Why is it Difficult for some People with Learning Disabilities to Socially Integrate in Wider Society

Contents

Why is it difficult for some people with learning disabilities to socially integrate in wider society? Outline and evaluate some of the ways in which learning disability services can help individuals with learning disabilities realise their dreams of developing friends and relationships with others.

Why is it difficult for some people with learning disabilities to socially integrate in wider society? Outline and evaluate some of the ways in which learning disability services can help individuals with learning disabilities realise their dreams of developing friends and relationships with others.

Introduction

Learning disabilities refer to a group of disorders whereby individuals may display significant difficulties in listening, speaking, reading, writing, reasoning, mathematical abilities and social skills (Kavanagh & Truss, 1988). These individuals find it difficult to socially integrate in wider society (Gresham and Elliot, 1987); this issue will be referred to social functioning in this essay. Indeed, this is a problem; not only does this have consequences for social functioning, but consequences for academic achievement (LaGreca & Stone, 1990). Therefore, it is important to understand the mechanisms that explain the relationship between learning disabilities and social functioning, and the methods used to promote social functioning. Researchers have proposed a number of possible explanations to explain the relationship between learning disabilities and a lack of social functioning. These are social skill deficits (e.g., Bryan, 1991), communicative deficits (e.g., Storey, 2002) and anxiety (e.g., Beauchemin, Hutchins and Patterson, 2008). Individuals with social skill deficits do not have the social skills in their repertoire to interact appropriately with peers (Gresham & Elliot, 1987). Individuals with communicative deficits have difficulty communicating with partners, such as proximity, eye contact, expecting the other individual to communicate and to respond sufficiently (Downing, 2005). Whereas social skills may include non-communicative behaviours (e.g., dressing appropriately), communicative skills are solely relational; that is, the interaction between individuals (Downing, 2005). Furthermore, anxiety refers to the high state of arousal for individuals with learning disabilities, which, in turn impacts on social skills (e.g., Beauchemin et al., 2008). A number of interventions have been designed based on the above potential mechanisms. These are social skills training (e.g., Vaughn, 1985), communicative skills training (e.g., Downing, 2005) and mindfulness meditation (e.g., Beauchemin et al., 2008). Overall, the research suggests that social skills training, communicative skills training and mindfulness meditation offer modest results. These findings suggest these interventions provide little support for helping individuals with learning disabilities to develop friends and relationships. However, these modest effects may be limited to methodological limitations, such as how concepts are defined and measured. These interventions are viewed best as experimental interventions with theoretical structures that need rebuilding.

Social skills training

There is a consensus in the learning disability research literature that social skill deficits are a defining feature of learning disabilities (e.g., Forness & Kavale, 1996; Kavale & Mostert, 2004). Social skill deficits may occur because a set of skills has not been learned and therefore cannot be performed (Kavale & Mostert, 2004). Social skills training is based on the assumption that if social skills can be taught, learned and performed, social competence will develop. Social competence is an umbrella term, which refers to the perceived adequacy of one’s social functioning (Maag, 2005). For example, as an individual acquires listening skills, they will begin to develop peer acceptance, which, in turn, infers social competence. Social skill training is an increasingly popular intervention used to increase the social competence of individuals with learning disabilities (Kavale & Mostert, 2004). Social skills training programmes often involve developing a comprehensive set of skills, such as social problem-solving, expressing feelings, working cooperatively and learning how to listen (Kavale & Mostert, 2004). Training is delivered in a range of styles, such as direct instruction, coaching, modeling and prompting (e.g., Combs & Slaby, 1978; McIntosh, Vaughn & Bennerson, 1995). For example, McIntosh, Vaughn and Bennerson (1995) developed an interpersonal problem-solving intervention, which involves carrying out social tasks between individuals, as opposed to isolation. McIntosh, Vaughn and Bennerson (1995) argue that if social skills are considered in multiple contexts (e.g., parents and peers), it is more likely to deliver long-term benefits (McIntosh, Vaughn & Bennerson, 1995). In order to assess whether social skills training should be included in intervention programmes it is important to assess their effectiveness. By effectiveness, this refers to whether it is possible to teach students with learning difficulties social skills so that they can cope and adapt to the larger social environment (Kavale & Mostert, 2004). A number of comprehensive reviews in the research literature of learning disability have investigated the effectiveness of social skills training (e.g., McIntosh, Vaughn & Zaragoza, 1991; Sridha & Vaughn, 2001). However, the findings of these reviews have been mixed (Kavale & Mostert, 2004), therefore offering tentative conclusions (i.e. conclusions that are not certain). This mixed support makes is possible to question the effectiveness of social skills training and whether individuals with learning disabilities can develop friends and relationships with others. Alternatively, meta- analyses have investigated the effectiveness of social skills training (e.g., Kavale & Forness, 1995; Forness & Kavale, 1996). A meta-analysis is a quantitative research method, which involves the collection of research studies. The conclusion of a meta-analysis is calculated by identifying the common statistical measure shared between studies, such as the effect-size (Cohen, 1988). Meta-analyses are considered the most robust research method as they are a way of achieving the highest statistical power. This means that researchers can be confident with generalising about a certain intervention (Eden, 2002). Kavale and Mostert (2004) conducted a meta-analysis to investigate the effectiveness of social skills training. Findings showed that social skills training had small effects, meaning that social skills training had limited efficacy for developing individuals’ social competence (Kavale & Mostert, 2004). Kavale and Mostert (2004) suggest that the small effects associated with social skills training may be due to a number of theoretical and design issues. Perhaps one of the reasons social skills training has small effects is due to how social skills are conceptualised. Indeed, there is a continual debate in the literature over how social skills are defined (Gresham, 1986). For example, some researchers refer to social skills as certain actions used to respond to social tasks (e.g., McFall, 1982). In contrast, other researchers refer to social skills as behaviours that help individuals initiate and maintain relationships and adapt to the larger social environment (e.g., Walker, Colvin & Ramsey, 1985). Therefore, if there is a lack of a universal concept surrounding social skills then research studies will evaluate the effectiveness of social skills training in different ways. Another potential explanation as to why social skills training have small effects is related to measurement issues. Indeed, in the learning disability research literature there is a common problem of psychometric issues i.e. the design of quantitative tests (Gresham, 1986). For instance, researchers have identified that there has been a poor rationale for the inclusion of certain items in questionnaires. In addition, items often present poor reliability (i.e., items that produce inconsistent results across consistent conditions) and poor validity (i.e., items selected do not truly measure what they intend to measure). Therefore, if questionnaires to not obtain valid measures of social skills, research studies will find it difficult to show that social skills training works. To overcome these methodological issues, researchers have developed more robust instruments. These are the Social Skills Rating System (Gresham, 1986) and the Walker-McConnell Scale of Social Competence and School Adjustment (Walker & McConnell, 1988). However, in Kavale and Mosterts’ (2004) meta-analysis, very few research studies utilised these instruments. A recommendation for future research would be to utilise instruments with good psychometric properties, in order to estimate the true efficacy of social skills training.

Communicative skills training

Individuals with learning disabilities show deficits in communication. Therefore, researchers have focused on developing individuals’ communicative skills in order to promote communicative competence. Communicative skills training develop these communication skills at job sites, such as employment offices (Storey, 2002). A responsive communicator refers to one who is aware that they are required to wait sufficiently for their partner to finish, before responding with relevant information (Downing, 2005). These communication skills lack in individuals with learning disabilities. This type of intervention is based on the foundation that communication is relational. Indeed, communication is characterised by the interaction between at least two individuals, or more, where there is a sender of a message and a receiver of a message. According to Downing (2005), using communicative partners in interventions is necessary for individuals with learning disabilities to understand the social aspects of communication. Like social skills training, communicative skills training use a variety of methods, such as modelling, role-playing, feedback and problem-solving. Furthermore, communicative skills interventions use reciprocity, facilitation and co-worker support. For example, Lamb, Bibby and Wood (1997) designed a programme, which included peer-communication activities. Participants were presented with publications of communication paradigms. The task required a speaker to describe the illustration to the listener who is then required to draw the illustration. An author supported this interaction. The author demonstrated the task first and provided regulatory strategies such as asking, answering and checking to encourage effective communication. Participants were told that if they would need to use these regulatory strategies in order to complete the tasks. This programme consisted of 12-weekly sessions, which each lasted about an hour. Results showed that by the end of the programme, individuals engaged in these strategies more and became more effective at communicating. This suggests that communicative skills training is an effective intervention used to promote the social functioning of those with learning disabilities. A systematic review carried out by Alwell and Cobb (2009) investigated the effectiveness of communication skills training for the social functioning of individuals with learning disabilities. Findings showed modest support for communicative skills training, suggesting that communicative skills training promote individuals’ social functioning. This systematic review has a number of methodological strengths. First, this review only included studies that had robust methodology, such as high internal validity, high internal reliability, and studies that provided important statistical information, such as effect sizes. Therefore, researchers should have greater confidence that the results are reliable, at least across educational settings. Nevertheless, although it is a strength that the review only included studies that provided effect sizes, it can also be argued as a limitation. Alwell and Cobb (2009) raise the issue that excluding studies reduces the breadth and depth of the research pool, which, will reduce the quality of the systematic review. Therefore, future research should consider reporting their effect sizes so a larger pool of studies can be included in systematic reviews.

Mindfulness Meditation

Mindfulness meditation is an alternative approach to other interventions that can also be used to target the social functioning of individuals with learning disabilities (Beauchemin et al., 2008). Mindfulness refers to paying attention to one’s emotions, thoughts and sensations, in the present moment and in a non-judgmental way (Kabat Zinn, 1994). Mindfulness was originally identified as a method for improving mental health and reducing psychological distress (Bishop et al., 2004). However, it is recently becoming recognised as a technique that can be applied to a range of issues. A study conducted by Beauchemin et al. (2008) investigated whether mindfulness-based meditation intervention promoted social skills. The intervention included meditation sessions to be carried out every day, over a period of five weeks. Specifically, students were instructed to focus on their breath as they inhaled the breath and exhaled the breath, in an attempt to achieve a sense of calmness. After students had achieved a sense of calmness, students were instructed to mentally note the thoughts and feelings they experienced during the exercise. Students were instructed that if they felt over-involved in their thoughts and emotions that they should identify and acknowledge these experiences in a non-judgmental way. Findings showed that mindfulness meditation had modest results for promoting individuals’ social skills (Beauchemin et al., 2008). This suggests that mindfulness meditation may be a method disability services can use to increase the social functioning of individuals with learning disabilities. This relationship between mindfulness and the improvement of social skills can be partly explained by the cognitive-inference model of disability. The cognitive-inference model of disability suggests that mindfulness meditation reduces anxiety and the self-focus of attention, which, in turn improves social skills (Wine, 1971; 1982). For example, if an individual with learning disabilities is thinking about their competence and negative thoughts, they are likely to experience higher anxiety, which, in turn, will impact on their social functioning. Indeed, mindfulness meditation was significantly associated with a reduction in anxiety, providing support for the cognitive-inference model (Beauchemin et al., 2008). The study conducted by Beauchemin et al. (2008) has a number of strengths. First, the Social Skills Rating System (SSRS) developed by Gresham and Elliot (1990) was utilised. This instrument is a self-report instrument, which assesses student, teacher and parent ratings of the individuals’ social skills. The SSRS is a robust instrument, which has demonstrated acceptable internal validity and reliability (Harper, Webb & Reynor, 2013). By using instruments that have good psychometric properties, researchers can be more confident about the efficacy that mindfulness meditation has for promoting social competence. However, the generalisability of this study is subject to a number of limitations. First, the study did not utilise a control group (i.e. a group that does not receive the intervention). In experimental studies, control groups often serve as a comparison group, to evaluate interventions. In this instance, a control group was not used, producing threats to internal validity because the researchers cannot be sure that the behavioural changes observed are due to the intervention. Therefore, future research should consider randomly allocating participants to intervention and control conditions to ensure that changes in behaviour can be attributed to the intervention (Harper, Webb & Reynor, 2013). There is a robust set of research showing that mindfulness meditation reduces anxiety (e.g., Maags, 2005). However, there is a lack of research demonstrating the long-term effects of mindfulness meditation for promoting social skills (Beauchemin et al., 2008). Longitudinal studies are required in order to determine a causal relationship. Future research should consider conducting longitudinal studies in order to investigate the long-term impact mindfulness meditation has for promoting social skills.

Conclusion

This essay has provided potential explanations to explain the why individuals with learning disabilities find it difficult to socially integrate in wider society. These are social skill deficits (e.g., Bryan, 1991), communicative deficits (e.g., Storey, 2002) and anxiety (e.g., Beauchemin et al., 2008). This essay has also outlined the different ways learning disability services can promote social functioning. These are social skills training (e.g., Vaughn, 1985), communicative skills training (e.g., Downing, 2005) and mindfulness meditation (Beauchemin et al., 2008). This essay also evaluated these interventions based on meta-analyses, systematic reviews and research studies. Overall, the research suggests that social skills training, communicative skills training and mindfulness meditation offer modest results. These findings suggest that these interventions provide little support in promoting the social functioning of individuals with learning disabilities. In light of the importance social functioning has for developing friends and relationships, these results are somewhat disappointing. However, these modest findings are limited to a number of methodological limitations. Some of these include the lack of agreed concepts (e.g., Gresham, 1986), the lack of robust instruments (e.g., Gresham, 1986) and the lack of control groups (e.g., Beauchemin, 2009). Because of these methodological issues, the theoretical structures of these interventions remain incomplete, limiting the efficacy interventions have for social functioning. These interventions are viewed best as experimental interventions, and future research should consider rebuilding them.

References

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Wong (Ed.), Learning About Learning Disabilities (pp. 195-231). New York: Academic Press. Combs, T. P., & Slaby, D. (1978). Social skills training with children. In B. Lahey & A. Kazdin (Eds.), Advances in Clinical Child Psychology (Vol. 1, pp. 38-57). New York: Plenum Press. Donahue, M., Pearl, R., & Bryan, T. (1983). Communicative competence in learning disabled children. In I. Bialer & K. Gadow (Eds.), Advances in Learning and Behavioral Disabilities (Vol. 2, pp. 49-84). Greenwich, CT: JAI Press. Downing, J. E. (2005). Teaching Communication Skills to Students With Severe Disabilities (2nd ed.). Baltimore: Paul Brookes. Forness, S., & Kavale, K. (1996). Treating social skills deficits in children with learning disabilities: A meta-analysis of the research. Learning Disability Quarterly, 19, 2–13. Gresham, F. M. (1986). Conceptual and definitional issues in the assessment of social skills: Implications for classification and training. Journal of Clinical Child Psychology, 15, 16-25. 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Every Action is a Selfish One and Thus True Altruism does not Exist.

Contents

Discuss in relation to theory and research on pro-social behaviour.

Discuss in relation to theory and research on pro-social behaviour.

Introduction

Helping behaviour has been a focus of social psychological research since the 1950's (Hogg and Vaughan, 2008) and within this literature; there exists an abundance of studies concerned with the concept of altruism. The main aim of this essay is to consider the assertion that every action is a selfish one and thus true altruism does not exist. In order to do this, relevant theory and research on pro-social behaviour will be explored. Broadly speaking, pro-social behaviour involves carrying out an act that benefits another (Hogg and Vaughan, 2008) and the interest in this topic since the 1950's, from a research point of view, has impressive longevity. Altruism, as a concept, has attracted much debate and is a type of helping behavior, essentially involving helping another without any expectation of personal gain (Batson and Coke, 1981; Macaulay and Berkowitz, 1970). Perhaps it is rather difficult to realistically suggest that an act could ever be categorised as truly altruistic or indeed if it is not, then it must be selfish. This essay will help to support the view that altruism exists to some extent but often there can be benefits for the individual in demonstrating this behaviour. Research has unfortunately at times aimed to minimise the assertion that a motive to help others without personal benefit can exist (Krueger, 2012).

Theory and Research

Wilson (2015, p.5) very recently documented that "the question of how altruism evolves is such a controversy that is just entering its resolution phase." Altruism is a fairly complicated concept to explore and some of Wilson's (2015) writings reflect this. For instance, Wilson (2015) alludes to the idea that it can be challenging to truly understand an individual's intention when helping another in that it may be to feel better, win favour with God or ensure the other person is in debt to you. The question therefore might be along the lines of what constitutes truly altruistic behaviour and when does it become selfish. Wilson (2015) also helpfully simplifies how one might view altruism by focusing, temporarily, only on the behaviour. An example is illustrated by Wilson (2015) whereby if one individual helps another at a cost to themselves then that demonstrates altruism regardless of what they thought or felt about the situation. Pro-social behaviour theory provides mixed support for the idea of true altruism. For instance, altruism does not particularly receive support from the well-known bystander-calculus model (Piliavin, Dovidio, Gaertner and Clark, 1981), if one is to accept it. This model would assert that individuals would take action in an emergency essentially to reduce their own unpleasant arousal (Batson and Oleson, 1991). This theory clearly makes reference to the significance of the thoughts and feelings of the individual. It may suggest that in part, the helper is to a degree being selfish, but at the same time, is actually carrying out an act that helps another. From this point of view, altruism is perhaps not the correct term since the individual is driven to act, to an extent, to serve his or her own interest. Egoism and altruism have historically been framed as a "versus relationship" with Hogg and Vaughan (2004) summarising that a significant number of psychologists side with the theory supporting the egoism argument whereby behaviour is driven by personal gain. The work around egoism tends to feel like the darker side of pro-social behaviour theory and research. Some of the evidence showing apparent support for this theory is rather questionable. For instance, Manucia, Baumann, and Cialdini (1984) conducted an experiment whereby certain participants were given a placebo pill but told that by taking it, their current mood would "freeze." This led to people under this condition apparently being not as likely to help an individual in need since it would not improve their mood. Brown and Maner (2012) praised the intelligence of this study although it does have an artificial feel about it and one could question how much it might reflect a real-life scenario. It cannot necessarily be used as evidence that altruism does not exist since for some people, the motivation in the first instance might be to actually help the other person (Brown and Maner, 2012). The above mentioned study is somewhat at odds with a review of theory and research regarding altruism at that time (Piliavin and Charng, 1990). One conclusion by these authors was that evidence from a number of fields such as sociology and social psychology among others suggest that altruism is indeed a feature of human nature (Piliavin and Charng, 1990). Bierhoff (2002) builds on this and suggests that altruism exists and reported that it is arguably perfectly captured in the parable of the Good Samaritan whereby having empathy for the victim led to the unselfish act of helping the victim to safety, even at personal cost. This parable is still taught in the modern day and apparent acts of altruism remain a feature of everyday society. This is not to discount the assumption that there could be side effects whereby the individual may experience private rewards for acts of altruism. It is now necessary to consider relevant research studies in more detail in order to further explore the rather controversial central claim that every action is a selfish one and true altruism does not exist. It has been unfortunate in a way that researchers have, more often than not, chosen to focus on "anti-social" rather than pro-social behaviour. This perhaps reflects a tendency to be more interested in the worst in people. This also leads to the idea that people may be more likely to dismiss altruism and consider other explanations for this type of helping or selfless behaviour. May (2011, p.25) implies that caution should be taken when interpreting altruism-based research in stating that "the consensus among psychologists (and common sense) is that a great number of our mental states, even our motives, are not accessible to consciousness." As mentioned above, Wilson's (2015) more recent writings seem to have certain parallels with this and it may be that one has to accept that knowing the individuals intent to help may not be possible.A This could cast doubt on the reliability of much of the experimental work in the field of altruism, particularly when self-reporting measures are so commonly used. Cialdini and colleagues certainly invested much effort in demonstrating that true altruism does not exist. In a related piece of research, Maner, Luce, Neuberg, Cialdini, Brown and Sagarin (2002) explored the effect of manipulated perspective taking with a focus on the empathy-helping relationship, which they suggested underpins altruism. Interestingly, the study featured 169 university students who had an incentive to participate in the study in order to help fulfill their academic requirements. There is a certain irony about this in that it does not reflect altruism towards the researchers. Following observing the views of participants who had listened to a particular interview, Maner et al. (2002) suggested that negative emotional states like sadness are more likely to lead to helping others rather than genuine altruism. While it is difficult to prove that true altruism does exist, Batson and colleagues adopted a very different angle with regards to this concept. For instance, in a similar but earlier study, Batson, Sager, Garst, Kang, Rubchinsky and Dawson (1997) again used only university students to assess empathy and helping behaviour towards a young woman in need. In certain conditions, this woman was depicted as being from a rival university yet the students displayed empathy and a willingness to help. As with much of Batson's research, this paper argued that empathy for others brings about natural altruism in people. These above examples highlight the entirely different ways in which altruism can be framed. Krueger (2012) alludes to the idea that the search for true altruism is one that cannot realistically bring success. Research has unfortunately historically been rather black and white in its mission to explain altruism. It has almost featured a rivalry between benefitting the self against motives to benefit others. Krueger (2012, p.397) argues that it is "more important to protect the motive to benefit others from being discounted" while essentially avoiding branding people as selfish. It is perhaps possible to learn something valuable about the nature of altruism from a piece of research regarding "giving blood" (Evans and Ferguson, 2013). It is difficult to generalise findings to the wider population given that it involved only university students. However, this particular paper examined, via surveying an impressive 414 responders, the motivating factors underpinning white blood donation. Evans and Ferguson (2013) reported that giving blood does not appear to be an act that reflects the actual definition of pure altruism. Instead, a blend of factors such as a sense of contributing to society, a feeling of being able to benefit others and personal satisfaction might explain blood donation. There are apparent benefits to the individual giving blood in the experience of positive emotions, described as "warm glow" by Evans and Ferguson (2013). This may not reflect true altruism. It would however seem unfair to suggest that the generally accepted altruistic act of giving blood is selfish. If one continues to accept the view earlier put forward by May (2012), it would help to have some acceptance that it may not be possible to really know if true altruism exists. In a cross-cultural qualitative paper, Soosai-Nathan, Negri and Delle-Fave (2013) documented evidence from Indian and Italian cultures that illustrated that altruism can be more than a pro-social behaviour. Soosai-Nathan et al. (2013) suggest that altruism can help to improve relationships and boosts happiness and wellbeing. It would also be useful to view this in a positive light if possible while clearly, these types of "personal" rewards may well reinforce the altruistic behavior. It is fundamentally a good human quality though. This may be a more useful area for further research - to improve wellbeing - rather than aiming to disprove altruism, which has quite a dehumanising feel to it.A It would however be ignorant to bypass the idea that altruism is influenced by a number of factors. It would be overly simplistic to accept that it is just a natural trait of individuals. The area of giving money to fundraisers adds interesting insights to the understanding of altruism. Andreoni, Rao, and Tratchtman (2011) conducted a natural field experiment involving monitoring the giving of money to fundraisers in a particular area of Boston, USA, and noted that a high volume of people avoided, via a number of means, the fundraisers who were standing at exits of a shopping centre. Robson (2002) warns of the dangers of these types of studies, e.g. loss of ability to control variables and loss of validity. Nonetheless, Andreoni et al. (2011) suggest that people may avoid eye contact with a fundraiser as empathy may be triggered otherwise, leading to the giving of money. On the other hand, people may give as they would like to be seen as being altruistic. There may also be a compromise between giving money to charity and balancing personal finances. Andreoni et al. (2011) conclude that altruism in people is influenced significantly by a combination of social cues and psychological mechanisms. This is perhaps unsurprising but helps to illustrate the complexity of human altruism.

Conclusions

Firstly, it would seem incorrect to necessarily reject findings from pro or indeed anti altruism research. May (2012) summed things up nicely, reminding that so often, people's true intentions and thoughts about a situation are not visible even to themselves. If one accepts this then there might not be great confidence in suggesting either that altruism definitely exists or that all acts are selfish. Altruism can certainly be viewed as a fairly controversial concept and one that has featured in social psychology theory and research for some years. It would appear that it is extremely difficult to be involved in a truly altruistic act and Staub (1974) much earlier alluded to this as generally when one acts in a pro-social way, inwardly, it can be rewarding, bringing about positive feelings. When considering all of the available evidence, perhaps it can be concluded that altruism in its truest sense, as its very definition states, does not exist. However, there is likely to be an altruism continuum upon where most people in society would sit, rather than acts necessarily being classed in a fairly black and white fashion as altruistic or selfish. Krueger (2012) adopts a common sense stance on altruism and is suggestive that it exists and people do engage in acts designed to benefit others, without intended personal gain.A

References

Andreoni, J., Rao, J. M., & Trachtman, H. (2011). Avoiding the ask: a field experiment on altruism, empathy, and charitable giving. (No. w17648). National bureau of economic research. Batson, C.D., and Coke, J.S. (1981). Empathy: A source of altruistic motivation for helping? In Rushton, J.P., and Sorrentino, R.M. (eds.), Altruism and helping behaviour: Social, personality, and developmental perspectives (pp. 167-183). Hillsdale, NJ: Erlbaum. Batson, C.D., and Oleson, K.C. (1991). Current status of the empathy-altruism hypothesis. In Clark, M.S. (ed), Prosocial behaviour (pp. 62-85). Newbury Park, CA: Sage. Batson, D.C., Sager, K., Garst, E., Kang, M., Rubchinsky, K., and Dawson, K. (1997). Is empathy-induced helping due to self-other merging? Journal of personality and social psychology, 73 (3), 495-509. Bierhoff, H-W. (2002). Prosocial behaviour. East Sussex: Psychology Press. Brown, S.L., and Maner, J.K. (2012). Egoism or altruism: Hard-nosed experiments and deep philosophical questions. In Kenrick, D.T., Goldstein, N.J., and Braver, S.L. (ed), Six degrees of social influence: Science, application and the psychology of Robert Cialdini (pp. 109-118). New York: Oxford University Press. Evans, R. and Ferguson, E. (2013).Defining and measuring blood donor altruism: A theoretical approach from biology, economics and psychology. The International journal of transfusion medicine, 106, 118-126. Available from https://onlinelibrary.wiley.com/doi/10.1111/vox.12080/pdf (Accessed 01/10/15). Hogg, M.A., Vaughan, G.M. (2008). Social psychology (5th Edition). England: Pearson Education Limited. Krueger, J.I. (2012). Altruism gone mad. In Oakley, B., Knafo, A., Madhaven, G., and Wilson, D.S. (ed), Pathological altruism (pp. 395-405). New York: Oxford University Press. Macaulay, J.R., and Berkowitz, L.A (eds.) (1970). Altruism and helping behaviour: Social psychological studies of some antecedents and consequences. New York: Academic Press. Maner, J.K., Luce, C.L., Neuberg, S.L., Cialdini, R.B., Brown, S., and Sagarin, B.J. (2002). The effect of perspective taking on motivations for helping: Still no evidence for altruism. Personality and social psychology bulletin, 28, 1601-1610. Manucia, G.K.,Baumann, D.J., and Cialdini , R.B. (1984). Mood influences on helping: Direct effects or side effects? Journal of personality and social psychology, 46 (2), 357-364. May, J. (2011). Egoism, empathy and self-other merging. Southern journal of philosophy, 49, 25-39. Piliavin, J.A., and Charng, H-W. (1990). Altruism: A review of recent theory and research. Annual review of sociology, 16, 27-65. Piliavin, J.A., Dovidio, J.F., Gaertner,S.L., and Clark, R.D. (1981). Emergency intervention. New York: Academic Press. Robson, C. (2002). Real world research (2nd edition). Oxford, UK: Blackwell Publishing. Soosai-Nathan, L., Negri, L., and Delle-Fave, A. (2013). Beyond pro-social behaviour: An exploration of altruism in two cultures. Psychological studies, 58 (2), 103-114. Staub, E. (1974). Helping a distressed person: Social, personality and stimulus dterminants. In Berkowitz, L. (ed.), Advances in experimental and social psychology (Vol. 7), pp. 294-341. New York: Academic Press. Wilson, D.S. (2015). Does altruism exist?: Culture, genes and the welfare of others. New Haven: Yale University Press.

