  • Direct labor efficiency variance

In addition, they would like to understand how the variances are calculated and what caused them. They would also like a recommendation on what might be done to improve the variances.

For this assignment, compute all required amounts and explain how the computations were performed. Describe whom you would work with to determine the causes of the variances and hypothesize on what caused the variances. Based on your analysis, recommend actions that management could take to improve the variances.

Superior papers will:

  • Perform all calculations correctly.
  • Articulate how the calculations were performed.
  • Assess the variances computed and evaluate the operational results (i.e., is performance better or worse than budgeted?).
  • Explain with whom you would work to identify the root causes of the variances.
  • Propose well-thought-out causes for each variance.
  • Conclude on which variances require management’s attention and recommend courses of action.

Assignment will be grade on each of the following:

  • Provides correct values for computations. 30%
  • Articulates the approach to solving the problem and how the calculations were performed. All formulas are correct for the 6 variances. 20%
  • Assesses the variances computed and evaluates the operational results as having favorable or unfavorable variances. Explains with whom one would work to identify the root causes of the variances. 15%
  • Proposes well- thought-out causes for each variance. Concludes on which variances require management’s attention and recommend courses of action. 15%
  • Writing Clarity and Quality 10%
  • APA Formatting 10%

 

Analyze and debate professional values, ethical and legal frameworks which impact on holistic care delivery in different clinical settings.

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Assignment Brief

Please, use journals (Evidence) Less than 5 years old and UK Based avidence

Learning Outcomes:

  1. Demonstrate the ability to systematically appraise and clinically apply a range of evidence including research.
  2. Examine strategies to facilitate personal and professional development.
  3. Formulate collaborative and holistic nursing care that safeguards and empowers the public, whilst maintaining comfort, dignity and human rights.
  4. Analyze and debate professional values, ethical and legal frameworks which impact on holistic care delivery in different clinical settings.

Module: Professional Values and Evidence Based practice

Word Limit: 2000 words

Assignment Guidance

You must write a 2000 word essay, incorporating the requirements of the different sections as set out below. Please refer to the frequently asked questions sheet regarding word count. The sections reflect the content of specific themes and case studies taught/referred to within in the module.

Assignment Content

  • Introduction (200 words).

Write a brief introduction to the essay. Describe how you are going to answer each section of the essay, and refer to your field specific case study.

  • Section 1- Nursing Care (500 words).

Identify one nursing problem and analyze why that poses a risk to the comfort or dignity of the patient. This is in reference to your field specific case study (Theme 1 or 5). Choose one nursing care intervention, and analyze why that intervention would promote the comfort or dignity of the patient.

To answer this section successfully you must:

  • Define and analyze- the concept of comfort or dignity, and how this relates to your case study (Theme 1 or 5), by Identifying and analyzing an actual or potential nursing problem.
  • Choose one nursing intervention and analyze how this could reduce the risk of the patient/service user, comfort or dignity being breached. The intervention needs to be specific, with analysis of the arguments for and against the implementation of your chosen intervention.

Section 2 – Empowerment and Collaborative Care (500 words)

Identify one collaborative initiative, and analyze how this could empower the patient/carer to increase their self-management within your field specific case study (Theme 2).

To answer this section successfully you must:

  • Define and analyze the concept of empowerment, and discuss how this relates to the case study (Theme 2), by identifying and analyzing a situation that demonstrates disempowerment.
  • Choose one collaborative intervention, and analyze how the initiative could increase a patient/carers/services user’s level of empowerment within your case study. The analysis needs to consider the possible barriers to implementation, and how they can possibly be overcome.

Section 3 – Law and Ethics (600 words)

Critically analyse one hospital, or community based situation, from your field specific case study, which has legal and ethical implications within the delivery of care to the patient/ service user (Theme 4 or 5).