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What is Intelligence Within Psychology? is it Innate or Culture?

The concept of intelligence and understanding the mechanisms that create, sustain and develop it have both captivated and bemused scholars for millennia. For sure, as self-reflexive beings we are destined to comprehend or delineate the question of knowledge; the retention of information – the immaterial – that has a pivotal function in not only creating the psycho-social world but allowing it to evolve. The purpose of this essay is to examine the definitional nightmare that has plagued our conception of what intelligence is or how it should be described, before exploring the contributions made by psychology in capturing and measuring this phenomena. In turn, this essay will explore one of psychology’s longstanding dichotomous dilemmas, the ‘nature vs. nurture’ debate, to explore whether intelligence is an inherent virtue or something ascertained through interaction and culture.A This essay is one of exploration, a discovery and piecing-together of various strands within psychology, to provide an account of what intelligence is and its place of origin. It seems somewhat obvious that our academic ancestors would have been heavily persuaded by the supernatural and otherworldly, before the emergence of scientific discourse and so-called Enlightenment.

For Plato (2014), the soul existed independently of the corporeal, imbued with beauty, elegance and knowledge par excellence, residing in the sacred realms of perfect forms and facts before marrying with the body; a metaphorical prison that hindered the soul’s quest for actualisation. Thus, intelligence was a process of realisation or recollection, the overcoming of a fickle, polluted, and decaying body to a higher state of becoming; a master artisan of reflexivity or philosopher king (Plato 2014, 88). However, philosophers like Aristotle (2013) – often regarded as the ‘father of psychology’ -A A whilst sustaining the Cartesian Dualism somewhat, contended that there was a marriage (hylomorphic) between the mind and body; the former (passive intellect)A an infinite and immortal vessel that engages with the former (active intellect) and its five senses to assimilate and project into (inter)action. However intellect (nous) remains an abstruse and spiritualised entity. As Magee (2000) alludes, such philosophical interpretations have an artistic and somewhat godly quality pertaining to intelligence, its origin and ascertainment. The advent of pseudoscience’s like phrenology sought to locate intellect within the details of the human skull; dimples and dents where regarded as proof that human potential could be determined, thereby damming already marginalised groups and heightening the divide across race, class and the sexes (Uttal 2003). The succession of science, whilst discounting religion as an illogical and epistemologically restrictive domain, also had a disenchanting effect (Weber1946) on our understanding of intelligence; placing it within realms of quantification, a variant that could be detailed, standardised, examined and subsequently explained without the need for wonder and mystic. Accordingly, psychology became a prime protagonist in exhuming the mythical and establishing the measurable substance of intelligence, its elemental makeup and related descriptions. So, what is intelligence? Ironically, this topic remains hotly contested within psychology, though most accept that intellect is a necessary component for adaptation. It requires a host of mental operations (including a malleable brain), physical capabilities and ecological cues to converge – to some extent – in an orchestrated manner, allowing one to synthesise successfully, advance and ultimately master the environment around them. As the American Psychological Association suggest, it is the “global capacity to profit from experience” (APA 2015). The work of Piaget (1972) has assisted immensely in our understanding of (child) development and the cognitive-intellectual building blocks or schemas that emerge from birth, his preoccupation with how knowledge grows led to several assertions. In principle, intelligence is the creation of these mental representations through a process of assimilation i.e. the generation and deployment of schemas to manage (new) situations and/or objects, and accommodation which can be likened to schematic adjustments or transformations as new (updated) information is confronted.

For Piaget (2001), intelligence is a process of four unique stages of increasing complexity, beginning with the sensorimotor stage at birth where the infant relies heavily on its motor senses to engage with the world, and ending with formal operations stage where the child develops abstract thought, employs deductive reasoning and differentiates oneself from others – progressing from primitive to infinitely complex structures, concepts and coding’s.A Similarly, for Cattell (1963) intelligence may be dissected into two dialectical concepts: the broad function to think logically and problem-solve through unfamiliar processes called fluid intelligence (Gf) and the ability to reason and implement based on previously acquired knowledge or what he called crystallised intelligence (Gc). However these original conceptions have been subsequently expanded to include a whole host of mental abilities (Lubinski 2004), including memory, visual and auditory processing. Yet, interaction with the world demands what Salovey and Mayer (1990) call emotional intelligence whereby, as social creatures, humans can appropriately gauge and control their own emotive state whilst determining that of others – what Weber (1946) calls ‘verstehen’ – to act with purposeful and productive intent both individually and collectively; this requires social learning and a mastery over ones emotive impulses – where biological impulse and society meet, the latter defusing, moulding and directing the former (Lieberman 2013). Indeed, as an extreme example, we discover in psychopaths the inability to form emotional bonds or act empathically, tending to mimic emotive demonstrations (Raine and Glenn 2014), leading to dysfunctional and extremely harmful individuals.

Ironically, typical traits of psychopaths include a high level of general intelligence which is understood as the capacity to assimilate, comprehend and apply facts, laws and principles. Indeed, in his psychometric investigations, Spearman (1927) introduced the term general factor (g) to denote that humans possessed – to varying degrees – a core construct of cognitive capacity or mental energy. This was assessed by tapping into what he called specific factors (e.g. arithmetic, logic, and written) using a variety of mental tests; his findings showed that those participants demonstrating high performance on specific mental tasks tended to achieve in others.A In addition, arguing the case for multiple intelligences, Thorndike (1920) posits an additional social intelligence, which parallels with our capacity as sentient animals, that includes our aptitude for participating and profiting within the social milieu; to act wisely, assimilate norms and values and interact with others. These techniques and interactive strategies are learned through social conditioning and vary across societies (Goleman 2007). Thus, intelligence appears to be multifaceted in its conceptual makeup, often hierarchical and including subdivisions of specificity. For cognitive theorists, there has been a tendency for proponents of the psychometrics to focus purely on the realm of conceptual structure whereas they place impetus on uncovering the process through which intelligence is gained; a computer analogy is often deployed to describe how information is processed through various senses, mental nodes and serial formations.

Importantly, as Jensen (1987) postulates, mental processing speed may play a pivotal role in intelligence, as well as how effectively we collate, compartmentalise and articulate mental representations of information. Theorists consider the basic components or models of cognition, such as creativity, attention, thinking and perception, and how these function. A variety of computer-like models have been generated as a kind of heuristic device or ideal-type (Huneman 2007) to detail mental procedures. For example, Atkinson and Shiffrin (cited in Ashcraft and Raduansky 2013) outline a multi-stage model of memory that shows various phases through which information is collated, stored and retrieved in a kind of processor-like input-storage-retrieval procedure; a variety of systems, including attention, sensory memory and the rehearsal loop, are involved in deciphering, coding, storing and retrieving memories. A variety of research conducted on brain-function has provided some concrete evidence for cognitive theories inasmuch as the brain might be divided into sectors of functionality; the temporal lobes are involved in speech, memory and behaviour whereas the frontal lobe has been considered responsible for behaviour, movement and intelligence (Smith and Kosslyn 2008). Indeed, whilst certain regions of the brain can be attributed with particular tasks, most researchers accept the interconnectedness nature involved in creating intelligence.A As Eysenck and Keane (2010) suggest, in order to measure cognitive phenomena and attempt to illuminate the genealogy of intelligence, researchers employ a host of “mental tests”, including the “original” Binet-Simon (later Stanford) intelligent quotient (IQ) – originally devised to identify underperforming children – which assesses general components of intellect, to more specific skill-related tests that account for memory, verbal, speed and emotional aptitude. In some cases, such tests have a high level of reliability, validity and standardisation providing a reasonable indicator (correlation) of aptitude and achievement potential. However, such tests have come under considerable criticism, particularly because of their class, race and cultural biases (Greenfield 1997); what should define intelligence and how this should be measured/assessed remains a problematic issue for all testing. Also, appreciating that the mind is a malleable organ and suited to adaptation based on environmental demands, it seems logical that humans will evolve differently across cultures; measures, values and descriptions of intellect will vary accordingly (Nisbett 2009). Similarly, aspects of intellect will be heightened according to environment, for example, in hunter-gatherer societies, spatial awareness and attention may be regarded as more useful tools (and may be accentuated in such cultures) than maths or verbal abilities (Smith and Kosslyn 2008). Sadly, despite the implementation of scientific measurement, the psychology of intelligence remains somewhat speculative, hypothetical and dependant on mental constructs.

The biological approach to intelligence seeks to place intellect within the realm of hard facts as a means of explaining (rather than describing) behaviour. However, this reductionist view is considered complementary to cognitive models and computer analogies of intelligence (Claxton 2015). Indeed, many studies, using modern technologies like Magnetic Resonance Imaging (MRI) and Positron Emission Tomography (PET), have sought to pinpoint activity within the brain when performing specific tasks as a method of compartmentalising brain function and sources of intelligence. Similarly, there has been considerable research into brainwaves and the effect on task performance and blood-flow as an indicator of mental activity (Devlin and Fienberg 1997). The field of DNA has also revealed the contribution that genes make to intelligence (using various IQ test), especially in adulthood with the implication that we reinforce (or indeed resist) our genes as we develop. Also, investigation into twin studies – particularly identical or dizygotic pairs – has demonstrated a strong correlation (between 70-80% variance) between heritability and intelligence; identical pairs separated at birth show similar readings in intellect whilst adopted children show similarities to that of their birthparents (McCartney et al 1990). Moreover, our understanding of genetic disorders, such as dyslexia and neural diseases like Alzheimer’s and Downs Syndrome further illuminate the biological grounding of intelligence and its related brain functions (Slade 2009). Malyby and Day (2013) has also proposed how cultural influence interacts with the biological.

For example, (mal)nutrition, stress and ‘mental scars’ due to trauma can impede on intelligence; this pertains to various environmental factors, such as poverty, war and abuse. In fact, as a retort to the biological approach, is the consideration of culture in shaping intelligence. As Skinner (2011, 46) one expounded “give me a child and I’ll shape him into anything” alluding to the notion that the mind is a tabula rasa awaiting social imbuement. Yet, as Berg (2012) recounts, the (social) world is an asymmetrical field, where resources or architectural means to reach ones potential are stockpiled in the hands of a few; denoting that social inequality remains an important factor in pedagogic (indeed human) potential, conditioning across race, class and gender boundaries generates specific malignant societal formations that hinder progress. In addition, as Fox et al (2011) demonstrates, those who come from dysfunctional families, where domestic violence is present, or placed in foster care show lower IQ scores than non-institutionalised cohorts of similar attribute or those who are subsequently removed from such environments; these tend to perform better in testing once removed. A classic example of the impact environment has on not only intellect but psychosocial development is that of feral children; these individuals lack a host of higher-intellectual faculties, including human language, empathy and social behaviours (Ashcraft and Radvansky 2003). This illuminates the importance of culture in, at the least, coaxing and facilitating human potentials. In this essay we have explored the various conceptions and descriptions offered by psychologists and their philosophical ancestors to measure and explain intelligence. In truth, this appears to a definitional nightmare, filled with conjecture or hypothetical formations, though strenuous efforts are made using scientific measures to access the still illusive question of what intelligence is, a phenomena that has a multitude of variants across a range of societal and cultural spectrums. Yet, psychology has certainly offered an account of what may constitute intelligence, unlike our philosophical ancestors, science has permitted academics to fish through the lens of objectivism to uncover the composition of intelligence and its origin. Indeed, on the issue of nature versus nurture, it is apparent that both are interdependent; biology and genetic factors are certainly prerequisites for development and adaptation but both shaped by and dependant on environmental and social influences. Similarly, on a cellular or neural level, researchers observe the interrelations between various regions of the brain and, whilst on a conceptual level we find that a range of cognitive processes are involved in our intellectual makeup.

That said, to what extent remains a mystery; the psychology of intelligence continues to be a best guess, but arguably a respectable one that is under constant scientific revision.

References

American Psychological Association. 2015. Topic in intelligence found at:A https://www.apa.org/topics/intelligence/. 28th September 2015. Aristotle.2013.Reprint. The Works of Aristotle: The Famous Philosopher. CreateSpace Independent Publishing Platform Ashcraft, M. Radvansky, G. 2013. Cognition.

Pearson Education. Berg, G. 2012. Low-Income Students and the Perpetuation of Inequality: Higher Education in America. Ashgate Press: UK. Carroll, J. 1993.Human cognitive abilities: A survey of factor-analytical studies. Cambridge University Press: NY. Cattell, R. 1963. Theory of fluid and crystallized intelligence: A critical experiment. Journal of Educational Psychology, Vol 54(1), pp 1-22. Claxton, G. 2015. Intelligence in the Flesh: Why Your Mind Needs Your Body Much More Than it Thinks. Yale University Press. Devlin, B. Fienberg, S.1997. Intelligence, Genes, and Success: Scientists Respond to The Bell Curve.

Copernicus Press. Eysenck, M. Keane, M. 2010. Cognitive Psychology: A Student’s Handbook. 6th Edition. Psychology Press: London. Fox, N.Almas, A.Degnan, K.Nelson, C. Zeanah, C. 2011. The Effects of Severe Psychosocial Deprivation and Foster Care Intervention on Cognitive Development at 8 Years of Age: Findings from the Bucharest Early Intervention Project. J Child Psychol Psychiatry.

Vol 52(9), pp. 919–928. Glenn, A. Raine, S. 2014. Psychopathy: An Introduction to Biological Findings and Their Implications. NYU Press. Goleman, D. 2007. Social Intelligence: The New Science of Human Relationships. Arrow Publishers. Greenfield, P. 1997. YOU CAN’T TAKE IT WITH YOU: Why Ability Assessments Don’t Cross Cultures. American Psychologica. Vol. 52(10), pp. 1115-1124. Huneman, P. 2007. Understanding Purpose: Kant and the Philosophy of Biology.

University of Rochester Press. Jensen, A. 1987. Process differences and individual differences in some cognitive tasks. Intelligence. Vol 11(2), pp107-136. Lieberman, M. 2013. Social: Why our brains are wired to connect. Oxford University Press. Lubinski, D. 2004. Introduction to the Special Section on Cognitive Abilities: 100 Years After Spearman’s (1904) “‘General Intelligence,’ Objectively Determined and Measured”. Journal of Personality and Social Psychology, Vol 86(1), pp. 96-111. Magee, B. 2000. 2nd edition. The Great Philosophers: An Introduction to Western Philosophy.

Oxford University Press, U.S.A. Maltby, J. Day, L. 2013. Personality, Individual Differences and Intelligence. 3rd Edition. Pearson Press. McCartney, K. Harris, M. Bernieri, F. 1990. Growing up and growing apart: A developmental meta-analysis of twin studies. Psychological Bulletin, Vol 107(2), pp. 226-237. Nisbett, R. 2009. Intelligence and How to Get it: Why Schools and Cultures Count. W. W. Norton & Company. Piaget, J. 2001. The Psychology of Intelligence. Routledge Piaget, J. 1972. Psychology of the Child.

Basic Books. Plato. 2014. The Republic. xford. . CreateSpace Independent Publishing Platform. Salovey, P. Mayer, J. 1990. Emotional Intelligence. Imagination, Cognition and Personality. Vol 9 (4), pp. 185-211. Skinner, B. 2011. About Behaviourism.

Knopf Doubleday Publishing Group. Slade, M. 2009. Personal Recovery and Mental Illness: A Guide for Mental Health Professionals. Cambridge University Press. Smith, E. Kosslyn, S. 2008. Cognitive Psychology: Mind and Brain. 1ST Edition.

Pearson Press. Spearman, C. 1927. The Abilities of Man. American Psychological Association. Vol 67(9), pp56-105. Thorndike, E. 1920. Intelligence Examinations for College Entrance. The Journal of Educational Research. Vol 1(5), pp329-337. Uttal, B. 2003. The New Phrenology: The Limits of Localizing Cognitive Processes in the Brain. MIT Press. Weber, M. 1946. From Max Weber: Essay in sociology (Ed Gerth, H. Mills, C). Oxford University Press: Oxford.

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How Effective is Cognitive Behavioural Therapy in Treating Stress-related Disorders?

Contents

Introduction
Anxiety Disorders
Cognitive Behavioural Therapy (CBT)
The Efficacy of CBT in Stress-Related Disorders
Conclusion
- References

Introduction

Individuals respond to stressful events in different ways and their responses are influenced by a number of factors, such as personality characteristics or temperament, that can have an effect on the how the stressor is perceived (Anthony, Frederici, and Stein, 2009). Anxiety and stress are closely related, although stress tends to relate to a specific event or circumstances, whereas anxiety can be a non-specific, internal anticipation of something that might happen (Kahn, 2006). However, anxiety can cause stress - for example, imagining the consequences of being late (anticipation). Anxiety disorders are very common and can be debilitating and chronic, with patients experiencing distress over many years. It is suggested that anxiety is multifaceted and may be caused by biological factors - for example, high levels of serotonin, which is also a factor in depression. Another contributing cause to anxiety appears to be hyperactivity in the amygdala region of the brain, which results in high levels of neuroticism and anxiety. People who have a tendency towards neuroticism, for example, are more likely to experience anxiety disorders and negative emotions in response to stressors (Eysenck, 1967; Gray 1982). Psychological treatments and interventions focus on cognitive processes and behavioural responses that attempt to explain the acquisition and continuation of anxiety disorders (Anthony, et al. 2009). The aim of the following essay is to examine the efficacy of CBT interventions on treating anxiety and stress-related disorders.

Anxiety Disorders

The Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-V) classifies anxiety disorders into three main groups: anxiety disorders, obsessive compulsive disorders (OCD), and trauma and stress related disorders (American Psychiatric Association, APA, 2013). Anxiety disordersinclude separation anxiety disorder, phobias, social phobia, panic disorder, agoraphobia, and generalised anxiety disorder. Obsessive-compulsive disordersincludes hoarding disorder, while the third group, trauma and stressor-related disorders,includes post-traumatic stress disorder (PTSD) and acute stress disorder (DSM-V, APA, 2013). The DSM-V classifications of anxiety emphasise the relationship between disorders and therefore the possibility of comorbidity between anxiety, stress and depression (APA, 2013).

Cognitive Behavioural Therapy (CBT)

As will be discussed in the following section, many of the stress and anxiety related conditions listed in the DSM-V category of anxiety disorders can be treated using cognitive behaviour therapy (CBT). CBT aims to change negative and maladaptive thought patterns and behaviours to more positive ways of dealing with stress-related problems. Therapy is non-directive and a therapist will facilitate change through working with the client or patient to achieve a series of goals. The therapist will also challenge the client's negative beliefs and help the client develop strategies to manage their stress more effectively in the long term in order to prevent any relapses (Beck, 2011). Exposure-based CBT (Torp et al. 2015) has also been reported to be effective with young people and children. As discussed by Beck (2011) the relationship between the therapist and the patient is central to the success of the intervention, as it is necessary to have a rapport in order to sometimes discuss difficult topics.

The Efficacy of CBT in Stress-Related Disorders

In their meta-analyses of 269 studies that used CBT in studies, including anxiety disorders and general stress, Hoffman, Asnaani, Vonk, Sawyer and Fang (2012) found that the most effective results were for anxiety disorders and general stress (together with bulimia, somatoform disorders and anger control). A study comparing 65 patients with generalised anxiety disorder (GAD), who were randomly allocated to one of three groups - CBT, relaxation techniques, and a control group of patients on the waiting list - was undertaken by Dugas et al. (2010). The follow-up sessions took place 6-, 12- and 24-months after the intervention and consisted of self-report and clinician ratings. It was found that both CBT and relaxation were more effective than the control group, although long-term improvement continued only with CBT (Dugas et al. 2010). Other research has also found that CBT has been effective in generalised anxiety - for example, Otte (2011) states that a number of studies have demonstrated that CBT is effective for patients with anxiety conditions and states 'the efficacy and effectiveness of CBT in anxiety in adults appears to be well established' (Otte, 2011, p.418). However, despite the positive findings, Otto also states that there are there are various methodological problems in many studies, for example studies that do not include a control group, and therefore the effect size of the intervention is more difficult to assess. CBT has also be found to be effective in anxiety disorders in children, although as Hogendoorn et al. (2014) reports there are children who do not respond and therefore greater research is necessary in order to understand the mechanism that allows some children to respond well, while other children do not. In a study that investigated childhood anxiety and depression using CBT intervention it was found that there were more positive effects for anxiety than for depression in terms of behaviour and coping strategies used by the children (Chu and Harrison, 2007). It was concluded that there are different factors involved when using CBT in the treatment of anxiety and/or depression. According to Leichsenring et al. (2013) social anxiety is a prevalent disorder that can cause severe psychosocial problems and can co-exist with other disorders such as depression. Social anxiety is characterised by an individual having a fear of social interactions and therefore affects a person ability to work and have a good quality of life (Yoshinaga et al. 2013). There have been a number of reports regarding the efficacy of CBT in treating social anxiety, although many studies have small sample sizes and are conducted in one location. In their study Leichsenring et al. (2013) assessed 495 outpatients who were randomly allocated to either CBT intervention, (n=209), psychodynamic therapy (n=207), or a waitlist control group (n=79). The patient's baseline and post-treatment scores were compared using the Liebowitz Social Anxiety Scale (Liebowitz, 1987). It was found that both CBT and psychodynamic therapy were effective in treating social anxiety. Yoshinaga et al. (2013) also evaluated CBT and social anxiety in Japan using the Liebowitz Social Anxiety Scale (Liebowitz, 1987). The aim of the study was to assess whether results in Japan would be similar to those in Western countries. The intervention was over a 14 week period and measurements of social anxiety were taken before during and after the intervention. It was found that CBT was effective although there were a number of limitations in the study. The sample size was very small, with only 15 patients, which limits the generalisability of the study to other patients, particularly as it was a single-centre study. Another limitation was that the participants were mainly females, which again can limit generalisability of the findings to male patients. There was also no long-term follow-up, so the effects of CBT in preventing relapse were not assessed. Furthermore many patients were also taking medication which was not controlled for and may have had an effect on the results. Another stress-related condition which can cause serious impairment is OCD. The condition in adolescents and children is similar to that of adults, and OCD often begins in childhood (Torp et al. 2015). In a study undertaken in Denmark, Sweden and Norway, patients aged between 7- and 17-years diagnosed with OCD received CBT intervention in a community setting over 14 weeks. The study was an uncontrolled trial, which meant all patients received exposure CBT and were assessed using the Children Yale-Brown Obsessive Compulsive Scale (Scahill, et al. 1997), which both children and their parents completed, as well as other measures. The children had a range of behavioural and emotional problems and the study involved therapists and health professionals who evaluated the intervention. A strength of the study was that it was undertaken in different centres in three countries, which means it has good generalisability. The number of participants was also relatively high, which was also a strength of the study. The professionals helped the children and their parents complete the treatment and the findings showed a high success rate which was rated independently. It was concluded by Torp et al. (2015) that exposure-based CBT is an effective treatment for OCD in community children and adolescent outpatient clinics. The severity of the symptoms decreased in the patients and some were described as being in remission. However, there were a few limitations in the study - for example, the group was not ethnically diverse and the trials were not randomised (Torp et al. 2015). A final area where CBT has been found to be effective in stress-related disorders is PTSD, which is a disorder which can occur after an individual has experienced a major traumatic event. Typical symptoms include re-living the event, recurring thought of the event, avoidance, numbing and detachment and estrangement from family and other people. In looking at the efficacy of CBT in treating PTSD, Bisson and Andrew (2007) undertook a systematic review of research in which patients had been evaluated by clinicians for traumatic stress symptoms as well as self-rating by the patient of stress, anxiety and depression. Treatment included Trauma focused CBT (TFCBT), exposure therapy, stress management which included hypnotherapy and group CBT and eye movement desensitisation and reprocessing (EMDR) and a waitlist control group with no intervention. The findings showed that TFCBT, EMDR and group CBT were all effective in treating PTSD. In the long-term TFCBT and EMDR were found to be more effective, although some of the studies were found to have methodological flaws which means the data must be interpreted with caution. After the attack on the Twin Towers in New York, the CATS consortium was established to help deal with the trauma experienced by young people and also to assess the outcomes of the intervention using CBT. The CATS Consortium (2010) report on the efficacy of CBT being used with children and adolescents aged between 5- and 21-years who were traumatised after the attack. The young people (n=306) were allocated to one of two groups depending on the severity of their trauma. The first group involved trauma-specific CBT and the second group, brief CBT. The findings showed that for both groups there was a decrease in their symptoms and they were no longer diagnosed as having PTSD, and it was also found that the therapy could be effectively delivered in the community by trained professionals. The limitations of the study were that the design did not conform to a typical randomised controlled study and a control group was not used. The circumstances around the study were chaotic in the days after the attack and, as the authors state, the children may have improved without any treatment or intervention, which is, of course, the purpose of a controlled group. Nonetheless, the study has provided useful information regarding the use of CBT for young people after a traumatic event.

Conclusion

Overall, the evidence presented demonstrates that CBT is an effective intervention in a number of different stress-related conditions identified by the DSM-V (APA, 2013). Meta-analyses and systematic reviews are able to provide robust evidence regarding the effectiveness of interventions using CBT, although, as has been discussed, there are a number of methodological issues with some of the studies used in meta-analyses. Some of the limitations include small sample sizes, for example, which means that generalisation to other groups is not possible. Another limitation is the lack of a control group, where, as discussed by CATS Consortium (2010), the patients who were traumatised after the attack on the Twin Towers in New York may have recovered spontaneously over time without any intervention, and this can only be observed in a control group which has no intervention. Another potential issue is the use of different measures such as self-report and clinician's measures (Dugas et al. 2010), in comparison to other studies which used validated questionnaires such as Liebowitz Social Anxiety Scale (Leichsenring et al. 2013). This means that comparisons between studies are more difficult. However research using CBT has taken place in a number of different contexts and cultures - for example, Norway, Sweden and Denmark (Torp et al. 2015) and also Japan (Yoshinaga, et al. 2013) - and has been shown to be effective.