To answer this section successfully you must:

  • Identify one situation that relates to the patient/service user, and analyse the legal and ethical implications of the situation.
  • Choose one of the ethical principles shown below, and analyse how it relates to your field specific case study.
  • Beneficence, 2) Non-maleficence, 3) Autonomy or 4) Justice
  • Identify and analyze the legal frameworks that exist, and apply them to your case study situation.

One of the legal frameworks must be Human Rights Act (1998)

  • Conclusion (200 words) Provide a summary of the main points in the essay. Demonstrate an awareness of what you have learnt and how this will influence your future practice.

Structure and Presentation

The assignment should be structured so that each section and the required content is covered in a systematic and logical manner. Each section should be linked to ensure a clear flow to the next topic and part of the case study. It should be grammatically correct with clear use of appropriate paragraphing.

Sub-headings

The assignment may have sub-headings. If used, these will be: Introduction, Section 1 – Nursing Care, Section 2 – Empowerment and Collaborative Care, Section 3 – Law and Ethics, and Conclusion.

 Referencing

The essay must be referenced following the Harvard referencing system.

Marking Criteria

The essay will be marked according to the published university level 5 criteria. The module team would encourage attempts at analysis and debate in the essay.

Assignment – basic plan

Note: this is the assignment stripped right back to the bare essentials.  You will need to justify (provide an argument, substantiated by evidence) for the things you put below.

Theme 1

Nursing Care  Adult Scenario

Jeremy’s sleep habits had started to change and he often slept during the day and would then be awake in the early hours of the morning. He would wander around the house and try the doors to see if they were open. This worried Shirley as she was afraid he would get out of the house one day. Unfortunately Jeremy went out late at night unnoticed by his sister. He already had a bit of a cold and having got lost on a rainy night he fell and was unable to get up and get home. He was found the next morning by the postman. On admission to hospital it was found he had a chest infection and a urinary tract infection. It was impossible to get Jeremy to take part in an assessment of his memory as he found it very difficult to answer the questions and kept saying his mother would be looking for him and he had to get home.

 

Jeremy is charming in the mornings and tries to be helpful on the ward. He has been found adjusting the rate of flow of his neighbours drip. In the mornings he can usually understand that he is a patient who is ill and in hospital, but come mid-afternoon he becomes very agitated, repeats words (usually Mama and Shirley over and over again and tries to leave via the fire escape. He has urinated in the waste paper basket and tried to get into bed with a female patient in an adjoining bay. This has caused other patients to be frightened of him and some relatives have complained. In addition Jeremy is very reluctant to take his medication and staff have found some of his tablets tucked under his pillow. When questioned about his behaviour Jeremy becomes very angry with the nurses, some of whom feel it is only a matter of time before he lashes out and hurts someone.

 

In addition to these issues Jeremy is not taking adequate diet and fluids. He is reluctant to sit for any length of time at a table or in a chair to eat a meal. He becomes agitated at times and tends to wander off. Staff are concerned he will become dehydrated and malnourished.

Theme 2

During his hospital stay, Dr Armstrong’s condition improves to a point that Shirley feels that she will be able to cope with him at home. She is seen by all the members of the hospital social care team. However, she refuses offers of help at home as she feels Jeremy would not like “strangers” in his house. She also does not want to be a burden on the state especially as everyone is short of money and she has read in the news that the NHS is facing cuts.

She also feels that she can get some help from Claire and hopes that his son, James will be more accepting of his father’s condition and offer some more help. They had a family discussion last week and James said that he would do more.

2 weeks later, Shirley comes to the ward in a very upset state. She now realises that she is unable to cope at home. Jeremy is still wandering and is sometimes aggressive although this has improved.

The main problem is that Jeremy is now not sleeping at night. He tends to sleep for periods during the day and spends some of the night knocking on her door, calling out his wife’s name, pacing around the house and talking. She is able to settle him back down so that he gets some sleep. The main problem is that this occurs at around 2 – 4 o’clock in the morning when Shirley should be getting most of her sleep. She thinks the hospital admission altered his sleeping patterns.