References

American Psychiatric Association, (APA, 2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-V, fifth edition). Washington, DC: American Psychiatric Association. Anthony, M.M., Frederici, A. and Stein, M.B. (2009). Overview and introduction to anxiety disorders. In M.M. Anthony and M.B. Stein (Eds) Oxford Handbook of Anxiety and Related Disorders, pp. 3-18. Oxford: Oxford University Press. Beck, J.S. (2011). Cognitive Behaviour Therapy: Basics and Beyond. New York: Guildford Press. Bisson, J, and Andrew, M. (2007). Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews, 3, Art. No.: CD003388. CATS Consortium (2010). Implementation of CBT for youth affected by the world Trade Center disaster: matching need to treatment intensity and reducing trauma symptoms. Journal of Traumatic Stress, 23(6), 699-707 Chu, B.C. and Harrison, T.L. (2007). Disorder-specific effects of CBT for anxious and depressed youth: a meta-analysis of candidate mediators of change. Clinical Child and Family Psychology Review, 10, 352-372 Dugas, M.J., Brillion, P., Savard, P., Turcotte, J., Gaudet, A., Ladouceur, R., Leblanc, R. and Gervais, N.J. (2010). A randomized clinical trial of cognitive-behavioural therapy and applied relaxation for adults with generalized anxiety disorder. Behavior Therapy, 41(1), 46-58. Eysenck, H.J. (1967). The Biological Basis of Personality. Springfield, Il. Charles C. Thomas. Gray, J.A. (1982). The Neuropsychology of Anxiety. Oxford; Clarendon. Hoffman, S.G., Asnaani, A., Vonk, I.J.J., Sawyer, A.T. and Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy Research, 36(5), 427-440 Hogendoorn, S.M., Prins, P.J.M., Boer, F., Vervoort, L., Wolters, L.H., Moorlag, H., Nauta, M.H., Garst, H., Hartman, C.A. and de Haan, E. (2014). Mediators of cognitive behavioral therapy for anxiety-disordered children and adolescents: cognition, perceived control, and coping. Journal of Clinical Child and Adolescent Psychology, 43(3), 486-500. Kahn, A.P. (2006). The Encyclopedia of Stress and Stress-Related Diseases, (second edition). New York: Infobase Publishing Leichsenring, F., Salzer, S. Beutel, M.E., Herpertz, S., Hiller, W., Hoyer, J., Huesing, J., Joraschky, P., Nolting, B., Poehlmann, K., Ritter, V., Stangier, U., Strauss, B., Stuhldreher, N., Tefikow, S., Teismann, T., Willutzki, S., Wiltink, J. and Leibing, E. (2013). Psychodynamic therapy and cognitive behavioural therapy in social anxiety disorder: A multicentre randomized controlled trial. American Journal of Psychiatry, 170, 759-767. Liebowitz, M.R. (1987). Social Phobia. Modern Problems of Pharmacopsychiatry, 22, 141-173 Otte, C. (2011). Cognitive behavioural therapy in anxiety disorders: current state of the evidence. Dialogues Clinical Neuroscience 13, 413-412. Price, M. and Anderson, P.L. (2011). The impact of cognitive behavioral therapy on post event processing among those with social anxiety disorder. Behaviour Research and Therapy 49(2) 132-137. Scahill, L., Riddle, M.A., McSwiggin-Hardy, M. and Ort, S.I., King, R.A., Goodman, W.K., Cicchetti, D., and Leckman, J.F. (1997). Children's Yale-Brown Obsessive Compulsive Scale: reliability and validity. Journal of American Academy of Child and Adolescent Psychiatry, 36(6) 844-852 Torp, N.C., Dahl, K., Skarphedinsson, G., Thomsen, P.H., Valderhaug, Weidle, B., Melin, K.H., Hybel, K., Nissen, J.B., Lenhard, F., Wentzel-Larsen, T., Franklin, M.E. and Ivarsson, T. (2015). Effectiveness of cognitive behavior treatment for pediatric obsessive-compulsive disorder: Acute outcomes from the Nordic Long-term OCD treatment study (NordLOTS). Behaviour Research and Therapy, 64, 15-23. Yoshinaga, N., Ohshima, F., Matsuki, S., Tanaka, M., Kobayashi, T., Ibuki, H., Asano, K., Kobori, O., Shiraishi, T., Ito, E., Nakazato, M., Nakagawa, A., Iyo, M. and Shimizu, E. (2013). A preliminary study of individual cognitive behavioural therapy for social anxiety disorder in Japanese clinical setting: a single arm uncontrolled trial. BioMed Central (BMC) Research Notes 6, 74-81

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Does Machiavelli Reduce Politics to Force?

In this essay, I assess whether Machiavelli reduces politics to force.A To construct a response to this, it is necessary to explore what “force” means, since “force” is a philosophically weak concept.A In order to understand “force” as a philosophical concept, we need to separate the concepts of authority and power.A With a clear concept of what we mean by power and how it differs from authority, it becomes possible to discuss whether Machiavelli reduces politics to force.A Once the concepts of power and authority are clearly differentiated, the question becomes does Machiavelli reduce politics to force, where force is equated to power, or does Machiavelli rest politics on authority. In this essay, I argue that, despite Skinner’s attempts to re-habilitate Machiavelli and re-construct Machiavelli as a defender of liberty, Machiavelli does not rest power and politics on authority.A Instead, Machiavelli argues that power should be utilised for the purpose of “the common good”.A For Machiavelli, political necessity allows for incursions on liberty and the use of power, rather than authority.A Femia is alive to the implications of “the dark, authoritarian and militaristic element in Machiavelli’s writings” (Femia, 2004, p.15); and, in this essay, I argue that this should not be overlooked.A Goodwin argues that attempting to distinguish rigorously between power and authority “is ultimately doomed to failure” (Goodwin, 1997, p.314).A However, she argues that “the distinction between power and authority has exercised many philosophers, who feel there should be a sharp demarcation between the two” (Goodwin, 1997, p.306).A Whilst a “sharp demarcation” may not be possible, Goodwin does separate the two.A She argues that power “is the ability to cause someone to act in a way which she would not choose, [if] left to herself” (Goodwin, 1997, p. 307).A This can, obviously, occur in a number of ways, including threats and violence, but also through persuasion, propaganda and advertising.A However, authority Goodwin argues, has a basis in law; a government has authority if it has legal validity (Goodwin, 1997). A sharp distinction between power and authority may not be possible, and it may be made to see the concepts on sliding scale, with illegitimate power on oneside, and legitimate authority on the other side, with much in-between.A A This separation between power and authority is fundamental to this essay, as it is important to understand whether Machiavelli argues that politics ought to rest on authority or whether it can be reduced to maintaining power.A Therefore, in an attempt to summarise the “demarcation” between power and authority, I once more return to Goodwin, who says the individual “defers to authority… [but] yields to power” (Goodwin, 1997, p.313).A If Machiavelli reduces politics to force/power, his concern is that people must yield to the government; whereas, if Machiavelli argues that politics ought to rest on authority, his concern would be that the people deferred to the government, and recognised its legal legitimacy. Machiavelli’s political philosophy is more complex than the often one-dimensional interpretation of Machiavelli as a self-serving manipulator, promoter of immorality and defender of tyranny.A In contrast to the one-dimensional view of Machiavelli which implies that he reduces politics to the maintenance of power and a justification of tyranny, Machiavelli is a defender of a certain kind of liberty.A However, Machiavelli’s concept of liberty is about the liberty of the state or the Government.A He argues that in order for the people to be free, they must live a free state – a state free from external servitude.A Machiavelli’s concept of liberty prioritises the state in the relationship between the individual and the state: “it is not the well-being of individuals that makes cities great, but the well-being of the community” (Machiavelli, The Discourses: Book II, Discourse 2).A For Machiavelli, it is not the individual that is important, but the community or the state.A Therefore, the individual must yield to the will of the state for the liberty and well-being of the “common good”. In his interpretation of Machiavelli’s thought, Skinner emphasises the importance of the free state; and crucially, he stresses the seriousness of the metaphor of the body politic to neo-roman thought, which meant that Machiavelli could not conceive of a free individual without a free state.A This is only one of many interpretations of Machiavelli, and is not objective as it is underpins Skinner’s thesis that liberty was an important concept to Machiavelli.A Machiavelli defines the free state as one that is “removed from any kind of external servitude” (Machiavelli, The Discourses: Book I, Discourse 2).A Skinner expands this by relating it to the concept of the body politic, where, “just as individual human bodies are free… only if they are able to act or forbear from acting at will, so the bodies of nations and states are likewise free… only if they are similarly unconstrained from using their powers according to their own wills” (Skinner, 1998, p.25).A Skinner’s elaboration means that a state is only free, when it follows the collective will of the people, and thereby, liberty is equated to self-government, so a free state is defined as a community “independent of any authority save that of the community itself” (Skinner, 1981, p.52).A Machiavelli stridently defends the free state, arguing that “history reveals the harm that servitude has done to people and cities… [as they] have never increased either in dominion or wealth, unless they have been independent” (Machiavelli, The Discourses: Book II, Discourse 2).A This underpins Machiavelli’s perennial fear that freedom is fragile and liberty could succumb to external conquest or internal tyranny.A Skinner pursues this notion, and argues that overt coercion is not necessary for a state to be in a condition of slavery: if the maintenance of civil liberty is dependent upon the good will of arbitrary power, then the individual is already living as a slave (Skinner, 1998).A This is a rational consequence of Machiavelli’s bleak interpretation of human nature, where men do not promote the common good i.e. the preservation of the state’s liberty.A Machiavelli argues that humans are: self motivated – “men never do good unless necessity drives them” (Machiavelli, The Discourses: Book I, Discourse 3); bellicose – “security for man is impossible unless it be conjoined with power” (Machiavelli, The Discourses: Book I, Discourse 1); fickle and untrustworthy – they “will not keep their promises” (Machiavelli, The Prince: Chapter XVIII); pusillanimous – “when the state needs its citizens, few are to be found” (Machiavelli, The Prince: Chapter IX).A These attributes are a hindrance to a state that is trying to preserve its ability to enact the collective will without constraint.A Therefore, liberty requires overcoming men’s selfish inclination, so they can be fit to govern themselves, and this involves engaging in activities which are conducive to “human flourishing” (Skinner, 1990).A Given that it is contrary to mens’ natural inclinations to pursue the “common good”, it seems that this involves yielding to the power of the state.A Skinner’s eloquent term “human flourishing” describes the need to imbue each citizen with a sense of civic virtA¹, which is essentially, a public-spirited ethos, whereby the individual commits a great deal of time and energy to participating in the affairs of the state, and maintaining a vigilance to safeguard its freedom.A Skinner admits that civic virtA¹ requires placing “the good of the community above all private interests and ordinary considerations of morality” (Skinner, 1981, p.54). Machiavelli’s political philosophy rests on valuing the public sphere, with a resulting dismissive attitude toward the private sphere.A Thus, the citizens of the state are required to yield to the power of the state, and to relinquish their individual liberty, if it is perceived to be in the “common good”.A Machiavelli praises Rome where those who worked through the public sphere were honoured, but those working through private means were condemned and prosecuted (Machiavelli, The Discourses).A Machiavelli argues that a sense of duty to the community, which entails sacrificing the legitimacy of the private sphere, does not curtail liberty but preserve it, as civic virtA¹ is essential to ensuring the state is not constrained from acting upon its own will.A He quotes, (possibly apocryphally) from ancient history: “they rebelled because when peace means servitude it is more intolerable to free men than war” (Machiavelli, The Discourses: Book III, Discourse 44), which appeals to Machiavelli’s doctrine of public-spiritedness, and his promotion of the well-being of the community.A Machiavelli promotes the ideals of republicanism, and republican liberty, which entails a need to safeguard the state against internal tyranny, through citizens that are active, vigilant, and participate in the daily running of the community to ensure that the state is not subjected to the caprices of a minority; and that, instead, the community seeks the public interest.A Machiavelli criticises the consequences of internal tyranny with empirical reference to the greatness attained by Athens, once “liberated from the tyranny of Pisistratus…. [and] the greatness which Rome attained after freeing itself from its Kings” (Machiavelli, The Discourses: Book II, Discourse 2).A Thus, Machiavelli can be read as a defender of liberty by citing his belief that the conflict between the nobles and plebs was the primary reason Rome maintained her freedom (Machiavelli, The Discourses), and his assertion that a Monarch’s interests are usually harmful to the city (Machiavelli, The Discourses).A This interpretation of Machiavelli shows that he does not unambiguously reduce politics to the use of force and power.A Instead, he argues that politics rests on the order of a well-structured government.A However, for Machiavelli, a well-structured government and political authority are not necessarily synonymous, since he argues that political order may require the use of force and the wielding of power by a powerful leader. Machiavelli’s writings are littered with references to his love for strong leadership e.g. “dictatorship was always useful” in Rome (Machiavelli, The Discourses), or his defence of a Prince’s cruelty to keep his subjects united and loyal, as men are wretched and will pursue their own interest, unless they fear punishment (Machiavelli, The Prince).A There are clearly elements of Machiavelli’s writings that support the idea of the free state and a certain concept of liberty; for instance, he argues that “experience shows that cities have never increased in dominion or riches except while they have been at liberty” (Machiavelli, The Discourses: Book II, Discourse 2).A This allows Skinner to construct Machiavelli as a defender of liberty, by arguing that “what Machiavelli primarily has in mind in laying so much emphasis on liberty is that a city bent on greatness must remain free from all forms of political servitude” (Skinner, 1981, p.58).A Skinner’s reading of Machiavelli suggests that Machiavelli did not reduce politics to force and power; and that, instead, Machiavelli rested politics on political authority.A However, this re-habilitating of Machiavelli by Skinner overlooks a number of passages in Machiavelli’s writing that show he clearly was prepared to allow force and power to be used without linking it to authority. Femia takes the view that Machiavelli was not a defender of liberty, and did not place authority at the heart of politics.A Femia concludes that Machiavelli’s political thought can be characterised by the belief that “we cannot draw a sharp line between moral virtue and moral vice: the two things often change place.A Fair is foul and foul is fair” (Femia, 2004, p.11).A For Machiavelli, it is the state that is important, and the individual’s liberty can be subjected to power and force in order for the good of the city to prevail.A Machiavelli eradicates the private sphere, which allows Femia to draw a parallel between Machiavelli’s concept of freedom and fascists who also argue that “freedom comes through participating in a great whole… [and] nothing to do with limiting the state’s autonomy” (Femia, 2004, p.8).A Machiavelli primary concern is maintaining political order, and his advice in The Prince often seems to be more about maintaining power, than establishing authority.A In places, Machiavelli’s advice is brutal, and seems unambiguously to promote the exercise of force for the purposes of maintaining power. Machiavelli shows no regard for individual liberties, and allows The State to trample over its citizens when force and power are necessary, arguing that “it should be noted that one must either pamper or do away with men, because they will avenge themselves for minor offences while for more serious ones they cannot” (Machiavelli, The Prince: Chapter III).A This brutal, cynical observation is an instance of Machiavelli’s realism.A Such cynical realistic observations do not, in themselves, prove that Machiavelli reduces politics to force and power.A It is possible to argue that Machiavelli’s observation accurately observes politics, and he is simply drawing the reader to an important piece of wisdom about human nature.A However, this does not seem to be Machiavelli’s motivation.A He is not merely observing brutal realism, but appears to be advocating its application.A He argues that those the ruler “hurts, being dispersed and poor, can never be a threat to him, and all others remain on the one hand unharmed… and on the other afraid of making a mistake, for fear that what happened to those who were dispossessed might happen to them” (Machiavelli, The Prince: Chapter III).A The important word here is “fear”.A The people fear the ruler, and so obey.A This does not imply that the ruler that governs by authority. Instead, the implication is that the ruler holds power through force. Despite the ruthless, brutal and cynical methods that Machiavelli appears to advocate, it is important not to misread Machiavelli as someone who advocates force and violence merely for the sake of power.A Machiavelli is concerned with “The Common Good”, and thus he argues that the exercise of force – raw power – is only justified if it is exercised in pursuit of “The Common Good”.A Or, more simply, the “ends justify the means”.A Machiavelli does not advocate raw power, per se; instead, he argues that if the ends are “good”, then the use of force is justified.A This blurring of the common good and the use of power to promote it is evident when he argues that “a prince must not worry about the reproach of cruelty when it is a matter of keeping his subjects united and loyal; for with a very few examples of cruelty he will be more compassionate than those who, out of excessive mercy, permit disorders to continue… for these usually harm the community at large” (Machiavelli, The Prince: Chapter XVII).A This, however, exposes the paradox in Machiavelli’s thought, where cruelty is justified by the ends.A The problem is that Machiavelli’s initial concern is about holding power to prevent disobedience and disorder.A It is possible that this exercising of power may shift, and become authority; but, in its first instance, politics is about maintaining power. Machiavelli was a Renaissance writer; and, therefore, the differentiation between power and authority that Goodwin discussed had not become a part of political philosophy.A Therefore, to argue that Machiavelli did not seek political authority, but power, would be a mis-representation, as these concepts were not available to him.A However, for Machiavelli, political necessity dominates, and in a realist vein, he allows for incursions on liberty and the use of force and even cruelty to hold power.A Ultimately, he seeks authority in the common good, and this justifies whatever methods are used to hold on to power. Machiavelli doesn’t simply reduce politics to force, since force is used to pursue the common good.A However, Machiavelli is not concerned with the individual citizen, since he does not differentiate between the public and private realms.A Thus, Machiavelli is not concerned with individual liberty and individuals’ rights: when the “private person may be the loser… there are so many who benefit thereby that the common good can be realized in spite of those few who suffer in consequence” (Machiavelli, The Discourses: Book II, Discourse 2).A Without a clear separation of public and private, and between legitimate authority and illegitimate power, the common good can become the arbitrary will of the ruler.A The arbitrary will of a ruler – even one that is seeking to promote the common good – leaves politics very open to the use of force to maintain power, in the name of common good.A This notion of the use of force to maintain power is quite different from the use of force by a Government that governs through authority, under the rule of law.

Bibliography

Femia, J (2004) “Machiavelli and Italian Fascism”, History of Political Thought, Volume 25, Issue 1, pp. 1-15 Goodwin, B (1997) Using Political Ideas (4th edition), John Wiley & Sons, Chichester Machiavelli, N (1984) The Prince (Edited, Introduced and Translated by P Bondanella and M Musa) Oxford University Press, Oxford Machiavelli, N (1998) The Discourses (Edited, Introduced, Revised and Translated by B Crick, L Walker and B Richardson) Penguin Classics, London Skinner, Q (1981) Machiavelli, Oxford University Press, Oxford Skinner, Q (1990) “The republican ideal of political liberty” in Bock, G & Skinner, Q & Viroli, M (editors) Machiavelli and Republicanism, Cambridge University Press, Cambridge, pp. 293-310 Skinner, Q (1998) Liberty Before Liberalism, Cambridge University Press, Cambridge

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Consider Descartes’ First Two Meditations, and Answer the Question: Can you Know that your Experiences are Veridical?

The question of whether or not one can know whether one is dreaming has become a staple of philosophical discussion since Descartes wrote The Meditations in the 1600s. Engaging in philosophy for the first time, this can seem a bizarre question. However, Descartes’ reasoning for doubting the certainty that one is not dreaming is compelling. For Descartes, our ability to perceive reality cannot be guaranteed, since our senses can deceive us (Descartes, 1986). Thus, over the course of the first two Meditations, Descartes concludes that the only thing he is certain of is that there is some being that is “I”. He concludes that this “I”, however, may only be a mind (Descartes, 1986). Descartes reasons that even our perception of our bodies is a product of intellect.

Therefore, the only thing he feels certain of is that there is a mind doing the thinking. There are two separate questions that arise from this. Firstly, can I know that I am awake? Secondly, can I know that my belief that I am not locked “inside a dream” is not itself a dream? This second question evokes the plot to a sci-fi film, and elicits imagery of being “a brain in a vat”, where everything that one perceives is illusory. The “brain in a vat” is a modern re-imagining of the demon argument, produced by Descartes. The “brain in a vat” idea originates with Putnam; and, according to Brueckner, is inspired The Matrix films (Brueckner). It is this second idea which will be the main focus of this essay – Descartes’ “demon argument”, or the “mind in a vat” argument. This extreme form of scepticism, where one is merely a “brain in a vat” is surprisingly difficult to rule out with absolute certainty.

However, the implications of this may be less profound than they initially appear. The notion that we do not have a true perception of the external world, because our sensory perceptions are being manipulated by a demon or we are a “mind in a vat”, may not actually have practical implications for how we live in the world.

However, the discussion about whether we can know for certainty that we are not dreaming is not purely abstract and esoteric. There is an element of this that does pertain to a wider issue than merely dreaming. For instance, as Skirry explains, Descartes supposes that an evil demon may be deceiving him, and so as long as this supposition remains in place, there is no hope of gaining any absolutely certain knowledge (Skirry). If one cannot be sure that one is not being deceived by a demon, then one can have no absolutely certain knowledge about anything. However, as I will argue in this essay, concerning ourselves withA whether we lack true knowledge, because we are being manipulated by a demon does not help us to find solutions to the issues in the world which we believe we are living in. The sceptical account for not knowing whether one is dreaming or not has two levels.

First, our perception of what we are currently experiencing does not allow us to determine whether we are awake or dreaming. Dreams can have the same quality as waking experiences, and we can dream that we are awake. Therefore, the experience of being awake is not distinguishable from dreaming. Descartes provides the following example of this situation: “How often, asleep at night, am I convinced of just such familiar events – that I am here in my dressing-gown, sitting by the fire – when in fact I am lying undressed in bed!” (Descartes, 1986, p. 13). Given that in one’s dream, one’s perceptual experiences are not different from those when awake, it may be that I am dreaming that I am typing out this essay. This sceptical consideration of the possibility of not having the knowledge that one is awake is not as profound or extreme as it first seems. It leaves intact the idea that there are two states: dreaming and awake. The problem is that when we think we are awake, we may be dreaming. It is, for this reason, that this essay will leave this discussion aside, and move on to the second level of scepticism explored by Descartes. The second reason for doubting if we can know if we are dreaming takes scepticism to a deeper level.

The sceptical account for doubting our ability to know if we are awake or if we are dreaming is summed-up by Blumenfeld and Blumenfeld as the problem of the possibility of being in a dream within a dream: for all I know, I may be dreaming… now, then my belief that not all my experiences have been dreams is itself a belief held in a dream, and hence it may be mistaken. If I am dreaming now, then my recollection of having been awake in the past is merely a dreamed recollection and may have no connection whatever with reality. (Blumenfeld and Blumenfeld, 1978, pp. 243-244). There are two ways of illustrating this dilemma. First is the illustration devised by Descartes, whereby one is being deceived by a demon. The second is the one favoured by sci-fi films, whereby one is merely a “brain in a vat”, and all that we think we are experiencing has no relation to external reality.A This second level of scepticism speculates that all our experiences may be locked within a dream, including our experiences of waking and dreaming. Given the time period in which he was writing, Descartes invokes superstitious and supernatural ideas of a God or a demon to illustrate this.

Descartes imagines that there may be: some malicious demon of the utmost power and cunning [that] has employed all his energies in order to deceive me. I shall think that the sky, the air, the earth, colours, shapes, sounds and all external things are merely the delusions of dreams which he has devised to ensnare my judgement. I shall consider myself as not having hands or eyes, or flesh, or-blood or senses, but as falsely believing that I have all these thing (Descartes, 1986, p. 15). The modern sci-fi parallel is that I am actually, merely “a brain in vat”, probably millions of miles away, on some distant planet. This is the view that everything we experience of the external world is a deception. This modern, scientific alternative allows the modern reader to see Descartes problem more clearly, and prevents us dismissing it is an anachronism from the time of superstition. In the Second Meditation, Descartes convinces himself that because he is thinking, he does actually exist. Hence the famous phrase: Cogito, ergo sum or “I think, therefore I am” (Descartes, 1986, p. 17) ). This is important, as it does set a limit to scepticism, since Descartes’ conclusion is that “even if I am being deceived by an evil demon, I must exist in order to be deceived at all” (Skirry). The fact that I think is proof that I am at least a mind. However, this does not provide proof that I am also a body.

Descartes poses to himself the question: “what am I to say about this mind, or about myself?” (Descartes, 1986, p. 22). But he then tells the reader, “so far, remember, I am not admitting that there is anything else in me except a mind” (Descartes, 1986, p. 22). Descartes famous phrase cogito, ergo sum is part of the philosophical canon because it is Descartes’ demonstration that there are limits to scepticism – I think; therefore, I am a mind. However, the knowledge that I am thinking does not, in itself, rule out the possibility that I am merely a mind, i.e. that I am locked in a dream within a dream, where I am deceived into thinking that I have two states of existing: one, being awake; the other being dreaming. At the beginning of this essay, I said that, engaging in philosophy for the first time, the question, “can we know we are not dreaming?”, can seem a very bizarre question.

This can be seen in Blumenfeld and Blumenfeld’s paper, when they show that “a frequent charge against scepticism is that it shows that we cannot have knowledge only by adopting an implausibly strong definition of knowledge” (Blumenfeld and Blumenfeld, 1978, p. 249). Intuitively, the idea that “I” (whatever I am in this case) am merely “a mind in a vat” is implausible. This is why the question, “can we know we are not dreaming?”, seems bizarre. It may not be possible to know that we are not dreaming. However, this requires the construction of a rather implausible hypothesis. In other words, only by invoking something that seems implausible can the question “can we know we are not dreaming?” be made. However, to dismiss Descartes and the sceptics’ argument on these grounds is rather weak. Dismissing the demon argument on the basis that it is implausible does not falsify it. This is just an argument of probability.

The argument that it seems more probable that I am not dreaming, and I do experience an external world is not sufficiently sound, philosophically, to end the argument. There is a need to produce a more satisfying philosophical explanation.A Blumenfeld and Blumenfeld argue that it is not possible to justify empirical claims on the basis of probability (Blumenfeld and Blumenfeld, 1978). Therefore, they argue that to maintain the argument of an external world, and rule out the demon scenario, the hypothesis of an external world needs to be epistemically superior to the hypothesis of a world constructed by a demon (Blumenfeld and Blumenfeld, 1978).. However, Blumenfeld and Blumenfeld are not convinced that the hypothesis of an external world is epistemically superior. They argue: One might think that this could be argued on grounds of the greater simplicity of the external-world hypothesis. But it is hard to see in what respect the external-world hypothesis is simpler than that of the demon. The latter is committed to the existence of the demon (a spirit) with the means of and a motive for producing sense experiences, to a mind in which these experiences are produced, and to the sense experiences themselves.

The external-world hypothesis, on the other hand, is committed to all of the above, except the existence of the demon. But it is committed, in addition, to a physical world with the capability of producing sense experience. So, it is hard to see how the external-world hypothesis is simpler. (Blumenfeld and Blumenfeld, 1978, p. 250). Therefore, it is surprisingly difficult to rule out the idea that “I” am “a mind in a vat”, and that all my experiences of the external world are based on a deception to my sensory perception. However, the implications of this may not be as profound as they initially appear. Firstly, the implications that all our experiences of an external world are based on illusion would only come into existence if the illusion is broken. If there is a demon creating sensory experiences for me, or I am actually just “a brain in a vat”, the implication of this would only occur when I became aware of my “real” existence, and of the illusion and deception. Secondly, unless we become aware that all our past experiences, including those of being awake and of dreaming, are part of a dream, we are no better able to deal with the dilemmas of this world than we are currently. It is hard to see what the practical implications of this theory are. Or, more specifically and more importantly, how they can help us. For example, it isn’t going to work to tell a Syrian refugee, “don’t worry, go back to Syria, because the war isn’t real. We are actually ‘brains in a vat’, on another planet, many millions of miles away.” It may sound as though I am being facetious.

However, the point is a serious one. The question: “can you know that you are not dreaming?” may be a valid one – it might be surprisingly difficult to prove that I not “a brain in a vat”. However, it is not a very helpful question to be concerning ourselves with. In conclusion, demonstrating that our sensory experiences are not the trickery of a malicious demon proves unfruitful. Trying to satisfactorily refute the idea fails to recognise that the implications of this would only matter if we found out that in the “real” world, we were just “minds in a vat”. Meanwhile, there are practical concerns that require our thought, such as the Syrian refugee problem. The kinds of questions that scepticism is concerned with do not help us to deal with these practical issues. However, it does make us wonder if these “practical” issues are real.

Descartes’ hypothesis makes us ponder the possibility that the Syrian refugee crisis is not real, and is part of the deceptions of a demon. However, this kind of thinking does not help us to respond to the things that we think are important.

Bibliography

Blumenfeld, D. and Blumenfeld, J.B. (1978) “Can I Know that I am not Dreaming?” in Hooker, M (ed.), Descartes: Critical and Interpretative Essays. John Hopkins, Baltimore, pp. 234-253 Brueckner, T. (Retrieved October 15, 2015). “Skepticism and Content Externalism”. Stanford Encyclopedia of Philosophy, Available from: https://plato.stanford.edu/entries/skepticism-content-externalism/#2 Descartes, R. (1986) “First Meditation”, in Cottingham, J (trans.) Meditations on First Philosophy: With Selections from the Objections and Replies. Cambridge University Press, Cambridge, pp. 12-15 Descartes, R. (1986) “Second Meditation”, in Cottingham, J (trans.) Meditations on First Philosophy: With Selections from the Objections and Replies.

Cambridge University Press, Cambridge, pp. 16-23 Descartes, R. (1986) “Objections and Replies [Selections]” in Cottingham, J (trans.) Meditations on First Philosophy: With Selections from the Objections and Replies. Cambridge University Press, Cambridge, pp. 63-67 Skirry, J. (Retrieved October 6, 2015), “RenA© Descartes (1596—1650)”, Internet Encyclopedia of Philosophy, Available from:A https://www.iep.utm.edu/descarte/

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Are there any Arguments which Work to Prove the Existence of God?

Contents

The Teleological Argument
The Cosmological Argument
The Ontological Argument
Reference List

In this essay it shall be discussed whether there are any arguments which work to prove the existence of God. The teleological and cosmological arguments shall be first discussed, criticised by showing their reliance on the ontological argument, which shall then be shown to be an inadequate argument. It will then be concluded that there appear to be no arguments which work to prove the existence of God.

The Teleological Argument

The teleological argument, or the argument from design, puts forward the claim that God's existence is proven by the evidence that the universe is so well ordered, and its contents complex, to the point that they must have been designed. If this is the case, then there must be a designer of the universe, and this designer can only be God. The strongest version of this argument is put forward by Paley. He claims that should he find a stone on the ground, he might suppose that it had always been there. However, should he then come across a watch, he could not hold this same supposition. This, he claims, is because the watch's parts are such that "they are framed and put together for a purpose" (Paley, 1867: 11). The watch must have been designed and must therefore have a designer. Paley makes this same claim of the universe. He argues that: "Every manifestation of design, which existed in the watch, exists in the works of nature; with the difference, on the side of nature, of being greater and more…" (Paley, 1867: 21). Therefore, as the universe is of such a complex nature, in which all things are made of parts which allow them to fulfil their purpose in the same way the watch is made of mechanisms which permit its owner to tell the time, the universe must have been designed and must therefore have a designer. This designer, the argument concludes, is God. However, there are problems with this argument. Firstly, it can be claimed that the world isn't as perfectly designed as it would have been should God (being omniscient, omnipotent etc.) have created it. For example, there are many degenerative diseases which affect animals as they grow older, and therefore show the parts of their anatomy to be unable to complete their purpose of life. Secondly, there are other, scientific, arguments which give explanation for things in nature being fit for their purpose such that do not suppose the existence of God. The most prominent of these arguments is evolution, proposed initially by Darwin (Darwin, 1859). Evolution argues that living beings in nature come to fit their purpose by adaptation, and therefore, though appearing to be designed, are not.

The Cosmological Argument

The cosmological argument, or the argument from first cause, claims that everything in the universe must have a cause. Were all the chains of cause and effect to be traced backwards in time, they would lead to the creation of the universe. However, the creation of the universe must also have a cause, since the universe cannot be the cause of itself (as nothing but an ontological being can be). The cause of anything must be either a physical law or a personal being. The first cause must be a personal being, as no physical laws predated the universe, which is God. Therefore, simply in virtue of the fact that the universe itself exists, God must exist. (Reichenbach, 2012). As a first criticism against the cosmological argument, the argument relies on the existence of a being which can be the cause of itself. This, therefore, necessitates a reliance on the ontological argument which will later be shown to fail. There are two more direct criticisms of the argument. Firstly, modern science has set forth hypotheses which aim to establish what could have been the cause of the universe other than God. Of these, the most prominent is the Big Bang. According to this theory, the universe literally arose out of nothing, and there is therefore no need to rely on God's existence to explain the existence of the universe. A criticism against this may be that the Big Bang itself, since it was an event, must need a cause. However, to claim this is to misunderstand the theory of the Big Bang. The Big Bang did not occur within the space-time continuum; the continuum was created from the Big Bang. It therefore does not need to rely on the regular cause and effect model of the universe. A second criticism against the cosmological argument directly is that it relies on the claim that the universe itself must have a cause. However, should it able to be shown that the universe has existed for an infinite amount of time, it will need no cause, and therefore there is no reliance on God's existence. The argument that the universe cannot be infinite is that, if it were so, it would be impossible to reach the present moment from the beginning. Since we have arrived at the present moment, the universe cannot be infinite. However, Mackie argues that this representation of infinity is misleading. A true representation of infinity would not include a starting point. Whilst this may seem to make the arriving at the present moment more impossible, this isn't the case. Mackie argues that to truly understand infinity is to know that from any past cause, no matter how far back the cause, there will be a finite number of links in the chain of causality to the present moment. Therefore, even in an infinite chain of causality, it is possible to reach the present moment (Mackie, 1983).

The Ontological Argument

The ontological argument differs from the other arguments for God's existence because it argues that God must exist simply because of the concept of God, and not because of the existence of the universe, or some fact about it. As has been seen, the teleological argument and the cosmological argument both necessitate the existence of an ontological being. An ontological being is one which cannot but exist. The ontological argument claims that, simply in virtue of the concept of God, God must exist. That is, if we can conceive of the concept of God, without any contradiction, by the fact that it is possible, it must be true. The classical version of this argument is put forward by Anselm. He claims that the definition of God is "a being than which nothing greater can be conceived" (Anselm, 1077: chapter 2). By this definition, Anselm claims that God now cannot be conceived not to exist (Anselm, 1077: chapter 3). This is because if we conceive of God (with all his qualities, including omniscience, omnipotence, omnipresence), and then believe God not to exist, we are not in fact conceiving of God, as a being greater than this one of which we conceived could be conceived: one which existed. Whichever being is greater of the two, and Anselm claims the one which exists would be greater, must therefore be God (Anselm, 1077: chapter 3). A similar argument is found in Descartes' Meditations. He claims that God is a "supremely perfect being" (Descartes, 1641: 45); a being who holds all the perfections. However, included within this, Descartes claims that there is also the perfection of existence (Descartes, 1641: 46). If we conceived God to be without the perfection of existence, we would not actually be conceiving of God. Therefore, to conceive of the perfect being necessitates its existence, and God must exist. A criticism is put against this by Kant. Kant argues that if we deny something's existence, we do not contradict a concept, as the ontological argument would claim we do, because he argues that existence does not "add" anything to a concept. That is, he holds that stating that something exists cannot make a concept greater. In order that a concept may be made greater by a predicate (in relation to the concept as a subject), the predicate must be something which, were it to be removed from the subject, would create a contradiction. In the example of God, we cannot claim the concept cannot be omniscient, as this would create a contradiction with the predicate "God is omniscient". This, Kant claims, is a "determining predicate" (Kant, 1781:A598/B626). Existence, however, is not a determining predicate. Kant claims, even, that it is not a predicate at all. Instead, to say something exists is "merely the positing of the thing" (Kant, 1781:A598/B626); that is, to say that something exists does not add to the concept, but simply states that there is an actual occurrence of the concept. So when we state "God exists", we do not state anything extra of the concept as we would in saying "God is omnipotent"; instead, as Kant argues, "we attach no new predicate to the concept of God, but only posit the subject in itself with all its predicates" (Kant, 1781:A599/B627). Therefore, there is no reason to suppose that a being greater than which none can be conceived must necessarily exist. This is because there it is not necessary that there must be an actual occurrence of the greatest being in order that it is the greatest being. Therefore, the classic ontological argument fails. There have been more recent applications of the ontological argument. Platinga aimed to show that, by the possibility of certain concepts, God must exist. These two concepts are maximal excellence and maximal greatness. Maximal excellence, he argues, "entails omniscience, omnipotence, and moral perfection" (Plantinga, 1974: 108). That is, all the concepts one attributes to God. Secondly, a being has maximal greatness if it has "maximal excellence in every world" (Plantinga, 1974: 108); that is, every possible world. These two concepts, Plantinga claims, are not self-contradictory, and therefore possible. Plantinga then argues that if the concept of maximal excellence is possible, there is a being, in some possible world, which has maximal excellence; this need not necessarily be the actual world. However, if the concept of maximal greatness is also possible, this means that in every possible world there is a being which has maximal excellence, including the actual world. The being who has maximal excellence is God, and therefore God must exist. (Plantinga, 1974: 108). A criticism to be made of Plantinga is that the concept of maximal greatness, though it is not self-contradictory, may not necessarily be possible. Indeed, consider the case that it is possible that maximal excellence may not exist. Therefore, there is a possible world in which maximal excellence does not exist. However, if maximal greatness was to be possible, there must be a being with maximal excellence in the world in which there is no being with maximal excellence. This, of course, cannot be the case. Plantinga himself admits this. He writes: "We must ask whether this argument … proves the existence of God. And the answer must be, I think, that it does not. An argument for God's existence may be sound … without in any useful sense proving God's existence." Plantinga, 1974: 112). The argument only proves God's existence if the premise that maximal greatness is possible is accepted. However, this premise will only be accepted by people who already believe in God's existence. Therefore, the argument fails in proving his existence externally of prejudiced beliefs. In conclusion, the cosmological, teleological, and ontological arguments for God's existence have been put forward. The criticisms put against them, in that the two former arguments rely on the ontological argument, and the ontological arguments fail to prove God's existence, seem to indicate that there are no arguments which work to prove the existence of God.

Reference List

Anselm. (1077). Proslogium. Accessed online at: https://legacy.fordham.edu/halsall/basis/anselm-proslogium.asp. Last accessed at 24/09/2015. Darwin, C. (1859). The Origin of Species. London: Everyman's Library. Descartes, R. (1641). Meditations on First Philosophy. Translated and edited by Cottingham, J. (1996). Cambridge: Cambridge University Press. Kant, I. (1781). Critique of Pure Reason. Translated by Kemp Smith, N. (1933). London: The Macmillan Press ltd. Mackie, J. L. (1983). The Miracle of Theism. Oxford: Oxford University Press. Paley, W. (1867). Natural Theology. Ohio: DeWard Publishing Company. Plantinga, A. (1974). God, Freedom, and Evil. New York: Harper and Row. Reichenbach, B. (2012). "Cosmological Argument". Accessed online at: plato.stanford.edu/entries/cosmological-argument/. Last accessed at 23/09/2015.

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Instrumentalism Underdetermination Realism

Contents

Understanding Underdetermination in conjunction with realism and instrumentalism
Realism
Instrumentalism
Under determination
Historical background
Realism/Anti-realism

Understanding Underdetermination in conjunction with realism and instrumentalism

The present essay is about the understanding of under determination thesis in conjunction with the realism and instrumentalism. As we know that realism and instrumentalism are two opposite views in philosophy of science, so by explaining the two it would be much easier to grasp the concept of under determination thesis, which is one of complex doctrine. The intended audiences of this essay are science student's and people who are interested to know about the philosophical issues in science. I divide the essay into four of parts. The first part explains the realism and instrumentalism concepts, second part explains the under determination thesis in detail and then the third part will state the views of different philosophers about three schools of thoughts. The fourth and the final part conclude the whole argumentation

Realism

The word realism in the dictionary means the tendency to view or represent things as they really are. [dic]. In philosophy of science it can be defined as “the philosophical doctrine that abstract concepts exist independent of their names”. It can be explained as an approach in philosophy that considers objects as they are in the universe as real things and their characteristics as a secondary thing. The advocate of realism are called realist and it is important to differentiate the realist's. A person can be realist about the different kinds of things i.e. mountains, physical objects, numbers, universe etc. but in the case of a philosopher, it is required to specify that for what object/thing the philosopher is realist [book]. An American philosopher name Hilary Putnam stated that “A realist with respect to a given theory holds the following: What makes them true or false is something external that is to say, it is not in general our sense data, actual or potential, or the structure of our minds, or our language, etc. Furthermore he says that the positive argument for realism is that it is the only “philosophy that does not make the success of science a miracle”. [Book]. Generally, in science established scientific theories are treated as a true fact, but according to realist these theories would be treated as a successful explanation of the whole scientific process or its relation to an object, and not as a whole truth. [Book] An example is that sun, mountains, building etc. exists in this world, but the attributes like length, width, colour etc. are either dependent or independent of the environment. For example the sun is spherical in shape, so it is independent from any material thing of this universe. But in case of a building, its shape and size, all depend upon the person who designed or built it. So it can be said that reality is related to mind and environment. In general, Realism is supposed to be a term that relates to number of subjects i.e. ethics, aesthetics, causation, modality, science, mathematics, semantics etc. When we talk about the realism in the context of science then the intention is to elaborate the scientific realism which has a number of dimensions i.e. metaphysical, epistemological and methodological. Besides this it is also the truth that there is no single version of scientific realism which is being accepted by all the scientific realists. The doctrine of scientific realism states that “ the world studied by science exists and has the properties it does, independently of our beliefs, perceptions, and theorizing; that the aim of science is to describe and explain that world, including those many aspects of it that are not directly observable; that, other things being equal, scientific theories are to be interpreted literally; that to accept a theory is to believe that what it says about the world is true, and that by continually replacing current scientific theories with better ones. Science makes objective progress and its theories get closer to the truth”. Realism has two schools of thought, first one is called Extreme realism, represented by William, a French philosopher; according to him “universals exist independently of both the human mind and particular things”. The second one is moderate realism and according to which “universals exist only in the mind of God, as patterns by which He creates particular things”. The main proponent of this view was St. Thomas Aquinas and John of Salisbury. According to epistemological view of realism, things exist in this universe, independent of our understanding or perception. This point is totally opposite to the theory of idealism, which states that “reality exists only in the mind”. By having a brief explanation of realism, instrumentalism will be discussed, which is the opposite view of realism and most of time called Antirealism. Antirealism is a doctrine that rejects realism, and includes instrumentalism, conventionalism, logical positivism, logical empiricism and constructive empiricism.

Instrumentalism

Instrumentalism is treated as a doctrine that states “theories are merely instruments, tools for the prediction and convenient summary of data” [Book]. In other words it can be defined as “concepts and theories are merely useful instruments whose worth is measured not by whether the concepts and theories are true or false, but by how effective they are in explaining and predicting phenomena”. The point is that in order to make predictions from theories, logic is required, so it can be hard to say theories have no truth values. In view of this instrumentalists admit that theories have truth values, but do not accept this argument that theories should be treated as accurately true. In view of this T.S. Kuhn said that “Theories may have truth values but their truth of falsity is irrelevant to our understanding of science”. [Book] In other words instrumentalism evaluates the significance of a theory with respect to empirical evidence and did not require the understanding of the actual phenomena. For example Newton gravity model is understandable and working fine, but it has no theoretical foundation [Answer.com] The another aspect of instrumentalism is that it relates closely to pragmatism and this point of view opposes the scientific realism because according to this, theories are more or less true in nature. Moreover, instrumentalism refutes that theories can be evaluated on the basis of truth. Theories will not be perceived as air plane black box which gives output on the basis of observed input. The point is that there should be a clear distinction between theory and observation that further leads to a distinction between terms and statements in each type. Like in science for statement of observation there is a specific meaning for an observable truth, for example if "the litmus paper is red", so the observation terms have their meaning fixed by their referring to observable things or properties, e.g. "red". Theoretical statements have their meaning fixed by their function within a theory and aren't truth evaluable, e.g. "the solution is acidic", whereas theoretical terms have their meaning fixed by their systematic function within a theory and don't refer to any observable thing or property, e.g. "acidic". Though you may think that "acidic" refers to a real property in an object, the meaning of the term can only be explained by reference to a theory about acidity, in contrast to "red", which is a property you can observe. Statements that mix both T-terms and O-terms are therefore T-statements, since their totality cannot be directly observed”. There is some criticism of this distinction, however, as it confuses "non-theoretical" with "observable", and likewise "theoretical" with "non-observable". For example, the term "gene" is theoretical (so a T-term) but it can also be observed (so an O-term). Whether a term is theoretical or not is a semantic matter, because it involves the different ways in which the term gets its meaning (from a theory or from an observation). Whether a term is observable or not is an epistemic matter, because it involves how we can come to know about it. Instrumentalists contend that the distinctions are the same, that we can only come to know about something if we can understand its meaning according to truth-evaluable observations. So in the above example, "gene" is a T-term because, although it is observable, we cannot understand its meaning from observation alone. The explanation of realism and instrumentalism above has provided us the capability to understand the topic with much insight. Now, I switch to under determination thesis. From the above discussion we have the knowledge that instrumentalism is related to pragmatism and this point of view is in contrasts with the scientific realism, which states that theories are often more or less true. Here, I refer to Quine, who said that theories can be underdetermined by all possible observations [23], and Newton Smith's, treat this as a threat to realism. He said, realism in his sense has to be rejected if there can be cases of under determination of theories.

Under determination

As we know that under determination is a thesis that is “used in the discussion of theories and their relation to the evidence that is cited to support them”.[1] Arguments from under determination are used to support epistemic relativism by claiming that there is no good way to certify a theory based on any set of evidence. A theory is underdetermined if, given the available evidence, there is a rival theory which is inconsistent with the theory that is at least as consistent with the evidence. Moreover, under determination is treated an epistemological issue about the relation of evidence to conclusions.

Historical background

The subject gets its first attention by Ren© Descartes, a French philosopher and mathematician in the 17th century. He presented two arguments related to under determination. “While dreaming, perceived experiences (for example, falling) do not necessarily contain sufficient information to deduce the true situation (being in bed)”.[2] As we know that it is not always possible for a person to separate dreams from reality and the theory that what is real or dream at a certain time is underdetermined. The second argument of Descartes's is called demon argument “which is a variant of the dream argument that posits that all of one's experiences and thoughts might be manipulated by a very powerful being (an "evil demon") that always deceives. Once again, so long as the perceived reality appears internally consistent to the limits of one's limited ability to tell, the situation is indistinguishable from reality, one cannot logically determine between correct beliefs from being misled; this is another version of under determination”.[2] The second person who talks about under determination was David Hume, who does not use the word under determination specifically but an argument about the problem of induction. I will discuss the induction later in the essay while explaining the under determination types. The Under determination thesis gets the recognition in the twentieth century through the work of Thomas S. Kuhn, who is a famous theoretical physicist and philosopher. He was very much prominent due to his work, The Structure of Scientific Revolutions that offered an alternative to linear models of scientific progress. According to Kuhn the under determination has a place to for argumentation against theories in the philosophy of science, and scientific realism. According to Khun the under determination can be divided into two types the weak and strong under determination. The both could be stated in the following words: Weak underdetermined is that the currently available evidence is not sufficient to prove the argument, but some evidence that will be available in the future might do this. Strong underdetermined is to claim that it is principally impossible to get evidence that could fully resolve the argument between the opponent theories. Besides strong and weak underdetermined theory there are two other attributes called deductive and inductive under determination. The two rival theories could be deductively underdetermined when the available evidence does not completely deny either theory. The theory is inductively underdetermined when theories are compatible with the available evidence, but still tries to determine, which theory could be a better failure A weak under determination can turn to a strong one if it avoids the attainment of future evidence that turns it into deductive under determination. A counter argument is that it is not possible for a theory to be accurately strong and inductive. In general weak under determination arguments are focused on the availability of evidence for an explicit set of theories, and strong under determination mostly entails common epistemological arguments that relates to the type of evidence and its viability for a particular or general theory. Furthermore, it is generally acknowledged that all theories are weakly underdetermined, but in case of some specific purpose all theories are strongly underdetermined. Explaining the types of under determination thesis, Ludan said that “for any finite body of evidence, there are indefinitely many mutually contrary theories, each of which logically entails the evidence”. So in other words it can be said that deductive under determination is under determination of selecting theory through a logical method. Finally, the term under determination as thesis is associated with two respectable names Pierre Duhem and W.V. Quine in philosophy of science, “that neither the truth nor the falsity of any scientific theory is determined by evidence”. According to Duhem-Quine Under determination is a “relation between evidence and theory. More accurately, it is a relation between the propositions that express the (relevant) evidence and the propositions that constitute the theory. Evidence is said to underdetermine theory”. From the above it can be said that evidence is not enough to prove the theory, belief or truth. Moreover, only the availability of evidence is not enough to make the theory a credible one. In view of this we can call the first argument a deductive and the second inductive under determination. Hence, according to under determination thesis, both arguments have required some definite epistemic proposition, and belief in a theory could not be justified on the basis of evidence. For under determination types, Duhem, also said that “logic alone cannot take us from the falsification of a prediction to a refutation of an isolated hypothesis. Importantly, deductive under determination does not mean that theory choice is underdetermined, nor does it mean that there is more than one reasonable conclusion given certain experimental evidence”. Up until now we have a basic understanding of the under determination thesis, so now I will discuss what realism actually is, the theoretical frame and the origin of the concept. Another argument against scientific realism, deriving from the under determination problem, is not as historically motivated as these others. It claims that observational data can in principle be explained by multiple theories that are mutually incompatible. Realists counter by pointing out that there have been few actual cases of under determination in the history of science. Usually the requirement of explaining the data is so exacting that scientists are lucky to find even one theory that fulfils it. Furthermore, if we take the under determination argument seriously, it implies that we can know about only what we have directly observed. For example, we could not theorize that dinosaurs once lived based on the fossil evidence because other theories (e.g., that the fossils are clever hoaxes) can account for the same data. Realists claim that, in addition to empirical adequacy, there are other criteria for theory choice, such as parsimony. In particular, it must not be confused with what Newton-Smith takes to be a "minimal common factor among the wide range of philosophers who in recent years have advocated a realist construal of scientific theories". This common factor consists of the following theses: (1) "Scientific theories are either true or false and which a given theory is, it is in virtue of how the world is", (2) "If a theory is true, the theoretical terms of the theory denote theoretical entities which are causally responsible for the observable phenomenon whose occurrence is evidence for the theory", (3) "We can have warranted beliefs (at least in principle) concerning the truth values of theories", (4) "The historically generated sequence of theories of a mature science may well be a sequence of false theories but it is a sequence in which succeeding theories have greater truth-content and less falsity content than their predecessors". We may refer to (1) as the objectivity, (2) as the causality, (3) as the decidability, and (4) as the convergence of scientific theories. Newton-Smith uses the name "realism" for the combination of these four theses, and he also seems to hold that this is the standard use of the term. It is clear that theoretical realism in the weakest sense entails neither objectivity, nor causality, nor decidability, nor convergence. In particular, some theoretical propositions may be true even if no scientific theory as a whole is either true or false. Moreover, it is doubtful whether realism in Newton-Smith's sense entails theoretical realism. For example, if all theoretical propositions are false, then theoretical realism is false, but realism in Newton-Smith's sense might still be true. In any case, one of Newton-Smith's main theses is that realism in his sense has to be rejected if there can be cases of under determination. In particular, he claims that either objectivity or decidability has to be weakened if under determination can occur to give up decidability is what he calls the ignorance response (to under determination). This "involves embracing the possibility of inaccessible facts - facts concerning whose obtaining we could have no information". To give up objectivity is what he calls the arrogance response. This "amounts to holding that if we cannot know about something there is nothing to know about". 36 Notice, that this holds only for under determination in Newton-Smith's sense, i.e. under determination by all possible data. It does not hold for the other kinds of under determination mentioned above. In other words, it is only when an underdetermined theory is empirically viable that we cannot know that it is true or that it is false (either because it is neither true nor false, or because we cannot know, even in principle, what its truth value is). In general, we cannot have under determination (of any kind) together with empirical viability, objectivity, and decidability. If a theory is underdetermined, we cannot know that it is true. This I accept. At first, it appears that Quine would not accept this. He holds that there may be two best total theories which are empirically viable and incompatible, but that we may know, at least in principle, that one of them is true and the other false. However, it seems that Quine is then using "true" and "false" in a non-realistic sense; according to him, "to call a statement true is just to reaffirm it". He does not seem to assume that there is some objective reality, "the world", such that the truth of a statement consists it its correspondence with this reality. Hence, presumably he would reject the objectivity thesis which is part of realism in Newton Smith's sense.

Realism/Anti-realism

Given the various epistemological difficulties (under determination, problem of induction, rationality, social forces), and the lack of a consensus on these issues, why should we think that our theories are actually describing reality? The apparently large gap between observational and theoretical knowledge inspires worry about realism Metaphysical difficulties come into play here as well—we do not have good understandings of the nature of laws and causation, explanation, so how can we claim that we are discovering the nature of the universe?

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Transcendental Knowledge Philosophy

Immanuel Kant is responsible for introducing the term “transcendental” to the philosophical discussion. By doing this it was his goal to reject everything that Hume had to say. His argument proved that subjects like mathematics and philosophy truly existed. One of his main arguments was the idea that gaining knowledge was possible.