The promised increased help from Jeremy’s son has not happened and Claire, his wife can only do so much. Shirley is now asking for care to be put in place so she can cope at home. She says she has the advantages of a large (£500,000) house. Jeremy has £40,000 in savings and a good NHS pension. Shirley herself only has a state pension. However, she has lasting power of attorney for property and financial affairs.

Theme 3

The recent admission to hospital has not helped Jeremy’s confusion and when he returns home he finds it difficult to settle, even though the surroundings are familiar.

Shirley asks for support to adapt the house so it will be safer and more befitting to Jeremy’s needs thus empowering her to continue caring for Jeremy at home. The changes also help empower Jeremy to remain in a more familiar environment.

Small changes are made such as improved lighting and the removal of rugs to help prevent falls. Hand rails are installed on the stairs so Jeremy can climb the stairs more safely. The use of a nightlight is suggested to help with disorientation in the dark.

Pictures and signs were put on the toilet door so Jeremy knew where the toilet was which helped to prevent some of the accidents he was having. Cupboards were labelled with pictures also to help Jeremy identify where things were in the kitchen.

Theme 4

 Law and Ethics Scenario

Dr Armstrong has had a stroke and has been readmitted to hospital, his speech and swallowing have been affected and he can only communicate via hand gestures and nods.

The speech and language therapists have assessed him as being unsafe to take diet and fluids orally due to the risk of inhalation, consequently he has had a naso-gastric tube passed and the medical staff are discussing the need for a PEG to be inserted, his son is keen for this to happen.

Dr Armstrong has pulled his naso – gastric tube out on several occasions and he is indicating in gestures that he wants to have a drink orally. When you check in his patient record you find he has written an advanced decision 10 years ago stating that he does not want any unnecessary procedures or interventions if he ever becomes a ‘cabbage’.

What are the legal, ethical and professional issues involved and how would you address this situation?. What say does his son have in this matter?

Theme 5

Towards End Of Life Care

Two weeks ago Jeremy was admitted to hospital. Jeremy had noticeably lost weight over the previous month, become increasingly disinterested in food and increasingly agitated. Shirley finally became unable to cope when he developed a urinary tract infection which caused incontinence.  James, Claire and Shirley all felt anxious about his hospital admission though relieved that this would give them some respite and his care would be reviewed.

During his admission to a care of the elderly medical ward Jeremy’s urinary infection responded well to antibiotic treatment. On re-assessment however his MMSE was noted to have declined further to a score of 8, due to having a further stroke. Nursing staff observed that he frequently coughed with the small amounts of oral intake he took. He was referred for a Speech and Language Therapy (SALT) assessment and was found to have mild dysphagia. A soft diet was recommended but both nursing staff and Jeremy’s family all found supporting him to meet his nutritional needs very challenging. Naso – gastric feeding was started but this caused further care and legal and ethical difficulties.

Jeremy developed in his second week on the ward an increasing tendency to spend more hours than normal asleep. Towards the end of that week he developed a fever, his respiratory rate increased, his respiratory pattern become shallow and he appeared to be dyspneoic. Shirley, James and Claire could see clearly that Jeremy looked increasingly unwell. A chest x-ray identified that he had a right lower lobe pneumonia. A MDT meeting was called and it was concluded that it was highly likely that he had developed pneumonia due to aspiration of food (aspiration pneumonia).

The care of the elderly consultant conveyed her opinion to Shirley, James and Claire that Jeremy is unlikely to survive this condition. Discussion was held regarding the possibility of fast track discharge to facilitate his death to occur in the more familiar surroundings of home. Consensus was reached however that in Jeremy and his particular families’ circumstances the most appropriate option was that he stay in hospital for this critically important stage in his life.

We will be looking in the field session, and through the supporting learning resources, at how best to care for Jeremy’s physical, psychological, social and spiritual care needs at this challenging and special time.