Without this idea of knowledge there would be no reason for a discussion. Since we know that knowledge is possible we must ask how it got this way. According to Kant, one of the conditions of knowledge is the Transcendental Aesthetic, which is the mind placing sense experience into a space and time sequence. From this we understand that the transcendental argument is an abundance of substances situated in space and time, with a relationship to one another. We cannot gain this knowledge from sense-experience (Hume) or from rational deduction alone (Leibniz), but showing how knowledge exist and how it is possible. Kant makes the claim in the Transcendental Aesthetics that space and time are ‘pure a priori intuitions.’ To fully understand what this means we must define what an intuition is. According to Kant an intuition is raw data of sensory experience. So basically intuitions are produced in the mind.

Kant is saying that space and time are things that are produced in the mind and given before experience. Space is a necessary a priori representation, which underlies all outer intuitions. It does not represent something in itself or any other relationship.

Space is only a form of appearance represented outside of the mind. Time, on the other hand, is a necessary representation that underlies all intuitions and therefore is a priori. Since time is only one dimensional there is no way that we could access it quickly. We know that space and time are both a priori because of all of our experiences. Kant also claims that space and time are ‘empirically real but transcendentally ideal’. When Kant says that space is ‘empirically’ real he is not presupposing external objects.

There is no way for space to be an empirical concept. We cannot just come up with the idea of space; a representation of space must be presupposed. When we experiences things outside ourselves it is only possible through representation. For space and time to be ‘transcendentally’ ideal Kant is basically saying that “they are not to be identified with anything beyond – or anything that transcends – the bounds of possible experience or the a priori subjective conditions that make such experience possible in the first place.” Before Kant begins to explain the transcendental aesthetic he claims in the introduction that mathematical knowledge is synthetic a priori. This statement is based on Kant’s Copernican Revelation. According to Kant, time and space taken together are the pure forms of all sensible intuitions.

This is our way of creating a priori synthetic propositions. These propositions are limited in how they appear to us but not present within themselves. We have a priori knowledge of synthetic judgements. According to Kant our judgements/statements can either be analytic or synthetic. An analytic judgement would be where the concept of the predicate is part of the concept of the subject. If it is denied then there would be a contradiction. A synthetic judgement, on the other hand, is where the concept of the predicate is not contained in the concept of the subject. So, if we denied it then there would be no contradiction involved. An analytical judgement would be “all bachelors are unmarried”. The concept of bachelor is defined as being unmarried. In analyzing this word we would say that it is an unmarried male adult. When we analyze concepts the parts come out.

Therefore, when broken down our predicate concept of “unmarried” is shown. The mind is capable of finding this concept without going outside and experiencing it. If we tried to deny this statement there would have to be a contradiction, therefore making it false. An example of a synthetic judgement would be “the sun will rise tomorrow”. When we say this it is our way of taking two separate and distinct ideas and putting them together. There could be no contradiction in this statement because we can image that something like this could occur. In Section I of the Transcendental Aesthetic, Kant gives four arguments for the conclusion that space is empirically real but transcendentally ideal. As we know space is not an empirical concept. We cannot physically derive the idea of space. The only way that we can receive these outer experiences is through our representation. When it comes to space we cannot represent the absence of space but we can imagine space as being empty. In order to be given any content in our experience we must presuppose space.

Knowing that space is not a general concept we can only discuss one space at a time and if we speak of diverse spaces we only mean parts of the same space. The parts cannot decipher the bigger space but only what is contained in it. Since space is seen as only one, the concept of spaces depends on a limit.

Concepts containing an unlimited amount of representations cannot be contained within itself. All parts of space are given to us at once. Therefore it is an a priori intuition not a concept. All of the previous information is Kant’s way of showing that the synthetic a priori knowledge of mathematics is possible. As we know mathematics is a product of reason but is still synthetic.

But how can this knowledge be a priori? The concepts of math are seen a priori in pure intuitions. This just means that the intuition is not empirical. If you do not have intuitions then mathematics would not even be a concept. Philosophy, on the other hand, progresses only through concepts. Philosophy uses intuitions to show necessary truths but those truths cannot be a consequence of intuitions. The possibility of math only occurs because it is based on pure intuitions which only occur when concepts are constructed.

Like pure intuition, empirical intuition, allows us to broaden our concept of an object by providing us with new predicates. With pure intuitions we get necessary a priori truths. Synthetic a priori knowledge in mathematics is possible only if it refers to objects of the senses. The form of appearances comes from time and space which is assumed by pure intuitions.

Doubting that space and time do not belong to the object in themselves would cause us to not have an explanation about a priori intuitions of objects. We have to come to the conclusion that in space and time objects are only appearances entailing that it is the form of appearances that we can represent a priori. Concluding that a synthetic a priori knowledge of mathematics would be possible. What is the Transcendental Deduction? This is the way concepts can relate a priori to objects. Kant says, “If each representation were completely foreign to every other, standing apart in isolation, no such thing as knowledge would ever arise. For knowledge is [essentially] a whole in which representations stand compared and connected.” Kant lays out a threefold synthesis about experience: a synthesis of apprehension in intuition, a synthesis of reproduction in imagination, and a synthesis of recognition in a concept. We should not divide these steps into one but they should all be intertwined as one. So what we see must occur consecutively.

Therefore our idea of the Synthetic Unity of Apperception comes into play. This is where every possible content of experience must be accompanied by “I think”. Everything in your mental state should be able to be accompanied by “I think” if not then it will not matter at all. “I think” is not something that consists in sensibility. It is an act of spontaneity. It precedes all possible experience.

The unity of this particular manifold is not given in experience but prior to it. Thinking substances can only perceive what is going on inside as perception goes on at all times. This is where our awareness of a manifold comes into play. We are aware of one thing after another. Each impression is different from one other. We must say that these impressions are mine. Basically accompanying them with the phrase “I think”. As for the Transcendental Unity of Apperception we are never aware of ourselves as the thinker but just the intuitions.

All of our experiences must be subjective to this combination of things. I must actively pull them all together as them being a part of my experience. The only way that I can be aware of this “I” is if I am able to pull together all of these representations. In this we can see the idea of objective unification. There is a connection between transcendental unity of apperception and objective unification. When we speak of objective unification we believe that there is a right way to put things together. This concept basically comes from our categorical synthesis which involves a priori concepts.

With the categorical synthesis it is our way of putting together intuitions in a category. We must be able to make a judgement. For example we must be able to say this is how things seem to me because of pass experiences. By saying this it would be a near judgement. Whereas a judgement would be us just saying this is how things are. To make a judgement is to say this is how things are out there; how they objectively are rather than how they appear subjectively. For a manifold to be complete the sensible intuitions have to be subject to the category.

This is how we can have a categorical synthesis. We cannot have sense impression unless I can bring them together under a unified manifold by knowing they are objective rather than subjective. Any intuition that we have must be subject to the category. We could not have an awareness of one event coming before the other unless there is a manifold of “my”. Appearances are not objects in themselves. They are not just representations; they are separate intuitions therefore having no connection between them. Imagination is what connects the manifold of sensible intuitions. Nature is just appearance.

Anything that appears to us must conform to law. We have to complete this synthesis in order to have experiences. It is presupposed that there is an objective to all of my experiences. Without it there would be no way to put them together and I would not be aware of them as experiences.

Both the threefold synthesis and a transcendental unity of apperception are necessary to have ordered experience for any sort of theory of experience. 3. Kant defines Idealism as “the theory which declares the existence of objects in space outside us either to be merely doubtful and indemonstrable or to be false and impossible.” Since I am conscious of my own existence, objects in space must also exist. Having knowledge, the only thing that we are aware of is our representations. These representations are only achievable through an object outside of me not by the representation of that object. Therefore I exist in time because I am capable of perceiving actual things outside of me. I am conscious of my existence in the same frame of time as I am conscious of those objects existing outside of me. When referring to idealism it is believed that our immediate experience is inner experience and from this particular experience we only receive outer objects. It is quite possible that these representations come from within.

When considering the representation “I am” a subject is included. We do not know what that subject is though. So according to circumstances we do not have any experience of that subject. To fully understand the knowledge of the subject we must have intuition. But the only way to receive this inner experience is through our outer experience. To have the existence of outer objects we must be conscious of ourselves. This does not mean that our representation of them involve true existence because they could also be produced by our imagination. The representations of our outer objects come from our perceptions. According to Kant “all that we have here sought to prove is that inner experience in general is possible only through outer experience in general.

Whether this is or that supposed experience be not purely imaginary, must be ascertained from its special determinations, and through it congruence with the criteria of all real experience.” According to Descartes, we really know only what is in our own consciousness. We are instantly and honestly aware of only our own states of mind. What we believe of the whole external world is merely an idea or picture in our minds. Therefore, it is possible to doubt the actuality of the external world as being composed of real objects. “I think, therefore I am” is the only idea that cannot be doubted. This is because self-consciousness and thinking are the only objects that can be experienced in the real sense.

Descartes presented the main problem of philosophical idealism which was an awareness of the difference between the world as a mental picture and that of a system of external objects. Locke’s theory, on the other hand, encompasses the mind as the origin for modern conceptions of identity and “the self”. Locke was the first philosopher to define the self through a continuation of “consciousness.” He also speculated that the mind was a “blank slate” or “tabula rasa”. These two strategies are very different from the above strategies of Kant. At the beginning of early modern philosophy, in Descartes, we seem to see our familiar world slipping away. At the culmination of early modern philosophy, in Kant, however, we get our familiar world back through at a price. In the following essay I will discuss this process, beginning with Descartes, ending with Kant, and discussing two of the four philosophers we have examined this semester. In Meditation One Descartes gives three separate arguments. From these particular arguments one can conclude that we cannot claim to know with certainty anything about the world around us. Everything might seem probable but in reality that does not mean that it lacks doubt. If we can never be certain how can we know anything. This is the main reason for Descartes bring this issue up. Basically his entire argument is based on Scepticism. Scepticism is very important and is seen as an attempt for our knowledge and understanding of the world. It is really hard to doubt that someone really exists but there is no way that one could get rid of the idea of scepticism The one thing that we know is that Descartes does not just randomly doubt everything. He provides very concrete reasons for the things that he doubts. As he sets up this doubt he has to be very rational about it. If he does not then his argument is not going to work.

The KK thesis that Descartes uses is to show how these arguments work. The KK thesis follows: if a knows that p, then a knows that a knows that p. basically this means that if I know that there is snow outside then I know that I know that there is snow outside.

The problem with this argument is that if we are not sure about our senses then there is no way that we can be sure about the knowledge that we possess. In making this thesis work one must have a strong understanding of what “knowing” really means. But there is no way that one can actually have this understanding. One must have self-knowledge or basically one must really know himself/herself. Therefore if you do not have that notion of self then you do not possess any knowledge. As we can see the KK thesis works in favour with what Descartes is saying in all of his arguments.

The only problem is that he does not believe that his argument about God is that strong. He feels that if there is an Omnipotent God then there is no way that he could ever deceive us. There is no way that he could be all knowing and make us doubt the things that we do. On the other hand there is no way that there could be no God because our senses had to be created by someone. Therefore there must have been an evil demon that has deceived us. But since he doubts everything then he is not mislead into the false believing of a demon. So, in a later meditation he proves that there is a God and that he is not a deceiver. We turn to Liebniz and we continue to see the world slipping away as he discusses the monad. In looking at the things that Liebniz said it is believed that monads (Entelechy) are not physical or mental but biological. Therefore, the ultimate cogs of the world are biological elements or Entelechies. In doing this there is no distinction made between inanimate and animate objects, which would make everything, animate. If these monads are really just biological there is no way that they can make changes in each other. The only way for this to happen is if God caused these changes to happen. The reason that monads cannot bring changes in bodies is because that is not what they were programmed to do. They were created so that compound substances could be made.

The biological nature of Monads makes their essential qualities to be apperception and appetition and even motion itself. Their relation is more of a final cause than an efficient cause. This is why he considers final causes as the principle of efficient causes and gives priority to final causes. Therefore, this made it hard for a monad to bring change in a body. As we can see, God is the unifier of the monads but he also brings harmony.

Leibniz came to the conclusion, by using metaphysics and the nature of monads, that God was the ultimate monad and the Creator of this world. We are now at a point where nothing is the same. We believed in one thing but now it is completely different. The first problem that Berkeley would have with this objection is the fact that ideas cannot exist if they are not perceived. If we cannot perceive of the idea then there is no way that we can truly conceive of the thing. For example if I do not have the idea of the sky being blue then there is no way that I am going to walk outside, look up, and say the sky is blue. I do not have the concept of blue in the first place. He says that we cannot say what reality is like without using language. You cannot use a word well if you do not know the meaning of that word. When we are describing an idea it is based on what we feel.

There is no way that I can say what I mean if I have no conception of the word. According to Berkeley, ideas do not do anything so it cannot cause anything to happen.

The mind is active; it is able to perceive of new ideas by imaging. The one thing that the mind cannot do is actually form ideas. It can perceive the ideas but cannot come up with ideas that will resemble the mind when it does this. So, therefore there is no way that we can perceive of any sensible things without knowing what the words mean in the first place. If you do not know what the words mean then you cannot come up with ideas and without the ideas you cannot perceive anything. As we continue we start to see some changes. Berkeley is bring us closer to what Kant has to say. We finally come to Kant and we get our world back through pieces. The way that we do this is through the Kantian price.

The Kantian price is how we get our world back through space and time. We have to realize that we would not exist without a world of space and time. Space is not empirical; the idea of space cannot be conceived of. Space is of only one thing. It cannot be talked about in parts because parts are only contained in the overall bigger picture. All space is, is a form of all appearances of the outer sense. As for time it is a little different. Time is not something, which exist of itself. An intuition taking place within is what time is. Time cannot be removed from appearance even though it does not have to actually possess appearances. These appearances can come and go but time cannot be taken away. It is only suitable in conjunction to appearance not for objects preoccupied or taken in general.

Time and space are the pure forms of all sensible intuition and so are what make a priori synthetic propositions possible. Therefore, bring back our world through a price. We get a chance to see how Kant breaks down what everyone is saying and shows us how the world is not really slipping away but it is just seen in a different way.

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Examine Hobbes’ Proposition that ‘people Need Governed’

The debate surrounding our original state of nature or species being has been hotly contested by scholars for centuries and remains a pivotal line of enquiry in contemporary pedagogic circles. In societies across the globe we observe entire populations governed by (religious) laws and practices designed to manage, control and otherwise police the boundaries of individualism whilst accentuating solidarity and protecting the collective norm (Stiglitz 2003). In this essay, we explore the various conceptions that have sought to trace and detail the genealogy of human beings to their primordial or so-called primitive condition, with particular emphasis on exploring Hobbes' (2008) proposition that the disposition of human nature is chaos and thus, as humans, we are compelled to forgo our instinctual nature and find sanctuary within the realms of social collectivism and central governance.

In this vein, we confront the age-old nature versus nature conundrum; are we social and moral animals by design, altruistic in nature, or does civilisation transpire from egotistical obligation to co-operate in order to thrive. As ever-increasing demands are placed on social-scientific research to maintain pace with an ever-changing world, it is commonplace for scholars to forget the (historical) dictums of our primal beginnings; such investigations are often marginalised – afforded little time, finance and credence – in a world seeking solutions to contemporary problems.

Yet, to paraphrase Marx (1991), the ghosts of the past weigh heavy on the minds of the living; understanding our roots may become the greatest social discovery and contribution to forging our future as human beings. Thus, social science, by definition and direction, is arguably obsessed with the social constructs that humans generate, frequently dismissing (perhaps through arrogance) the undeniable fact that we remain animals, imbued with the same instinctual drives and impulses as other species. Indeed, one need only observe the effect of social neglect in the case of feral children, unfettered by societal constraints we return to barely recognisable beasts, uncivilised and unconcerned by social pretentions, decorum, normative expectations and values (Candland 1996). For Hobbes' (2008) humankind in its original state of being is an evil scourge upon the earth; a ruthless and egotistical creature perpetuated by self-gain and absolute dominance a survival of the fittest nightmare (Trivers 1985). Thus, paralleling the works of Plato (2014), he asserts that the individual, possessing the principle of reason, must sacrifice free-will to preserve their ontological wellbeing, acquired resources, property and way of life or what he calls a 'commodious living' (78).

As Berger and Luckmann (1991) argue, we willingly accept social captivity as it offers a protective blanket from the otherwise harsh conditions; a remission from the barbarism and bloodshed that transpired previously. This led Hobbes' (2008: 44) to assert that 'people need governed' under a social contract or mutual agreement of natural liberty; the promise to not pillage, rape or slaughter was reciprocated and later crystallised and enforced by the state or monarch. Indeed, whilst his belief in the sovereigns' traditional (rather than divine) right to rule was unwavering, he was certain that a despotic kingdom would not ensue as reason would triumph over narcissism. In response, Socrates (cited in Johnson 2011) hypothesised that justice was an inherent attribute where humans sought peace as a process of self-fulfilment - of regulating the soul - not because of fear or retribution; to paraphrase: 'the just man is a happy man' (102). The state would therefore stand as a moral citadel or vanguard against the profane.

Similarly, Locke (2014) rejects the nightmarish depiction offered by Hobbes (2008), asserting a romanticised state of nature permeated with God's compassion – whereby humans seek liberty above all; not individual thrill-seekers but rather banded by familial bonds and communes a pre-political conjugal society - possessing parochial values, norms and voluntary arrangements. However, he also appreciated that, without the presence of a central regulatory organisation, conflict could easily emerge and continue unabated. Hence, humanity ascends into a civil contract, the birth of the political, as a means of protecting the status quo of tranquillity, prosperity and ownership. Similarly, Rousseau (2015) also proposes a quixotic rendition ofA humanities social origins, considering such times as simplistic or mechanical (Durkheim 1972) inasmuch as populations were sparse, resources abundant and needs basic, implying that individuals where altruistic by nature and morally pure.

Yet, the ascension of state, particularly the mechanisms of privatisation, polluted and contorted humankinds natural state into something wicked that not only coaxed but promoted tendencies of greed, selfishness and egocentrism. In this account, we find strong parallels with Marx (1991), specifically his critique of capitalism, which is conceptualised as a sadistic mechanism tearing humanity from its species-being - the world of idiosyncratic flare, enchantment and cultural wonder – and placing it into a rat-race of alienation (from ones fellow being), exploited labour and inequality. As Rousseau (2015) ably contends: 'man is born free, and everywhere he is in chains' (78). Thus, government and the liberalism it allegedly promotes is a farce, seeking to keep the architectural means to create the social world within the possession of a minority – this he calls the current naturalized social contract. He calls for a new social order premised on consensus, reason and compassion; we must reconnect with ourselves, re-engage with our neighbours and discover who we are as a species.

The supposition of our philosophical ancestors is that we require governance as a process of realisation, we are social animals that demand and reciprocate encounters with others; alongside the impulse for sustenance and shelter is the yearning for social contact – indeed love and belonging are included in Maslow's (2014) hierarchy of needs. Yet, within many philosophical transcripts is the deployment of religion as a legitimate form of authority, since antiquity monarchs, pharaohs, dynasties and early tribal formations have claimed power through divine right or approval. In fact, conviction in a celestial realm has pervaded for epochs – carved in millennia-old cave paintings around the globe (Stiglitz 2003) – and perhaps emerged from an enchanted, speculative and awe-inspired outlook of the world in which our ancestors occupied; religion complemented the life-cycle, delineating the sacred from the profane (Foucault 1975). As Schluchter (1989) argues, later missionaries would propagate their dogma; a prime example of this is the upsurge, dissemination and (even today) domination of Christianity as it overran its pagan predecessors, witchdoctors and mystics. Thus, religion has been attributed with generating social mores, collectivism and ushering the rise of civilisations. Indeed, Elias (2000), details the social evolution of humanity as the animalistic fades to the backstage - with the gradual monopolisation of violence and (political) power - and presented civil self takes credence. Initially, this was necessary for survival as people became more interdependent and significantly influenced later by the royal courts who became a celebrity-like beacon of perfect decorum and taste.

By the 19th century, most of Europe was regarded as civilised whilst other developing parts where considered savage lands; the violence, exploitation and subsequent domination of such nations as India and Africa by western societies is well documented (Buckinx and Treto-Mathys 2015). As Elias puts it: "people were forced to live in peace" (2000, 99). This was also accompanied with the advent of Enlightenment whereby the rule of logic, rationalisation and pragmatism disrobed and effectively dismantled the prevailing supremacy of religion; though religion remains a powerful force in certain cultures and is frequently accompanied with its own medieval brutality. As Anderson (2008) alludes, in Africa and the middle-east, where Christianity, Judaism and Islam prevail and to varying degrees dominate life, purported barbaric acts like (female) genital mutilation, segregation, and (domestic) violence - that affects mainly women - and public violence and executions are commonplace and sanctioned.

Thus, secularisation and the rise of empiricism unshackled humankind from its beastly beginnings and rehomed them within the embracing idioms of consensus, free-will and reciprocal courteousness – humans had undergone a transformation or courtisation whereby mannerisms, hygiene and self-restraint became governing tenants, the barbarian was adorned (concealed) with socially acceptable masks, equipped with approved social scripts and the rules of the game – Goffman's (1990) social actor and his/her presented selves was born. In this conceptualisation,A self-governance or policing is prerequisite for progress and forms the basis for society; enhanced with consciousness we are capable of resisting our impulsive drives – Freud's (2010) Eros and Thantos are forsaken for the greater good – and creating a utilitarian civilisation. Today, in late-capitalist societies, we live in relative prosperity and peace; the elected government and its respective agencies provide sustenance, infrastructure, healthcare, protection and political democracy; this template of humanity is – like our religious proselytisers – distributed globally, perpetuated by the mass media, globalisation and free-markets (Stiglitz 2013). For Nietzsche (2013), this contemporary worldview was tantamount to emptiness where humanity had escaped their animalistic state of being, finding virtue in religion and will-to-power within to overcome and ascend, but is now found wanting with the demise of faith and contemporary nihilism that has proceeded (his famous 'God is dead' (13) quote).

Indeed, he is dismissive of science, philosophical and religious idioms, particularly their totalitarian tendencies which (for him) inhibit, enslave or otherwise surrender life-affirming behaviours; similarities may be drawn with Marx and Engels (2008) critique of religion as the 'sigh of the oppressed creature' (45); religion (like governments or social contracts) demands that individuals relinquish or capitulate part of themselves; to genuflect the laws, tenets and values that rule. Such things seek to (re)capture or incarcerate our species being within a straightjacket. Therefore, humanity must re-engage their instinctual resolve – which Nietzsche (2014) regarded as stronger than our urge for sex or survival – and become supermen (Aœbermensch) untrammelled by instinct, to find wonder in the fluidity and unpredictability of nature and good conscience by re-evaluating our values, expectations and shortcomings as a species. Namely, a stateless civilisation, unhindered by permanency, premised on the continual refinement of self. Yet, whilst Nietzsche (2014) highlights the stifling effects of dogma, it seems unrealistic to suggest humans are capable of living in constant flux – even a war-torn nation offer consistency (Stiglitz 2003) – insofar as we instinctually seek to structure the surrounding environment in a comprehendible manner; we assign labels, judgements and behavioural codes as we produce order – predictability is the precondition for life and offers humans ontological security and wellbeing (Berger and Luckmann 1991).

However, given the asymmetrical nature of society, some possess the architectural means to govern others – reformulated as a form of symbolic violence or barbarism. For example, the credence given to hegemonic masculinities and subsequent denigration and objectification of women or the subjugation of nations to western ideals (Mulvey and Rogers 2015). Moreover, the free-markets offered by capitalism seek to segregate, exploit and captivate masses into a consumerist world of shiny prizes (Marcuse 2002), coaxing our selfish and cut-throat tendencies, whilst so-called liberalist governments attempt to impose their civility globally through violence, bullying and manipulation; a wolf in sheep's clothing (Kinker 2014). So, even under the rule of government and presence of civilisations our so-called animalistic (violent) heritage pervades, like a ghostly presence haunting the present. Hobbes (2008) reasons for why individuals need governed - to cage our inner beast - seems defective. As Walsh and Teo (2014) allude, a major fault with many of the propositions outlined above is the emphasis placed on linearity – government is seen as a progressive necessity – rather than appreciating that as social creatures we are capable of creating communities with their own normative flows, ebbs, fluxes and (more importantly) governing ourselves both as matter of necessity or self-preservation and as a means of self-fulfilment or belonging; contemporary modes of practice have become so integrated and reified that finding a parallel alternative or a "way back" seems implausible.

That said, as Browning (2011) argues, in an increasingly interdependent and global world, the requirement for centralised states seems unavoidable to handle the sheer mass of human activity and to maintain a level of equilibrium; an inevitable course of human progress.A This essay has been both illuminating and simultaneously problematic; the proposition of whether humans are capable of cohabiting without the requirement of a state or intervening supra-organisation remains a mystery.A In fact, such an assertion is premised on how one defines the original state of nature; are we barbaric creatures who engage in a social contract for personal gain or are we instinctually social and empathic animals whose predisposition is not only to safeguard our interests but to generate genuine communal bonds and interconnections with others.

The latter affords more manoeuvring for alternative (flexible) social figurations without government, where humanity can bask in the wonder of difference, variety and levels of unpredictability, whilst the former finds sanctuary only in the incarceration of humanity to defined idioms and laws imposed by a centre of authority and power. It is tempting to concede that, despite Hobbes' depiction of government as the epitome of civility, on the contrary it appears to be (in this era of modernity) the primary agent of (symbolic) violence and struggle, whether masquerading as a religious, communist or neo-liberal state. Thus, one is reluctant to accept Hobbes assertion that people should be governed by a reified or separate entity. Instead, with a level of Nietzschean sentiment, perhaps people should be permitted and empowered to re-evaluate and govern themselves.

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Does Virtue Ethics Offer a Convincing Account of what it is to be Right?

This essay shall discuss whether or not virtue ethics offers a convincing account of what it is to be morally right. It shall focus on Hursthouse’s version of virtue ethics, which shall be outlined first, and the positives of this argument: that it allows for different actions in different situations, and does not justify mass atrocities as a result. Four criticisms shall then be put against virtue ethics: that it is not action guiding; it does not explain cultural difference; it offers no guidance for virtue conflict; and that it relies on either a circularity or, at best, the argument being superfluous.

With only one of these criticisms being answerable, it shall then be ultimately concluded that virtue ethics does not offer a convincing account of what it is to be right.

Hursthouse’s argument of virtue ethics is an updated version of Aristotle’s original work. She claims that an action is right “iff it is what a virtuous agent would characteristically do in the circumstances” (Hursthouse, 1996: 646). Virtue ethics, then, makes an essential reference to the virtuous person, which Hursthouse claims is a person who “acts virtuously … one who has and exercises the virtues” (Hursthouse, 1996: 647). It is a trivial truth that a virtuous person does what is right, according to all moral theories. However, virtue ethics differs from other arguments in that it claims that an action is right in virtue of it being what the virtuous person would do.

The concept of what is a virtue, then, must be established.

In this, Hursthouse makes her claim to Aristotle, arguing that a virtue is “a character trait a human being needs for eudaimonia, to flourish or live well” (Hursthouse, 1996: 647). This links to Aristotle’s work The Nicomachean Ethics, in which he claims eudaimonia is living a flourishing, happy life, which he views as the ultimate end and goal of a person’s life (Aristotle, 340bc).

A virtue is any trait which will make an addition to this flourishing life, arguably termed the “positive traits”, such as kindness or charity. Here, virtue ethics demonstrates a shift from the deontic concepts of deontology and consequentialism; not claiming that an action “ought” or “ought not” to be done. Instead, there is a justification of actions in terms of areteic concepts; claiming that an action is “kind” or “callous”, for example. It can now be summarised what makes an action right according to virtue ethics.

An action will be right iff it is what a virtuous agent would characteristically do in the circumstances.

The virtuous agent would characteristically do the action in the circumstances iff the trait which leads to the action is a virtue. Finally, the trait which leads to the action will be a virtue iff it would increase the eudaimonia of the agent. There are positive things to be said of Hursthouse’s argument for virtue ethics. Firstly, by stating an action is right “iff it is what a virtuous agent would characteristically do in the circumstances”, there is an allowance for variation in action dependent on the situation, which is more in line with our pragmatic moral practice. This escapes the rigidity and often counter-intuitive rules of deontology.

Secondly, whilst it allows for variation in moral practice, it doesn’t allow for the atrocities which consequentialism justifies as a consequence of its situational variation. This is because virtue ethics’ argument depends on what the virtuous person would do and, arguably, it would be said that the virtuous agent would not act in the way consequentialism argues for, by allowing mass murder or torture under certain extreme circumstances, for example.

However, there are decisive criticisms against virtue ethics. The first criticism is that it does little to tell us exactly how to act; it is not action guiding. Virtue ethics states that we should act as the virtuous person would.

This gives no other instruction than “act virtuously”, which perhaps can be further developed into “act kindly” or “do not act callously”. However, there is no further instruction than this, and nothing to say whether an action will be kind or just; a person is left to rely on their pre-understanding and belief. Hursthouse’s response to this criticism seems to be that this is all the instruction that we need. She argues: “We can now see that virtue ethics comes up with a large number of rules … each virtue generates a prescription – act honestly, charitably, justly.” (Hursthouse, 1996: 648). When acting, we need only ask ourselves “is this act just?” or “is this act kind?”, and the response to the question, being either “yes” or “no”, will dictate whether or not an act should be done or not.

This response to the objection does little to answer the original concern, and leads to the second criticism.

Hursthouse claims that in order to determine whether an act is just, or kind, or deceitful, a person should seek out those who they consider to be their moral and virtuous superior, and ask their advice (Hursthouse, 1996: 647-648). Not only does this rely on a preconception in measurement of virtue (in that we must have an understanding of what is just in order that we may decide which acquaintance is most just), it does little to recognise what is a second criticism for virtue ethics: the variation in morality between cultures.

There is a variation in virtues for different cultures in three senses.

Firstly, cultures may vary on which virtue is to take precedence in cases of virtue conflict (though this is a separate criticism in itself). In the second sense, cultures vary in their conception of whether a trait is, indeed, a virtue. Thirdly, cultures vary on what they believe the action would be which the virtue leads to. MacIntyre writes: “They various thinkers and cultures offer us different and incompatible lists of the virtues; they give a different rank order of importance to different virtues; and they have different and incompatible theories of the virtues.” (MacIntyre, 2007: 181).

He gives the example of Homer, who claimed that physical strength was a virtue. This, MacIntyre claims, would never be accepted as a virtue in modern society and, consequently, the difference in Homer’s idea of a virtue or an excellence is vastly different to that of ours (MacIntyre, 1981: 27).

Though this demonstrates that one trait may be accepted as a virtue by one culture and not by another, it is also highlights the third sense of cultural difference: that different cultures can accept the same trait as a virtue, but what constitutes an act being virtuous may be varied. For example, all societies believe justice to be a virtue, yet one might consider capital punishment to be just and therefore virtuous, whilst the other may hold capital punishment to be unjust and therefore not virtuous. To the defence of virtue ethics, Hursthouse claims that the problem is one which is equally shared by deontology, arguing: “Each theory has to stick out its neck and say, in some cases ‘this person/these people/other cultures are in error’, and find some grounds for saying this.” (Hursthouse, 1991: 229) Yet this causes concern for virtue theory.

Hursthouse is here claiming that some cultures are wrong in believing that certain traits truly lead to an increase in eudaimonia, and are therefore wrong about them being virtues. This presents a circularity in reasoning for virtue ethics.

Before the circularity criticism is discussed, a defence can be made of one aspect of conflict: when two virtues are in conflict, not across cultures, but with one another in a situation. The third criticism is that situations are easily imagined in which two virtues can be in conflict in this manner. For instance, a police officer may apprehend a robber.

On hearing the robber’s story, it turns out that he stole food in order to provide for his starving children. The police officer must then decide whether to act on the virtue of justice, and arrest the robber who, despite the circumstances, has committed a crime, or to act on the virtue of sympathy and charity, and allow the robber to take the food and feed the starving children.

Hursthouse claims that “in such cases, virtue ethics has nothing helpful to say” (Hursthouse, 1991: 229). However, a response can be contested.

The degree of conflict can be very broad, dependent on the circumstances. In some situations, the correct answer is obvious; in the above case, it would be hard to justify not allowing a man a stolen loaf of bread to feed his starving children. In other situations, the degree of conflict can be much narrower, making the decision much more difficult. In keeping with the argument of virtue ethics, the correct decision is going to be the one which adds to eudaimonia.

If both traits will lead to an increase in eudaimonia, the correct choice will be the one which adds most to eudaimonia. As the difference in the amount of increase narrows, the choice becomes harder, but the moral recompense in choosing wrongly will be less.

Ultimately, if both virtues will increase eudaimonia equally, then they are equally the correct choice.

However, the most decisive criticism is that the argument which virtue ethics puts forward for what is morally right rests on a circularity. This is brought forward when it was demonstrated that virtue ethics necessitates the existence of some other criterion being the case in order that it can be said some cultures are right and others wrong in their approach to the implementation of virtues and what it is that they hold to be a virtue. If virtue ethics is to explain why some cultures are wrong in their implementation of the virtues, then their argument must work as follows: a culture is wrong because what they are advocating as right would not be done by the virtuous person. It would not be done by the virtuous person because the trait which leads to the action is not a virtue.

The trait which leads to the action is not a virtue because it would not add to the person’s eudaimonia.

The reason, then, that a culture is wrong, is because they are mistaken in assuming that the trait which would lead to the action is a virtue, because it will not add to the persons’ eudaimonia. It must therefore be considered what it takes for a trait to lead to an increase in eudaimonia. To this end, it must be claimed that a trait can only add to eudaimonia, and therefore be a virtue, because of something about the trait: if it is morally right. Herein is the circularity. Virtue ethics states that an action is right iff it is what the virtuous person would characteristically do in the situation.

However, it has already been shown that there must be something about a trait which is morally right in order that it can add to eudaimonia and therefore be a virtue, so that the virtuous person may act on it.

To avoid the circularity, for a trait to be morally right, there must be a criterion of rightness other than it is what the virtuous person would characteristically do in the situation. If such a criterion exists, virtue ethics’ argument becomes superfluous to explain what is right. In conclusion, the argument for virtue ethics’ account of what it is for an action to be right has been set forward.

Firstly, the positives to this argument were shown: that it avoids the rigidity of deontology and the atrocities of consequentialism. It was then criticised with four arguments: it is not action guiding; the difference in cultures’ morality; concerns when two or more virtues come into conflict; and the necessity for another criterion of rightness which, if accepted, renders virtue ethics unnecessary or, if rejected, leads to a circularity in virtue ethics.

Therefore, it is concluded that virtue ethics does not offer a convincing account of what it is for an action to be right.

Reference

Aristotle. (340bc). The Nichomachean Ethics.
Translated by Ross, D. Edited by Brown, L. (2009).
Oxford: Oxford University Press.
Hursthouse, R. (1991).
Virtue Theory and Abortion. In Philosophy and Public Affairs. Vol. 20, No.
3, pp. 223-246.
Hursthouse, R. (1996). “Normative Virtue Ethics”. In Ethical Theory: An Anthology.
Edited by Shafer-Landau, R.
(2013). Chichester: John Wiley & Sons, pp. 645-652.
MacIntyre, A. (1981).
The Nature of the Virtues. In The Hastings Centre Report. Vol. 11, No. 2, pp.
27-34.
MacIntyre, A. (2007).
After Virtue: A Study in Moral Theory. 3rd edition.
Notre Dame: University of Notre Dame Press.

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Photosynthesis Pigments Plant

Contents

Part A
Analysis
What factors are involved in the separation of the pigments?
Would you expect the R value of a pigment to be the same if a different solvent were used? Explain.
Part B
Purpose
Variables
Independent Variable
Dependent Variable
Control Variable
Measurement
Hypothesis
Procedures
Conclusion
Analysis
What is the function of DPIP in this experiment?
What molecule found in the chloroplasts does DPIP “replace” in this experiment?
What is the source of the electrons that will reduce DPIP?
What was measured with the spectrophotometer in this experiment?
What is the effect of darkness on the reduction of DPIP? Explain.
What is the effect of boiling the chloroplasts on the subsequent reduction of DPIP? Explain.
What reasons can you give for the difference in the percentage of transmittance between the live chloroplast that were incubated in the light and those that were leapt in the dark?
Identify the function of each of the cuvettes

Lab Four: Plant Pigments and Photosynthesis

Part A

Table 4.1: Distance Moved by Pigments Band (millimetres)

Band Number	Distance (mm)	Band Colour
1.	15	Yellow
2.	35	Yellow
3.	73	Green
4.	172	Olive Green
5.	-	-

Distance Solvent Front Moved 180 (mm) Table 4.2: .083334= Rf for Carotene (yellow to yellow orange) .194445= Rf for Xanthophyll (yellow) .405556= Rf for Chlorophyll a (bright green to blue green) .955556= Rf for Chlorophyll b (yellow green to olive green)

Analysis

Page 47-48 (1-3)

What factors are involved in the separation of the pigments?

The factors that are involved in the separation of the pigments are the pigments solubility, the formation of the intermolecular bonds, and the size of each individual pigment particle. Since capillary action is the method by which the solvent moves up the strip of paper, the attraction of the molecules to the paper and to each other molecule is essentially determined by those factors.

Would you expect the R value of a pigment to be the same if a different solvent were used? Explain.

No, because in different solvents, the solubility of the pigments would be different causing the Rf value to be different. In different solvents, the solvent rate would be affected, and since the rate is different, the distance travelled would also be affected, causing the Rf value to also be different. What type of chlorophyll does the reaction centre contain? What are the roles of the other pigments? Chlorophyll a is contained in the reaction centre. Because it is the primary photosynthetic pigments in plants, other chlorophyll a molecules, chloroplast b, and the carotenoids (carotenes and xanthophylls) capture light energy and transfer it to the chlorophyll a at the reaction centre. (College Board, 46)

Part B

Purpose

The purpose of this lab is to measure the effect of various conditions of chloroplast on the rate of photosynthesis or percentage of light transmittance. By using unboiled chloroplast in light, unboiled chloroplast in dark, and boiled chloroplast in light, DPIP was placed into each cuvette and a colorimeter was used to measure the rate of light transmittance. Since DPIP is the electron acceptor, as there is more light present, the DPIP absorbs more elections thus reducing the DPIP. Eventually the reduction causes the DPIP to change colour from a deep blue to a clear or opaque colour.

Variables

Independent Variable

The independent variable in this lab is the different forms/conditions of the chloroplast. These include boiled chloroplast in light, unboiled chloroplast in light, and unboiled chloroplast in dark.

Dependent Variable

The dependent variable in this lab is the rate/ level of light transmittance over a period of time measured by the colorimeter. From this data we can determine the rate of photosynthesis because as the DPIP becomes excited and reduced by the electrons, the colour changes indicating the rate of photosynthesis.

Control Variable

The control variables in this lab includes the type of cuvette, size of cuvette, type of buffer used, amount of phosphate buffer used (1mL), and the time intervals (min) used to measure the % or level of transmittance in the colorimeter.

Measurement

To measure the dependent variable, in this lab, a colorimeter and DPIP was used to determine the level of light transmittance. As the electron acceptor, DPIP was placed in each cuvette. Later after a certain interval of time, each was placed into a colorimeter which determined the level of light transmittance. As electrons were accepted, the DPIP became excited and reduced causing the color in the cuvette to also change, thus affecting the level of light transmittance as measured by the colorimeter.

Hypothesis

Since photosynthesis is the process by which plants, bacteria, and other autotrophic organisms obtain energy to produce sugars, the right conditions and the right environment are necessary in order to carry out this complex process. Based on prior knowledge and information from this lab, cuvette 3 will have the highest percent of light transmittance and the highest rate of photosynthesis. Since photosynthesis requires light and functional chloroplast to absorb and produce sugars, without either one, the process is interrupted and cannot function properly. Unboiled chloroplast will have a higher percent of light transmittance than boiled chloroplast because of the impact temperature has on the proteins/enzymes of the chloroplast. As high temperatures, like the boiling point, the heat generated will denature the enzymes/proteins thus reducing its effect on photosynthesis. Without functional chloroplast to absorb the energy from the light, the electrons will not be bumped to a higher energy level and will not be able to reduce DPIP. Of the two cuvettes with unboiled chloroplast, the cuvette place in front of the light will have a higher percent of light transmittance than the cuvette placed in the dark because with light, energy can be absorbed, DPIP can be reduced, ATP can be created, and photosynthesis can be carried out. Similar to functional chloroplast, light is another essential component of photosynthesis, without light photosynthesis cannot occur. Therefore, the cuvette placed in the dark may have functional chloroplast but without light to provide the necessary energy, the reaction will either occur very slowly or not at all. Finally, the cuvette with no chloroplast will not photosynthesize at all, because without chloroplast to absorb the energy from the light, the solution will not carry out photosynthesis.

Procedures

First, a beaker of water was positioned between the samples and the light source which was to be the heat sink. Next, an ice bath was created to preserve the phosphate buffer and chloroplast by filling an ice bucket with ice. Then, before the cuvettes could be used, they had to be cleaned out with lint free tissue to ensure the light transmittance goes smoothly and uninterrupted. Before anymore is done with each cuvette, both boiled and unboiled chloroplast were obtained in pipettes and place in the ice bath inverted. Next, of the five cuvettes labelled 1 to 5, cuvette 2 had a foil container constructed for the sake of keeping light out of the solution. Each cuvette then received the corresponding amount of phosphate buffer, distilled water, and DPIP. The colorimeter was then set up by starting up the computer program that would read the colorimeter and was linked accordingly. The first cuvette received three drops of unboiled chloroplast, and then shaken up and placed in the slot of the colorimeter. The first solution would be the first calibration point of reference for the colorimeter at zero percent light transmittance. Following the setting of the first calibration point, the second calibration point was also set. In cuvette 2, three drops of unboiled chloroplast was added and immediately timed with a stopwatch and the light transmittance was recorded. The same cuvette was encased with the foiled created earlier and then placed in the light. Cuvette 3 also received three drops of unboiled chloroplast at which the time and the light transmittance was also recorded. Right afterwards, the cuvette returned to the light. Cuvette 4 received three drops of boiled chloroplast at which the time and the light transmittance was also recorded. Just like cuvette 3, cuvette 4 was returned to the light. Curette 5 the control would receive no chloroplast but still has the time and light transmittance recorded. The light transmittance for each would continue to be recorded at an interval of every five minutes (5 minutes, 10 minutes, 15 minutes) following the same procedure until all data had been collected.

Conclusion

The process of photosynthesis is described as the conversion of light energy to chemical energy that is stored in glucose and other organic compounds. Essential to the development of plants and animals, light from the sun or from an artificial source is necessary for this process to occur and to carry out its benefits. Having performed this lab, the results obtained supports this concept and it also supports my hypothesis. After gathering all the data, cuvette 3 did have the highest percentage of light transmittance and the fastest rate of photosynthesis. Because of the unboiled chloroplast in the cuvette absorbing the light and a light source available to provide energy to reduce the DPIP, the conditions were right for photosynthesis to occur. In cuvette 3, photosynthesis did occur because when the light shined on the unboiled chloroplast, the electrons were excited and moved to a higher energy level. This energy was then used to produce ATP and to reduce DPIP causing the solution to change colour creating a higher and faster rate of photosynthesis/light transmittance. This cuvette essentially showed that light and chloroplast are needed in order to carry out photosynthesis. Although the graph may show the rate of photosynthesis slowing down, the reason why the curve begins to slow down and level off is not because of photosynthesis but because as the process of photosynthesis occurs, the DPIP will begin to be used up causing the reaction to slow down and level off. Cuvette 2 showed different results in that no photosynthesis occurred because there was no light present for the chloroplast to absorb and to reduce the DPIP. Photosynthesis requires light but without out light, photosynthesis could not occur causing essentially no change in the cuvette. The data table and graph does show that there were some change in the rate of photosynthesis but that occurred because since we had to take the cuvette out of the aluminium sleeve to place in the colorimeter, the DPIP broke down because of the brief exposure to the light. However, overall, the data shows that because there was no light present, photosynthesis could not occur causing no change. Cuvette 4 also showed little increase or change in the percentage of light transmittance because since the cuvette had boiled chloroplast, the high temperatures denatured the proteins/enzymes found in the chloroplast rendering them ineffective. Because the light could not be absorbed by the chloroplast, photosynthesis could not occur or it occurred at a very slow pace. Similar to cuvette 2, the date table and graph also shows that there were change in the percentage of light transmittance in cuvette 4 but because the DPIP was exposed to the light, the DPIP did break down causing a slight change in the rate of light transmittance. Essentially, this cuvette showed that chloroplast in addition to light is required for photosynthesis. Cuvette 5 also showed no change in the percentage of light transmittance because without the presence of chloroplast, the light could not be absorbed to excite the elections and to reduce the DPIP. Without the functions of chloroplast, photosynthesis could not occur because the DPIP would not be reduced and ATP would not be created. Any fluctuations in the data or graph for cuvette 5 could be explained by human or data error.

Analysis

Page 52-53 (1-8)

What is the function of DPIP in this experiment?

The function of the DPIP in this experiment is to act as the electron acceptor, replacing the usual NADP found in plants. When the light shines on the active chloroplasts, the electrons are excited, which causes them to jump to a higher energy level thus reducing the DPIP. As the DPIP is reduced, the colour changes from deep blue to colourless, which affects the rate and level of light transmittance when measured by the colorimeter.

What molecule found in the chloroplasts does DPIP “replace” in this experiment?

DPIP in this experiment “replaces” the electron acceptor NADP

What is the source of the electrons that will reduce DPIP?

When the light shines on the chloroplast, the light provides enough energy to bump the electrons to a higher energy level thus reducing the DPIP. The source of the electrons can also come from the photolysis of water.

What was measured with the spectrophotometer in this experiment?

The spectrophotometer in this experiment is used to measure the percentage/level of light transmittance through the cuvette based on the amount of photosynthetic activity.

What is the effect of darkness on the reduction of DPIP? Explain.

Because there is not an absence of light shining on the chloroplast, the DPIP could not be reduced because there was no or not enough energy to excite the electrons and move them to a higher energy level in order to reduce the DPIP.

What is the effect of boiling the chloroplasts on the subsequent reduction of DPIP? Explain.

Similar to the effects of darkness, by boiling the chloroplast, the proteins were denatured by the high temperatures which caused the process of photosynthesis to be slowed down and inhibited. Because the chloroplast could not absorb light and perform its job, the DPIP could not be reduced which reduced the percentage/level of transmittance.

What reasons can you give for the difference in the percentage of transmittance between the live chloroplast that were incubated in the light and those that were leapt in the dark?

Because light is essential for photosynthesis, the chloroplast placed in light was able to reduce DPIP and perform photosynthesis. As the chloroplast absorbed the light, the energy absorbed, pushed the electrons to a higher energy level which caused the DPIP to reduce. As the DPIP reduced, the colours changed and the rate of light transmittance was higher. In the dark chloroplast, however, because there is no energy source for the chloroplast to use and since the DPIP could not be reduced due to the lack of light energy, the percentages of light transmittance were lower.

Identify the function of each of the cuvettes

Cuvette 1: Cuvette 1 was used to measure how the absence of DPIP and chloroplast affected the percentage of light transmittance. This cuvette was also used to calibrate the colorimeter. Cuvette 2: Cuvette 2 was used to measure how the lack of light and unboiled chloroplast affected the percentage of light transmittance. It essentially showed how important light was to the process of photosynthesis. Cuvette 3: Cuvette 3 was used to measure how light and unboiled chloroplast affected the percentage of light transmittance. It essentially showed how light and active chloroplasts are needed to carry out the process of photosynthesis. Cuvette 4: Cuvette 4 was used to measure how light and boiled chloroplast affected the percentage of light transmittance. It essentially showed how the denatured proteins in the chloroplast prevented the light to be absorbed and the process of photosynthesis to be carried out. Cuvette 5: Cuvette 5 is the control of the experiment and is used to show how the availability of light but absence of chloroplast will prevent the process of photosynthesis from being performed and its effect on the percentage of light transmitted.

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Conservative Labour Party

Contents

Is Britain's two-party system in decline?
Introduction
History
Political Party's Agenda In Britain
Labour
Liberals
Why they have given up their seats to Liberals?
The Theory of power among two main British parties
Conclusions
The system is not two-party system today
The system is not unstable
The future developments unpredictable
Bibliography

Is Britain's two-party system in decline?

Introduction

A two party -system has existed in the United Kingdom since the late 17th century. Based on the evidence, since the mid 1920s until present, the dominant groups are the Conservative party and the Labour party. So There are also some smaller parties exist in the united kingdom e.g. The Liberal Democrats, the green party, the British, Scottish and Walsh nationalist parties, who are representing the minorities in the UK parliament. But the Welsh and Scottish nationalist parties are the dominant in the Wales and Scotland. However, I will be writing on the Britain's two-party system to see the system is developing or in decline? I think this topic is very interesting, because the past histories of political parties in Britain gives us the notions of how to discover that the two-party system is developed or whether in decline. Thus, as many intellectuals and politician are arguing that, there is different type of political systems exist in Britain. In order to find out or to understand the system, I will exclusively focus on the Conservative and Labour parties, as they have been the dominant parties since the 20th century until now. This essay will argue that why still some politicians and intellectuals in Britain have called the British political system is a two-party system? And what are their suggestions today? Well, for finding the facts and realities, I follow the ideas of some British politicians who have used their initiatives to examine the British politics on way of whether the British political system is a two-party system or the system in decline. For these ideas, the evidences to be used to show the argument is more clear. However, this essay will demonstrate the distinct between the Labour Government and Conservative government through the 20th century. Also, I am going to argue that the roles of the opposition parties are very important, because they have been contributed a lot to the government, which they are still struggling to make a strong and powerful opposition in parliament, so the recent and past elections are the clear guidance and leads us to the truth. So the roles of the electoral system are very crucial, therefore I had used my initiatives in order to gain relevant information relating to the topic. The arguments in this essay are based on the searches and readings that I have carried out during this essay writings. The debates within this essay are theoretical and empirical prospective in comparison with the past and present political developments and failures. Political system in Britain has always formed the government, the dominant party in parliament has the right to form the government policy for five years period during each election and represent the United kingdoms foreign policy too. Alderman's study of “1989 contemplated the possibility that Britain now had a one-party system similar to that of Japan.” But I think Alderman is totally wrong, because the political system in Britain in not a one-party model, because the vast majority of electors supported either the labour or conservative parties at a “general election- as in 1951 when the combined two-party votes were as high as 69.8 per cent”. (Garner& Kelly p12) Until 1974, the two parties' share of the vote was never much below 90 per cent, while the third party vote never exceeded the 11.2 per cent. But they did not prevent either of two major parties from governing alone, as they were unable to gain appropriate percentages of the votes from the public to influence the Westminster policy. However, as I noted from the past and recent elections, the margin between the two major parties were always closed enough, so the party in opposition had not a chance to share the power with the governing party. However, on this essay I am going to demonstrate the facts that led those two parties to win the elections and maintain as a dominant parties within the British society. For finding the facts and realities that lies on the political systems, we cannot ignore the past history of British politics. Therefore, it is very important to look over it in brief details.

History

“In recent years, there has been a great deal of argument and confusion concerning the true character of Britain's party system. This represents a sharp contrast with the situation obtaining for most of the post-war period, when Britain's two-party system was widely considered a supreme example of two-party model. “Writing in 1962, Ivor Jennings suggested that there was a natural tendency for Britain to have a two-party system, while in 1968 R. M. Punnett agreed that such a system was the logical outcome of both the Westminster model of Parliamentary democracy and the pattern of political debates in Britain”. 1n 1977, Drucker suggested that Britain's party system had become ‘multi-party' in character, citing in 1974 general elections as evidence. Three years later, an introductory chapter by S. E. Finer implied that the 1979 election had highlighted that Britain's was, in essence, still a two-party system. The emergence of the SDP-Liberal Alliance in 1981 prompted further conflicting speculation. By 1985, for instance,” Berrington believed that the system is three-party system. However, Benyon indicating in 1987 election the system is two-party systems not a three. “In 1988, however Crewe suggested that the three-party system Britain has known since 1981 is dead; while Alderman's study of 1989 contemplated the possibility that Britain now had a one-party system similar to that of Japan.” To make sense of these confusions, it is necessary to clarify each point that most scholars of British politics period to 1974 has appointed. There are in fact no three-party systems exist among British Politics, because the two main parties play a central and essential role in the political life. That is why Britain is often presented as a pure and perfect model of a two-party system at the time. Britain for the most of the post-war period had a classic two-party system, because the social class was the main foundation of the two-party system. “Since 1970s this system has come under persistent pressure, with the growth of support for a wider range of political parties; the impact of centre parties like the Liberals. Yet it has not been just the centre parties have benefited from the fragmentation of party support. The Scottish National party has commanded between 11 and 30 per cent of votes in Scotland in the last seven general elections, winning 11 seats and more votes than the conservative in October 1974. In Wales, Plaid Cymru has secured on average 8 per cent of votes at elections since 1970 and has become a veritable force in Welsh-speaking constituencies. The Green Party achieved almost 15 per cent of the votes in Britain at the 1989 European elections, a performance reflected and often battered by many of its members contesting local elections in the late 1980s. In the late 1970s, there was even increased support for the National Front, which came third in the three by-elections in the 1976 and 1977 while polling up to 17 per cent in certain local elections” (Garner& Kelly p4). Recent electoral movements in Britain appear to bring that country gradually nearer towards multi-party system, the slow decline of the Labour and Conservative parties have tended to conform to this model.

The implication of cold war on British political parties

How the cold war divided the ideologies in Britain?

What was the cause of dividing?

What was the consequence of the cold war?

Emerging the new political parties

Political Party's Agenda In Britain

what were their agendas

the agenda of Conservative

Labour

The introduction of devolution by the Labour party since 1997 has regionalised democracy even further and has resulted in the emergence of small nationalist parties such as the SNP in Scotland, Sinn Fein in Northern Ireland and Plaid Cymru in Wales, which have nope chance of holding government in Westminster but do receive a great deal of local support. Therefore at local and even devolved level, the UK can be classed as possessing the qualities of a multi party system. However at national level, this idea seems implausible as the vast majority of seats are shared by only two or perhaps three parties and therefore the smaller parties can be considered to have very little effect on the overall political situation. In conclusion, the UK can still best be described as a two party system, provided two considerations are taken into account. The first is that Conservative dominance victories between 1979-97 was not a suggestion of party dominance and that eventually, the swing of the political pendulum will be even for both sides. This can perhaps be seen today with Labour's two landslide victories in 1997 and 2001

Liberals

Why they have given up their seats to Liberals?

The Theory of power among two main British parties

“As McKenzie aim to assess the relevance of Michels's theory to the distribution of power within the two main British parties, He concludes, in line with Michels, that authority in both parties rests with parliamentary party and its leadership and that the role of the party outside parliament is limited to vote-getting rather than policy-making. Thus, McKenzie seeks to dispel what the sees as the myth that Labour Party, unlike the Conservative Party, is internally democratic. McKenzie argues that both parties have a similar power structure because they both accept the rules and convictions which govern the British political system. Thus, both parties accept that party leaders must exercise absolute power in the choice of their Cabinet colleagues and that MPs must be responsible to the electorate and not the extra-parliamentary party.” (Garner& Kelly p8)

Conclusions

The system is not two-party system today

Since the mid-1920s the dominant groupings have been the Conservative Party and the Labour Party. However, several smaller parties e.g., the Liberal Democrats, the Scottish and Welsh nationalist parties, and loyalist (unionist) and republican (nationalist) political parties in Northern Ireland - have gained representation in Parliament, especially since the 1970s. The two-party system is one of the outstanding features of British politics and generally has produced firm and decisive government.

The system is not unstable

And the decline of the two major parties was such that Britain appeared to have moved into the exceptional and seemingly transitional position of a 'genuine' three party system. If the proposition advanced earlier is correct, it would seem that in the next few years Britain will move to one of three types of further changes. The Liberals could return to their 'normal' position of small party; they could displace one of the two major parties, a split could occur among the supporters of one or both of the major parties and Britain might move from the two-party systems to the third or multi-party systems.

The future developments unpredictable

As the title indicates, this is a state in which just two parties dominate. Other parties might exist but they have no political importance.

Bibliography

*Garner, R.; Kelly, R. (1993) British political parties today (Manchester: Manchester University Press). *Punleanvy, P.; Gamble, A.; Holliday, I.; Peeple, G. (2000) Development in British Politics 6 (New York: St. Martin's Press). *Peter Mair (1990) The West European Party System, ed (Oxford: Oxford University Press), pp. 302-310

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Essay on Loss Supported by Relevant Academic Sources

Contents

Choose one event on loss and construct an academic essay supported by relevant academic sources

Choose one event on loss and construct an academic essay supported by relevant academic sources

INTRODUCTION

This essay explores my experience of loss and grief after the death of my father in 1997 and how my grieving process relates to theories put forward to explain and deal with bereavement. Hall (2014) suggests that "loss and grief are fundamental to human life"..Harvey (1998) perceives loss as a life experience relating to something irreversible and emotions towards what is lost. Hall (2014) defines grief as "the response to the loss in its totality – including its physical, emotional, cognitive, behavioural and spiritual manifestations – and as a natural and normal reaction to loss". It has been argued that in order to understand grief it is important to understand the role of attachment. Mallon (2008) observed that in order to have loss there must be attachment. As a result many theories of attachment play a major role in bereavement counseling. Bowlby (1980) emphasised the role of attachment in relationships. He suggests that a child's emotional growth will be compromised if the child does not have attachment to a significant other person. The consequences can be that the individual may have difficulties connecting with others. This essay will first explore some of the salient theories on grief and bereavement. Secondly, a discussion of my experiences grieving my father's death drawing on some key elements of bereavement theories will follow. Finally, a summary of the discussion will conclude the essay.

THEORIES OF BEREAVEMENT AND LOSS

Freud (1953 – 1974) was the first major contributor to the theory of grief. His theory stressed that grieving individuals search for an attachment that has been lost. His work involved the process of breaking the links that bonded the survivor to the deceased. He identified three elements namely:

Freeing the bereaved from the bondage to the deceased
Readjustment to life without the deceased
Building new relationships.

Parkes (1971, 1996) argued that Freud's concept of grief was useful in considering grief to be part of a rebuilding process which he calls 'psychosocial transition'. Freud (1953-1974) argued that the grieving experience for the bereaved requires that they acknowledge their separation from the deceased by going through a process that includes painful emotions of guilt and anger. Furthermore, these emotions must be expressed. Key to Freud's approach was the idea that if the bereaved failed to work with or complete their grief work, then the grieving process would become complicated and compromise recovery. This model stresses the importance of moving on as quickly as possible in order to return to 'normal' functioning. Influenced by Freud (1953-1974), several grief theorists including KA¼bler Ross (1969), Bowlby (1980) and Parkes & Weiss (1983) conceptualised grief as a process of predictable phases and tasks. One of the most recognised was KA¼bler Ross (1969), who proposed the five-stage model that constituted the following stages:

Shock and denial
Anger
Resentment and guilt
Bargaining
Depression and Acceptance.

The model insists that failure to complete the stages would result in acute mental health complications. Hall (2014) argues that the stage theories were popular because they suggest a sense of conceptual order while offering hope of recovery and closure. Despite their popularity, most stage theories attracted criticism in the same way that Freud's proposition attracted criticism for their lack of empirical evidence and their rigidity. Furthermore, the stage theories have been challenged for their inability to capture the complex, diverse and multi-faceted nature of the grieving experience. Baxter and Diehl (1998) argue that since grief is considered to be fluid, it is unlikely that individuals are able to go through the stages in a methodical manner as advocated by the stage theorists. In short, they do not take account of factors such as the physical, psychological, social, cultural and spiritual needs that impact on the bereaved people, their families and intimate networks (Hall 2014). Despite these criticisms, early stage theories have provided great groundwork and influence on current theories such as the Dual-Processing theory developed by Stroebe and Schut (1999) and Worden (2008). Hall (2014) argues that "these theories take account of many of the risks and protective factors identified by research and provide an important context for appreciating the idiosyncratic nature of attachment to the deceased that is lacking in the earlier stage theories". Both models provide frameworks that guide intervention. Richardson and Balaswamy (2001), when evaluating the Dual Processing Model, suggested that avoiding grief can have both positive and negative outcomes. They proposed that this is where bereavement is perceived as including Loss of Orientation and Restoration Orientation. The griever in the loss-orientation is preoccupied with emotions, yearning and ruminating about the deceased, whereas, restoration orientation involves taking over the responsibilities and the roles undertaken by the deceased and making lifestyle changes, setting up a new identity without the deceased (Richardson, 2007; Bennett, 2010a). Worden (2008) suggests that grieving should be considered as an active process that involves engagement with four tasks:

Accepting the reality of the loss
Processing the pain of grief
Adjusting to a world without the deceased (including both internal, external and spiritual adjustments)
Finding an enduring connection with the deceased whilst embarking on a new life.

To understand what the client is experiencing, Worden identified seven determinants that need to be considered:

Who the person who died was
The nature of the attachment to the deceased
How the person died
Historical antecedents
Personality variables
Social mediators
Concurrent stressors

EXPERIENCES OF GRIEF

In discussing my grieving process, I am going to draw on Worden's (2008) four tasks indicated above. The seven determinants indicated above will be used to guide the discussion and interpret the experience utilising relevant theoretical perspectives. i. To accept the reality of the loss I was in the UK undertaking my nursing course when my father died in Zimbabwe from a sudden heart related problem. I was informed early in the morning soon after my brother received news of his death. Since I was living alone, I had to make several phone calls home to confirm his death and to ascertain how he died and establish why more was not done. I remember crying but the tears did not correspond to my emotions. For a long time I felt detached from my feelings. My emotions appeared to be bottled up and were difficult to release. My immediate response to the news reflects Bowlby and Parkes (1970)'s proposed first stage of grief where the individual experiences numbness, shock, and denial. I had always dreaded the day my father would die. I remember pacing up and down my bedroom, feeling very alone and helpless. During one of the calls from my brother, he mentioned that he needed me there. That was the time that I realised that this was real. It was at this moment that I started to call friends and informing them of the news. I cannot remember most of what happened but I remember one of my friends took over and made the necessary travel arrangements and spoke to my family in Zimbabwe. I believe that I only accepted the loss much later when I found that I could not share with him that I had bought a beautiful house. I desperately needed his comments and praises. My letter with the surprise information and pictures was in the post box when he passed away. ii. To process the pain of grief I believe I experienced the pain of losing my father when I returned to the UK after going through three weeks of the funeral and other rituals related to death in my culture. The cultural rituals are a mixed bag of tears, laughter, praying, singing and sharing memories and kinship with the deceased. This, to a large extent, eased me into the grieving process. However, the real pain of his loss took place when I returned to the UK where I could grieve in private. I found myself avoiding friends and other associates. It was as if my identity had been taken away and that made me tearful. This echoes the suggestion by Caserta and Lund (1992) that the bereaved may have to redefine their identity. Prompting questions like 'Who am I now that I am no longer a daughter?' Hall (2011) and Caserta and Lund (1992) suggest that this can set in motion a process of re-learning ourselves and the world. On reflection, friends and associates reminded me of "the me" that I had lost. The pain would come and go. I often cried on my own. The crying and anxiety concurs with Bowlby's proposition that loss of the affectional attachment results in emotional disturbances such as anxiety, crying and anger (Freeman, 2005). I experienced this for over a year and felt lost. Although functioning, I was no longer myself. I started having frequent dreams of my father and would look forward to going to bed where I could be with my father. iii. To adjust to a world without the deceased It is difficult to identify exactly when it was that I adjusted to a life without my father. It took a long time. Although we lived far from each other, my father played a major role in most of my decisions and reassurances. Two events contributed to my adjustment. Firstly, my mother encouraged me to register for a Masters course that I was talking myself out of. Suddenly, I saw my father's qualities in her. The security and trust I had in my father had transferred to my mother. Secondly, crying uncontrollably at a church in the UK the day I received news that my brother had died in a car accident. On reflection I realised that although I was crying for the loss of my brother, I was also finally crying for my father. Taking over care for my brother's children added to the adjustment of living without my father. iv. Finding an enduring connection with the deceased whilst embarking on a new life Being ancestral believers, the bond between my late father and me remains but it manifests in a different form to the bond we had when he was alive. I believe that spiritually, my father and my forefathers protect me and help me achieve my ambitions by chasing away bad spirits and creating luck and opportunities for me. My family and I participate in cultural rituals in remembrance of him and our forefathers. Psychologically, my bond with my father remains as he continues to be my role model. As a result, I dedicate most of my achievements to him. This continued connection and perceived role played by my father 18 years after his death confirm Datson and Marwit's (1997) argument that continued bonds with deceased can have positive outcomes. Therefore, letting go is not necessarily the requirement for successful grieving. According to Hall (2014) "this idea represents recognition that death ends a life, not necessarily a relationship".

CONCLUSION

The discussion above illustrates that the theoretical perspectives of loss and bereavement have developed from emotional attachment to more holistic approaches. These theories not only carry on the influences of the early work focused on emotions and attachment but take account of the social, economic, cultural and spiritual needs experienced by bereaved people. Significantly, these theories do not center 'letting go' as a requirement of successful grieving. On the contrary, a continued bond with the deceased can be positive. My experience largely confirmed the complexity of the grieving process. Some of the experiences indicated above confirmed some of the early theorists observations such as the emotional rollercoaster and the early stage theorists' suggestions of shock in the early stages. I did not however experience the full stages of grieving in chronological order, and the experience was by no means quick. Factors such as my culture and spiritual beliefs contributed significantly to my grieving process and influenced the outcome of my continued bond with father. In view of this it can be argued that there is a place for the different approaches to loss and bereavement in supporting bereaved people. However, the multi-cultural society encouraged by globalisation requires that we take account of the wider aspects of the bereavement process.

REFERENCES

Baxter, E. A. and Diehl, S. (1998). Emotional stages: Consumers and family members recovering from the trauma of mental illness. Psychiatric Rehabilitation Journal, 21(4) Bennett, K. M. (2010a). "You can't spend years with someone and just cast them aside": Augmented identity in older British widows. Journal of Women and Aging, 22, (3), 204-217 Bennett, K. M. (2010b). How to achieve resilience as an older widower: Turning points or gradual change? Ageing and Society, 30 (03), 369-382. Bowlby, J. (1980). Attachment and loss. Volume 3, Loss, sadness and depression. New York: Basic Books Bowlby, J. and Parkes, C. M. (1970). Separation and loss within the family. In E. J. Anthony & C. Koupernik (Eds.), The child in his family: International Yearbook of Child Psychiatry and Allied Professions (pp. 197-216), New York: Wiley Caserta, M. S. and Lund D. A. (1992). Bereavement stress and coping among older adults: Expectations versus the actual experience. Omega, 25, 33-45. Datson, S. L. and Marwit, S. J. (1997). Personality constructs and perceived presence of deceased loved ones. Death Studies, 21 , 131 -146 Freud, S. (1953/1974). Mourning and melancholia. In J. Strachey (Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 14). London: Hogarth. (Original work published in 1917.) Freeman, S. (2005). Grief and Loss: Understanding the Journey. Belmont, CA: Thompson Brooks/ Cole. Hall, C. (2011). Beyond Kubler-Ross: Recent developments in our understanding of grief and bereavement.Retrieved June 19, 2015, from https://www.psychology.org.au/publications/inpsych/2011/december/hall/ Hall, C, 2014. Bereavement theory: recent developments in our understanding of grief and bereavement, Bereavement Care, 33:1, 7-12, .Retrieved June 19, 2015, from:https://www.psychology.org.au/publications/inpsych/2011/december/hall/ Harvey J. H. (1998). Perspectives on Loss, a Sourcebook. Philadelphia, PA: Taylor and Francis KA¼bler-Ross, E. (1969). On death and dying . New York: Springer Mallon, B. (2008). Attachment and loss, death and dying. Theoretical foundations for bereavement counselling. In Praise for the Book: Dying, death and grief: Working with adult bereavement. (pp. 4-17). London: SAGE Publications Ltd. Parkes, C. M. (1971). Psycho-Social Transitions: A field for study. Social Science and Medicine, 5. 101-115 Parkes, C. M. (1996). Bereavement: Studies of Grief in Adult Life (3rd Ed.). London, London: Routledge Parkes C. M. and Weiss R. S. (1983). Recovery from bereavement. New York: Basic Books. Richardson, V. E. (2007). A dual process model of grief counseling: Findings from the Changing Lives of Older Couples (CLOC) studyJournal of Gerontological Social Work, 48 (3/4), 311-329. Richardson, V. E. and Balaswamy, S. (2001). Coping with bereavement among elderly widowers. Omega: Journal of Death and Dying, 43 (2), 129-144. Stroebe M. S. and Schut, H. (1999). The dual process model of coping with bereavement: rationale and description. Death Studies 23(3) 197-224. Worden J. W. (2008). Grief counseling and grief therapy: a handbook for the mental health practitioner (4th ed.). New York: Springer

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Identifying a Patient, Stating the Reason for Admission/appointment

Contents

Identify a patient, stating the reason for admission/appointment.

Identify a patient, stating the reason for admission/appointment.

Identify a patient, stating the reason for admission/appointment. It must be on diabetes. Describe a specific problem that has been highlighted through the assessment process. Explore factors that may have led to their hospital admission/appointment. This could include physical psychological and social aspects.

Case details

In this essay we shall discuss the case of Mrs Singh. She is an elderly lady of 76 yrs. old. Who lives in warden assisted accommodation. She has done so for the last ten years since her husband died. She has had Type II diabetes mellitus for the last 17 years, and copes reasonably well considering her age and her comparative infirmity. She has been able to go out and get her shopping from the nearby shops and is otherwise self-caring, clean and tidy. According to the referral letter from her General Practitioner, who arranged this admission to hospital, a number of people had recently commented that she looked ill and was not caring for herself as well as she used to do. Her family live a considerable distance away from her and, although they see her about once or twice a month, they do not stay for long as they have a business to run. When she was admitted she was found to be lucid and coherent but her family told us that she had had a number of episodes of confusion recently. She was occasionally very sleepy and had left the gas burning on one occasion. She had a large infected ulcer on her left shin, which had clearly been there for a matter of weeks, but because of her habit of wearing long skirts, no one had noticed it. She had a degree of ankleoedema, but her physical examination was otherwise unremarkable, apart from the fact that she had a BMI in excess of 29. She is a moderate smoker.

Discussion

Mrs Singh as an individual is clearly unique, but sadly, she also represents a great many elderly diabetic patients who live in similar conditions. The thrust of this particular discussion will be the aetiology and management of her condition with particular relevance to her leg ulcer. Diabetes Mellitus, an overview Diabetes is a comparatively common disease process in the UK. In children it is the commonest major illness (after childhood infections). There are approximately 1.5 million diabetic patients in the UK at present and the number is relentlessly increasing. (Devendra et al 2004). The 1.5 million are not equally spread across all segments of the population. People from the Asian and Afro-Caribbean ethnic backgrounds have a markedly increased risk of developing Diabetes Mellitus (UKPDSG 1998) with one in four of all Afro-Caribbean women over the age of 55 being diabetic. (Nathan 1998). Increasing age and BMI also are both independent risk factors for Diabetes Mellitus (James 1997). Of this number, it is expected that about 10% will develop some form of lower limb ulceration while they are diabetic. (Amos et al 1997). To some extent, it is statistically more likely that those patients who have poor control of their diabetic state will develop ulceration (and other complications) than those patients who have good control. The other factor that is relevant in the aetiology of leg ulceration is the length of time a person is diabetic. Chronicity of the disease process is an independent variable for leg ulceration. (Simon P et al 2004). A number of authorities have estimated the burden of cost of Diabetes Mellitus to the NHS. A recent study by Newrick (et al 2000) considered that 9% of the total NHS budget was spent on diabetes and diabetic related issues. By far the biggest single portion of that amount (over half) was on the treatment of complications and the commonest clinically relevant complication is that of venous ulceration (Ellison et al2002) We can start by considering the pathophysiology of Diabetes Mellitus

Pathophysiology

This is a huge subject in its own right and we shall therefore present a brief overview as far as it is relevant to Mrs Singh. In broad terms Diabetes Mellitus is a condition where the body loses the ability to metabolise carbohydrates in general and glucose in particular. Glucose is absorbed from the gut, transported to the liver where is can be stored as glycogen, and then transported through the bloodstream to the cells in the periphery of the body, where it is one of the main metabolic substrates. It is absorbed from the blood into the cells by a specific molecular carrier system and this is totally insulin dependent. If there is a failure of insulin production, then the circulating level of insulin falls and the glucose is not transported into the cells. This leads, initially to hyperglycaemia and finally to ketosis and metabolic failure. This is the situation of Type I diabetes mellitus. The alternative is Type II diabetes mellitus where the cells lose the ability to respond to the circulating insulin levels. This also results in hyperglycaemia and eventual metabolic failure but is characterised by high levels of circulating insulin. In general terms, Type I diabetes mellitus is a comparatively acute illness whereas Type 1 diabetes mellitus tends to be far more chronic, sometimes taking many months or even years to become clinically apparent. (after Donnelly et al 2000)/ The complications of Diabetes Mellitus are many. The largest group are the micro- and macro vascular group of the cardiovascular complications. (Stratton I et al 2000). The macro vascular group are usually related to the process of atherosclerosis and present with either degrees of myocardial is chaemia or as peripheral impairment such as intermittent claudication or ulceration. In general terms the incidence of this type of complication is directly associated with the average levels of HbA1 (which is a long term indicator of diabetic control) (HSG 1997).

Nursing interventions

The major nursing intervention to discuss here is the management of the leg ulcer. In any medical intervention its important to establish a sound evidence base (Sackett, 1996). We shall therefore quote the literature relevant to each point. The first, and arguably most important consideration is whether the ulcer is primarily venous, arterial or (more rarely) neuropathic in origin. This is comparatively easily determined by an assessment of the ankle/brachial pressure ratio. This is measured by means of a Doppler measure and the ratio is easily calculated. If it is less than the critical level of 0.8 it is likely that an significant arterial element is present.(Partsch H. 2003). Mrs Singh was treated with a 4 layer bandage. Her ratio was significantly above the 0.8 threshold and the main aetiology of her ulcer was therefore judged to be venous. The composition and construction of a 4-layer bandage is very specific but it can be individually modified to suit the demands of the individual patient. The first layer is a cotton wool based bandage with the primary purpose of absorbing the copious amounts of exudates that are common with this type of ulcer. It also has the secondary purpose of spreading the pressure evenly across the underlying tissues the second layer is a crepe bandage which has the prime function of holding the lower layer in place. The third layer is a compressive layer, usually an elastic type of bandage is then applied and this is covered by a final binding layer. (Nelsonet al. 2004). The rationale behind the bandage is that in the typical diabetic venous ulcer there is an increased pressure at the venous end of the capillary bed which translates into stagnation in the capillary blood flow which renders the tissues less viable because of poor oxygenation. By exerting physical pressure of about 40 mm Hg on the tissues, this increase of venous pressure is negated and the circulation improved.(Thomas S. 2003). Clearly it follows that in an arterial ulcer, as there is a reduction in the arterial pressure at the arterial end of the capillary bed, any increase in physical pressure could further reduce the blood flow across the capillary bed, which is why it is vital to differentiate between the two types before applying the bandage.(Marston W et al. 2003). The second main nursing intervention, and possibly more beneficial in the longer term, would be the Health Promotion aspects of the nursing relationship. Mrs Singh is overweight. Her BMI is about 29 which means that her weight is not only contributing to the reduction in venous return, and thereby contributing to both the aetiology and the persistence of her ulcer, but the obesity is also a major factor in the aetiology of her Type II diabetes mellitus. If Mrs Singh can be persuaded to reduce her weight, her need for hypoglycaemic medication may well lessen. It is possible that it may reduce to the point that she could manage her condition on diet alone. (Terry T-K et al 2003). Smoking is not only an independent risk factor for Type II diabetes mellitus, but it is also a risk factor for cardiovascular disease. A major health promotion measure would therefore be to help Mrs Singh to give up smoking. This is not a short term measure, so is not particularly suited for hospital intervention, although the nursing staff spent a considerable amount of time with Mrs Singh to explain the problems associated with smoking. (Marks-Moran & Rose 1996). On discharge she was referred to, and seen by, the smoking cessation nurse at the local primary healthcare team. The whole concept of patient empowerment and education is most important in this field. If a patient understands why they are being asked to do something, they are much more likely to comply with the request from the healthcare professional (Marinker M.1997). The weight reduction needs to be carefully managed if it is to be successful. She was referred to the dietician who prescribed a low fat, carbohydrate regulated, 1,200 cal. per day diet. Because this is clearly going to be a long term intervention, arrangements were made for Mrs Singh to be followed up in the community dietetic clinic. Mrs Singh was in hospital for seven days when the multidisciplinary discharge team were able to arrange her discharge. This involved the assistance of an occupational therapist to assist with minor home modifications and the community nurses who continued the treatment with the 4 layer bandage. (Harrison, I. D et al 2005) The diabetic specialist nurse was also involved. As Mrs Singh's weight slowly reduced she was able to reduce and finally come off her hypoglycaemic medication.

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Mental Health: Simone Case Scenario

Contents

Mental Health: Simone Case Scenario
- Bibliography

Mental Health: Simone Case Scenario

Dual diagnosis, co morbidity and co-occurring disorders are terms often used interchangeably to describe mental ill health and substance abuse (drugs and/or alcohol) in various combinations. These disorders may occur at the same time or one may follow the other. Even though the diseases of mental illness and drug abuse are comorbid, causality is not implied and either condition may precede the other (Fortinash and Holoday Worret, 2012). The symptoms of one condition may mask or conceal the symptoms of the other, with either condition assuming priority at any given time. Alcohol is the most widely used drug. The National Institute for Clinical Excellence (NICE) estimated in 2011 over 24% of people in England consume alcohol levels that are potentially or actually detrimental to health. The co morbidity of depression and alcohol dependence are two of the most prevalent psychiatric disorders affecting the general population. Evidence suggests that alcohol use disorders are linked to depressive symptoms and that alcohol dependence and depressive disorders co-occur to a larger degree than expected by chance. However, it is not clear whether the depression causes alcohol problems, whether the alcohol consumption or alcohol problems caused depression, or whether both could be attributed to a third cause (Royal College of Psychiatrists, 2015). This assignment will consider the case scenario of Simone part time social worker, aged 43 with depression and alcohol abuse. Simone lives with her three children and the intervention of choice is Cognitive Behavioural Therapy (CBT). This section will define CBT and its uses and adopt the Critical Appraisal Skills Programme (CASP) toolkit (2013) to critically evaluate and discuss two CBT research articles in treating depression and alcohol abuse to evidence why this is an appropriate intervention for Simone. CBT is defined as 'a talking therapy that can help individuals manage their problems by changing the way they think and behave' (Frances and Robson, 1997). Commonly used to treat a range of mental health issues including depression, anxiety disorders, phobias, but also deemed valuable in treating alcohol misuse, especially as part of an overall programme of recovery. The goal of cognitive behavioural therapy is to teach the person to become aware of incidences and situations which trigger the need to drink, to learn to avoid putting themselves in these situations and to develop coping strategies to deal with other problems and behaviours which may lead to drinking. Until recently the effectiveness of CBT for comorbid alcohol had not been studied, however, the first of two research articles will now be critically evaluated and discussed below. Developing an Integrated Treatment for Substance Use and Depression Using Cognitive Behavioural Therapy (Osilla et al, 2009) is an American qualitative research article. The research goal was to design and develop a treatment programme for delivery by substance abuse counsellors in outpatient mental health settings. This was thought to be important because earlier research had indicated the effectiveness of CBT in depression and alcoholism separately. The research developed a group based integrated 18 session treatment plan involving 3 modules (thoughts, activities and people interactions) linking mood and alcohol use and provided strategies for identifying and modifying harmful thoughts and activities. Drawing on previous studies (Hepner, Watkins, Woo and Wiseman, 2006) they involved a treatment development team including researchers, clinicians, stakeholders and CBT experts. Recruited participants (N=7; 4 male, 3 female) were already enrolled in outpatient substance misuse treatment who had met the criteria for mild depression using the 9 item Patient Health Questionnaire with scores of 5 or > (no indication given whether other people had chosen not to take part as this sample is small). Client focus groups were conducted following the group treatment sessions led by two clinical psychologists who had observed the group sessions from behind a one way mirror, thus the methodology used is entirely appropriate for addressing the research goal. The article states that the clients provided informed consent but there is no information regarding how the research was explained to participants, whether ethical approval was sought or whether ethical standards were maintained. The data analyses consisted of the researchers reviewing notes and transcripts independently from the client focus groups to select, group and label salient issues that point to the acceptability of integrated CBT. Notable points with similar concepts were categorised if different participants had said the same things on a number of occasions over a given time frame e.g. comments which stated that alcohol and mood influenced each other. Underlying themes were generated from the data and quotes were analysed and identified that fitted each of the relevant themes. Each researcher independently sorted quotes by theme and together they reached a consensus on any discrepancies. Findings indicated that treatment was widely accepted by clients and counsellors. Clients stated that applying CBT skills help to treat both their depression and alcohol misuse whilst positively affecting other areas in their lives. Clients felt the treatment had built their confidence and the group process was helpful in learning from each other. The article produced no evidence of triangulation but stated that there were limitations to the study that affect the generalization of the results. The study evaluated a single case implementation, so future studies would be necessary to examine client views in several clinics over time with different treatment sessions in order to judge whether integrated treatment is truly acceptable and feasible given funding constraints. Clearly, integrated CBT for depression and alcohol misuse evaluated as being useful and beneficial but the research concluded that there is a need to develop more web based training or other innovative ways that effectively train substance abuse counsellors to a reasonable standard with minimal costs to provide a unified CBT approach to manage comorbid depression and alcohol misuse. A Randomized Controlled Trial of Cognitive Behavioural Treatment for Depression versus Relaxation Training for Alcohol – Dependent Individuals with Elevated Depressive Symptoms (Brown et al, 2011). The goal of this Rhode Island trial was to evaluate the efficacy of adding CBT versus relaxing training to partial hospital treatment for individuals misusing alcohol with elevated levels of depressive symptoms. This was deemed important because it was expected that the addition of CBT would result in reduced levels of depressive symptoms and in decreased quantity and regularity of alcohol use.166 men and women were recruited (aged 16 - 65 years) from an alcohol and drug treatment unit provided they met the Diagnostic and Statistical Manual of Disorders, Fourth Edition (2000) criteria for alcohol dependence and had a Beck Depression Inventory of 15 or more. Participants were informed about the study, consent was obtained and they were randomly assigned to receive 8 individual sessions of CBT (n = 81) or relaxation training (n = 84). The article didn't mention whether the personnel were blinded. Treatment conditions did not differ on demographics, individual alcohol consumption or depression related variables. Results indicated significant improvement in depressive and alcohol use over time for all participants. Compared with the relaxation training, the CBT group had significantly reduced levels of depressive symptoms at the 6 week follow up as measured by the Beck Depression Inventory. This effect was found to be inconsistent because there was no difference in the Modified Hamilton Rating Scale (MHRD) for Depression between conditions at that point in time or at any subsequent follow up. There was no significant in alcohol use between groups. The researchers were clearly disappointed that this study did not replicate the results of an earlier pilot study in 2007. However, plausible reasons given included the average length of hospital stay had reduced from 21.2 days to 3.9 resulting in treatment sessions being conducted in an outpatient setting making it difficult to compare results. The setting for this study was a private hospital with educated Caucasian patients and caution should be used in generalizing findings to populations with different characteristics. Interview data and treatment adherence had not been subject to reliability ratings. The need for the trial was clearly documented and further studies evaluating the efficacy of CBT in individuals with alcohol misuse and elevated depressive symptoms is required. Overall, the benefits outweighed the harm. Depressed people with alcohol misuse like Simone have complex needs which pervade every aspect of daily life including psychiatric, psychological, education, employment and social care. Supporting someone with depression and alcohol misuse is one of the biggest challenges facing mental health services (DH, 2006).Traditionally, substance misuse and mental health services developed separately but a national drug and alcohol dependence strategy was published in December 2010 (HMG, 2010), and a mental health strategy a few months later (HMG, 2011). Both strategies acknowledge the association between mental health problems and drug and alcohol problems. Successful outcomes for both problems need early intervention and effective joint working between drug and alcohol treatment and mental health services in integrated, recovery-oriented local systems. Furthermore, a NICE guideline (2011) includes principles of care, identification and assessment in all assessment areas and principles for interventions, underpinned by best available evidence (due for review in 2015). Regarding impact on future practice, co morbidity requires nurses to adapt multiple roles in order to achieve a comprehensive level of care. A primary diagnosis isn't necessary as both depression and alcohol misuse can be treated simultaneously. A non judgemental, person centred approach recognising that treatment will be long term is required. Good communication skills with multiple professionals and services are essential. Clinical skills include specialist alcohol misuse assessments, mental health and risk assessments, the provision of specialist advice on reduction and harm minimisation, appropriate interventions, treatment advice to other care professionals and the ability to work in a multidisciplinary team. In practice, it is not possible for nurses to be an expert in all of the skills required, however they should have a working knowledge of some. Training is required to deliver comprehensive alcohol programmes through developing skills particularly in cognitive behavioural therapy which seems to produce beneficial effects on both depression and alcohol outcomes.

Bibliography

Brown, A.B., Ramsey, S.E., Kahler, C.W., Palm, K.M., Monti, P.M., Abrams, D., Dubreuli,.M., Gordon,.A. and Miller.I.W. (2011) A Randomized Controlled Trial of Cognitive Behavioural Treatment for Depression versus Relaxation Training for Alcohol – Dependent Individuals with Elevated Depressive Symptoms. Journal of Studies on Alcohol and Drugs 72(2): 286-296 Critical Appraisal Skills Programme (2013) Qualitative Research Check List. Oxford UK. Critical Appraisal Skills Programme (2013) Randomised Control Trial Check List. Oxford UK. Department of Health (2006) The Dual Diagnosis Good Practice. Diagnostic and Statistical Manual of Disorders (2000), 4th Edition, Text Revision (DSM-IV-TR). American Psychiatric Association.Washington DC. Fortinash, K.M and Holoday Worret,P.A (2012) Psychiatric Mental Health Nursing, 5th edition. Australia, Mosby. Frances, R. and Robson, M (1997) Cognitive Behavioural Therapy in Primary Care. Jessica Kingsley Publishers. London. Hepner, K.A, Watkins, K.E., Woo, S. and Wiseman, S. (2006) Group Cognitive Behavioural Therapy for Depression in Substance Abusers: Substance Abuse and your Mood. Treatment Manual for non - traditional providers. HM Government (2010). Drug Strategy 2010 Reducing Demand, Restricting Supply, Building Recovery: Supporting People to live a Drug Free life. HM Government (2011). No Health without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of all Ages. National Institute of Clinical Excellence (2011) Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. London: National Institute for Health and Clinical Excellence. Osilla, K.C., Hepner, K.A, Munoz, R.F, Woos. S and Watkins, K. (2009) Developing and Integrated Treatment for Substance Use and Depressing Using Cognitive Behavioural Therapy. Journal of Substance Abuse Treatment 37(4);412-420 Royal College of Psychiatrists (2015) Improving the Lives of People with Mental Illness (online) available from: https://www.rcpsych.ac.uk/healthadvice/problemsdisorders/alcoholdepression.aspx (Accessed 13th April 2015) Lynskey,M.T.(1998 ) The comorbidity of alcohol dependence and affective disorders: treatment implications. Drug and Alcohol Dependence 52:201- 209 Miller, I.W.,Bishop,S.,Norman,W.H. and Maddever,H.(1995) The Modified Hamilton Rating Scale for Depression;reliability and validity. Psychiatry Research 14: 131-142 Mitcheson, L., Maslin, J., Meynen, T., Morrison, T., Hill, R. and Wanigaratne, S. (2010). Applied Cognitive and Behavioural Approaches to the Treatment of Addiction: A Practical Treatment Guide. Chichester: Wiley-Blackwell. NHS Information Centre for Health and Social Care (2011), Statistics on Alcohol: England 2011. The Health and Social Care Information Centre. NICE (2007). NICE clinical guideline 51. Drug Misuse: Psychosocial Interventions. London: National Institute for Health and Clinical Excellence. Raistrick, D.,Heather, N and Godfrey. ,C (2006) Review of the effectiveness of treatment for alcohol problems. The National Treatment Agency for Substance Misuse. Weaver, T., Madden, P., Charles, V., Stimson, G., Renton, A., Tyrer, P., Barnes, T., Bench, C., Middleton, H., Wright, N., Paterson, S., Shanahan, W., Seivewright, N and Ford, C. (2003). Comorbidity of substance misuse and mental illness in community mental health and substance misuse services. British Journal of Psychiatry, 183, 304-313.

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Effective Strategies in Supporting Student Nurses through the Transition to Newly Qualified Nurse.

Contents

Example Nursing Essay

Example Nursing Essay

It is estimated that approximately 60% of the nursing workforce consists of newly qualified nurses: consequently there is much literature that examines the transitions that individuals experience as they progress from the student nurse to the newly qualified nurse (Whitehead, 2001; 2011). The recruitment and retention of nurses globally is a major issue, and hence healthcare systems need to address how best to ensure smooth transition into the professional nurse role to ensure newly qualified nurses successfully adjust into their new roles (Duchscher, 2008). In facilitating such transitions, great emphasis has been placed upon providing effective work environments in which newly qualified nurses can be best supported through the use of supervisors and preceptorship, and in having their views acknowledged and valued (Department of Health, DoH, 2008; Nursing and Midwifery Council, 2006). Indeed the policy paper, 'A High Quality Workforce' (DoH, 2008) specifically acknowledged the role that the National Health System must adopt in improving not simply the quality of care but also the quality of support offered to NHS staff. Key DoH (2008) recommendations were placed on establishing more effective nursing training to ensure newly qualified nurses were better prepared for the realities of nursing practice, and providing avenues for appropriate continued professional development. However, studies still highlight that in reality, newly qualified nurses' experiences are not aligned with these recommendations and nurses are still experiencing great challenges and difficulties in adjusting to the newly qualified nurse role (Mooney, 2007; Nash et al. 2009). The aim of this essay therefore is to examine the challenges that newly qualified nurses' experience as they make their transitions into professional nursing practice, and to explore particular evidence based strategies to facilitate effective adjustment to their new role.

Nursing role transitions

The difficulties that student nurses experience in making the transition to newly qualified nurse has been highlighted by both the Department of Health (DoH, 2007) and the Nursing and Midwifery Council (NMC, 2006) who raise concerns around whether such nurses are being appropriately prepared to feel confident and competent in their new nursing positions. As the NHS ethos of the 6 Cs of care demonstrates, competence, and the courage to act with confidence, alongside communication, collaboration and continuity, are essential aspects of the nurses' role in order to practice effectively (NHS, 2013). The literature indicates however that student nurses are simply not being effectively supported by both the NHS health care system and pre-registration training, which is leading to ineffective training which results in poorly prepared student nurses with expectations that do not translate into their actual new 'professional' nursing roles (Mooney, 2007; O'Shea and Kelly 2007). As Clark and Holmes (2007, p.1211) state, nursing education does not offer students "the knowledge, skills or confidence necessary for independent practice". As O'Shea and Kelly (2007) also highlight, newly qualified nurses' transitions are further challenged by little knowledge of the diverse roles qualified nurses engage within, such as managerial, leadership, decision-making and clinical duties. Studies however reveal that amongst newly qualified nurses there are similar, shared personal values based on altruistic values of desiring to help, care and support patients', which promotes the person-centred model of care (DoH, 2000). However studies highlight that in practice, organisational constraints (Lack of time and staffing problems) combined with managers' high expectations create challenges for new nurses in implementing theoretical knowledge and personal values into practice (Mackintosh, 2006). Therefore there is much need to determine key strategies that can promote effective transitions for nurses to help them to negotiate new positions as newly qualified nurses that prevent disillusionment, frustration, stress and potential burnout (Mackintosh, 2006).

The shock of transition

Duchscher (2008) identifies two key processes, those of socialisation and professionalisation, that occur as student nurses adjust to becoming a newly qualified nurse, Duchscher states that in order for nurses to effectively adjust to the transition they must modify their professional and personal values so that they are more aligned with the actual role. Duchscher (2008) argues that these changes result in nurses experiencing a process of intellectual, emotive personal, professional, role, skill and relationship transitions, which lead to new understandings, expectations and, subsequently, experiences. Studies corroborate this by highlighting that the first three months of becoming a newly qualified nurse have been reported by such nurses to be a sharp shock, as prior expectations of theory-based nursing are challenged by having such ideals of person-centred care made often impossible through different care practices expected within NHS settings being reinforced within health care teams (Kelly and Ahern, 2009; Hollywood, 2011). As multi-disciplinary teamwork in NHS care systems is a key aspect of NHS policy (DoH, 2010; NHS, 2013), newly qualified nurses can feel coerced into adopting different care practices that challenge their theoretical understanding of best practice, which can lead to tensions and, as studies reveal, could lead to distrust and poor staff morale (McDonald, Jayasuriya, and Harris, 2012). The literature evidences that newly qualified nurses who feel pressured to follow the practices of other staff can become desensitised to the use of poor practice through rationalising the need for such practice as a result of environmental pressures, such as time or staffing issues, which can lead to the nurse also adopting them (Mackintosh, 2006). Mackintosh (2006) highlights how this can lead to newly qualified nurses re-negotiating new nursing roles where personal values are re-assessed to enable adoption of similar practices, which serves to further reinforce the use of poor care within NHS settings. Consequently as Kelly and Ahern (2009) identified, it is no wonder that newly qualified nurses report finding the transitional process overwhelming and stressful, confirming Mooney's (2007) findings that nurses are unprepared and experiencing unexpected difficulties. Whitehead (2011) and Scully (2011) argue that such difficulties are a result of a theory-practice gap, which leads to nurses experiencing a conflict amongst theoretical, personal and professional values (Maben, Latter and Clark, 2006). Mooney (2007) confirms this in research conducted with newly qualified nurses that reported that pre-registration training did not prepare them for the realities of actual practice. Mooney (2007) also demonstrated how the high expectations of staff-leaders and patients furthered nurses' feeling of lacking skills and knowledge, as no accommodation was made for their newly qualified status and lack of experience, which led to stress and disillusionment (Hollywood, 2011). As Maben et al. (2006) state, such treatment and lack of support places newly qualified nurses in vulnerable situations: they are at great disadvantage due to lack of experience and appropriate support strategies (Hollywood, 2011).

Addressing stress and expectations

Whilst studies highlight the difficulties that nurses experience in adjusting to the newly qualified nurse role (Whitehead, 2001; 2011), Edwards et al.(2011) reveal that appropriate support can minimise student nurses' anxiety and help to build confidence through enhancing greater understanding of their role and staff demonstrating acceptance within nursing teams. However, Edwards et al. (2011) identify that staffing issues, staff attitudes and time constraints often lead to such nurses being unsupported, and can foster inequalities across NHS settings in the level of support provided. Scully (2011) emphasises that in order to provide appropriate support to newly qualified nurses, the political, social, and cultural barriers inherent in such a context must be addressed to help such nurses to overcome the theory-practice gap. As Fenwick et al. (2012) recommend, staff support needs to support a re-negotiation of newly qualified nurses' expectations – resulting from theoretical training – to offer contexts in which discussions can be promoted that can address unrealistic expectations of the newly qualified nurse's role so that what Kramer (1974) terms as reality shock is prevented. Theory-practice gaps, if strategies are not developed, can lead to segregation across newly qualified nurses and experienced staff, as when high expectations are placed upon newly qualified staff, they are unable to re-negotiate their new roles as they have no understanding of how their role can be limited by the particular socio-political and organisational constraints that can impede their practice (Maben et al. 2006).

Supportive work environments

Consequently the actual NHS environment and organisational culture in which newly qualified nurses find themselves can elicit a major impact upon how such nurses manage their transitions and forge a new self-identity and come to make sense of the role of the newly qualified nurse (Mooney, 2007; Whitehead, 2001). A key strategy promoted by the Nursing and Midwifery Council (NMC) (2006) is the employment of preceptors and supervisors to facilitate newly qualified nurses' adjustment to their new practice settings (NMC 2006). Preceptorship within a nurse's first year of professional practice can be utilised to highlight newly qualified nurses' existing strengths and weaknesses, so that areas of development can be highlighted and addressed. However, it can also provide a valuable context in which fears, emotions and challenges can be discussed (NMC, 2006). Despite NMC (2006) recommendations however, the utilisation of preceptorship support strategies in practice is limited, with its use across the NHS being fragmented and inconsistent. However the literature does demonstrate that preceptorship strategies can be very effective in supporting newly qualified nurses in successfully managing such transitions, with student nurses reporting that preceptorship facilitated easier transitions into clinical practice and helped them to negotiate better understandings of their new roles (Mooney, 2007). Whitehead's (2001; 2011) studies' findings led to the recommendations that newly qualified nurses must have access to preceptorship, clinical supervision and some form of full time support so that difficulties can be addressed swiftly and reduce the number of newly qualified nurses living too hastily without appropriate discussion the nursing profession. As Whitehead (2011) states, social support and peer interaction can help to address and alleviate fears and stress through nurses being able to access appropriate emotional support and guidance at any time (Mooney 2007). A qualitative study by Jonsen et al. (2012) examined the impact that providing preceptorship support elicited upon nurses' successful transition into new practice, Jonsen et al. (2012) identified three key aspects, these being: preceptors; theory and practice; and reflection. Jonsen et al's (2012) findings revealed that student nurses found the availability of support through preceptorship facilitated positive working environments which promoted feelings of security and yet fostered enhanced confidence and greater clinical effectiveness. As Jonsen et al. (2012) state, preceptorship provides contexts in which nurses are able to reflect upon their clinical practice experiences, which provides an environment in which students are able to balance theory with practice and personal with professional values, which facilitates better practice and confidence.

Conclusion

In summary, this essay demonstrates that to ensure student nurses adapt and make effective transitions to the role of newly qualified nurse, vital support is needed to offer appropriate supportive working environments, which can help nurses to re-negotiate the theory-practice gap. NHS settings need to acknowledge, accept and address the unique and individual needs of newly qualified nurses so that strategies can be employed that can facilitate continued professional development and encourage nurses to discuss their actual fears, issues and needs. The provision of preceptors and supervisors is essential to enable newly qualified nurses to have access to contexts in which personal and professional values can also be discussed so that they are able to not simply assimilate dominant practices inherent in the NHS setting but to also question them. Such strategies can thus offer newly qualified nurses context in which to reflect upon such practice experiences so that they can make sense of their new roles and re-negotiate new identities. It is therefore recommended that nurse training must address the potential transitionary difficulties that newly qualified nurses can experience to better prepare individuals for the realities of professional practice. NHS health care contexts must also promote greater access to preceptorship for newly qualified nurses to cater to the specific needs of newly qualified nurses. It is anticipated that through this development and a universal shift to enabling newly qualified nurses access to support such as preceptorship, newly qualified nurses can act with greater confidence and feel more supported in their clinical practice.

References

Clark, T., and Holmes, S. (2007) 'Fit for practice? An exploration of the development of newly qualified nurses using focus groups'. International Journal of Nursing Studies, 44 (7), pp. 1210-1220 Department of Health (2000) NHS Plan. London: DoH. Department of Health (DH) (2007) Towards a framework for post registration nursing careers – Consultation document. London: Department of Health. Department of Health (2008) A high quality workforce. London: DoH. Duchscher, J. B. (2008). A Process of Becoming: The Stages of New Nursing Graduate Professional Role Transition. Journal of Advance Nursing. 5(2), 22-36. Edwards, D., Hawker, C., Carrier, J., & Rees, C. (2011). The effectiveness of strategies and interventions that aim to assist the transition from student to newly qualified nurse.International Journal of Evidence-Based Healthcare,9(3), 286. FenwickJ,Hammond A,Raymond J,Smith R,Gray J,Foureur M,Homer C,Symon, C. (2012) Surviving, not thriving: a qualitative study of newly qualified midwives' experience of theirtransitionto practice. Journal of Clinical Nursing. (13-14), 2054-63. Hollywood E. (2011) The lived experiences of newly qualified children's nurses. Journal of Clinical Nursing. 10-23; 20(11):665-71. Jasper, M. (1996). The first year as a staff nurse: the experiences of a first cohort of Project 2000 nurses in a demonstration district.Journal of Advanced Nursing,24(4), 779-790. Jonsen, E., Melender, H.L. & Hilli, Y. (2012) Finnish and Swedish nursing students' experiences of their first clinical practice placement. A qualitative study. Nurse Education Today. 11(2), 8-17. Kelly, J. and Ahern, K. (2009) Preparingnursesfor practice: a phenomenological study of the new graduate in Australia. Journal of Clinical Nursing, 18(6), 910-918. Kramer, M. (1974) Reality shock: Why nurses leave nursing. St Louis: CV Mosby. Maben, J., Latter, S., and Clark, J.M. (2006) The theory-practice gap: impact of professional-bureaucratic work conflict on newly-qualified nurses. Journal of Advanced Nursing, 55, pp. 465–477. Mackintosh, C. (2006) Caring: the socialisation of pre-registration student nurses: a longitudinal qualitative descriptive study. International Journal of Nursing Studies, 43 (8), pp. 953-962. McDonald, J., Jayasuriya, R., & Harris, M. F. (2012). The influence of power dynamics and trust on multidisciplinary collaboration: a qualitative case study of type 2 diabetes mellitus.BMC health services research,12(1), 63. Mooney, M. (2007) Professional socialization: The key to survival as a newly qualified nurse. International Journal of Nursing Practice, 13 (2), pp. 75-80. Nash, R., Lemcke, P., and Sacre, S. (2009) Enhancing transition: An enhanced model of clinical placement for final year nursing students. Nurse Education Today, 29 (1). 48-56. National Health Service (2013) Change management plan. London: DoH. Nursing and Midwifery Council (NMC) (2006) The future of pre-registration nursing education – NMC Consultation. London: Nursing and Midwifery Council. O'Shea, M., and Kelly, B. (2007) The lived experiences of newly qualified staff nurses on clinical placement during the first six months following registration in the Republic of Ireland. Journal of Clinical Nursing, 16(8), 1534-1542. Scully, N.J. (2011) The theory-practice gap and skill acquisition: An issue for nursing education. Collegian, 18, (2), 93–98 Whitehead, J. (2001) Newly qualified staff nurses perceptions of the role transition', British Journal of Nursing, 10 (5), pp. 330-339. Whitehead, D (2011) Are newly qualified nurses prepared for practice. Nursing Times. 107, 19/20, 20-23.

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How Can Promoting a Positive NHS Culture Promote an Increased Quality of Patient Care?

The National Health Service is the universal medical care provider for residents of the UK. The principles it was originally developed upon ensured the service was provided free to meet everyone's clinical need (NHS, 2013). This ethos is still at the core of its delivery, but additional principles have been added to its constitution to improve quality standards and to provide the public with rights as an NHS patient (Department of Health, 2012). Thus, for health professionals and the wider NHS workforce to achieve these principles, the patient needs to be central to the delivery of their healthcare. Therefore, the focus of this essay will be to explore the relationship between a positive NHS culture and increased quality of patient care. In this essay the phrase 'positive NHS culture' has two definitions: 1) its internal organisational structure and the working environments of staff 2) the public and patients' perception and experiences of the NHS as service users. Due to the limited word count of this essay, the following factors will only be discussed: multi-disciplinary working, patient engagement and the role of the media. Within an organisation, a positive work culture is the key to successful delivery to its customers, clients, service users or patients. An inclusive workplace is constantly promoted by governing bodies, trade unions and human resource professionals because it allows for greater happiness to be achieved at work through the creation of a positive working environment (Equality and Human Rights Commission, 2010). This is because when professionals are respected and their skills are valued, they feel a sense of autonomy and purpose (West et al, 2011). Furthermore, this supportive environment can create trusting relationships amongst colleagues, which can result in a positive internal work culture. Oppositely, within an organisation where there is a lack of respect and trust, the service of the quality being delivered can become compromised. For example, cases have been identified where clinicians did not trust the medical judgments of fellow clinicians and this resulted in clinical assessments being repeated on patients (NHS Institute for Innovation and Improvement, 2010). This mistrust can result in creating more worry for the patient, a negative relationship between clinicians, an increased waiting time for the result of the assessment and possibly delaying NHS services to another patient and wasting NHS money. It can be argued that this critical approach by one clinician can ensure the diagnosis of a patient is correct; however as the UK has a high standard in its medical education progammes, the knowledge of another clinician should be respected. Also, there are other processes to ensure the diagnosis and treatment/care of the patient is suitable and of a high quality through regular discussions with allied health professionals who have been trained in a varied way to meet specific service areas. This allows alternative methods and treatments to be discussed and leads to better quality decisions on patient care (Borrill et al, 2002). Multi-disciplinary working is essential for a large organisation like the NHS, who aim to provide healthcare for everyone regardless of what health and well-being support or treatment is needed by the patient (NHS Institute for Innovation and Improvement, 2010). It allows professionals to efficiently manage their times and reduce patient waiting times, and more importantly it ensures the patient is receiving care from the relevant expert. Multi-disciplinary working could in the future challenge the entrenched feature of 'waiting times' in the NHS healthcare system. It is often accepted by NHS professionals that it is normal for a patient to wait to be seen: this indirectly disrespects the status and clinical need of the patient, suggesting that their time is less valuable than the healthcare professional's time (Leape et al, 2012). Over time, a blame culture has developed within the NHS when poor quality of care has been delivered, or more extremely when a number of fatal cases have been reported within one trust. Multi-disciplinary working is used to promote a team effort in high quality care and it is also used to challenge and prevent poor quality care (Berwick and Department of Health, 2013). To ensure poor standards are not accepted, patient partnerships need to be created to allow patients to participate in planning future NHS care improvements. Furthermore, if healthcare professionals communicate with patients in a method which allows them to understand jargon and medical information related to their health condition, this can then empower them to make suitable decisions in regards to their healthcare (Leape et al, 2012). Furthermore, the patient may become confident enough to comment on their healthcare and also feel respected and comfortable in the medical environment which they are being treated within, hence positively influencing their perception of the NHS. To further support the comfort patients' feel when using the NHS services, practitioners need to have a level of emotional intelligence as well as the intellectual ability to provide high quality care. This is because 'good health' is a combination of mental, physical and social well-being (WHO, 1946). Intellectual ability is usually identified and revisited often in a practitioner's healthcare training because it is thoroughly assessed. However, emotional intelligence differs within training depending on the role of the practitioner. Also, trainers of technical skills would argue it is not easy to teach emotional intelligence because it is often connected to an individual's personality/character and the events they have experienced throughout their own personal life (Tapia and Hyter, 2015). Nursing staff initially deal with difficult patient situations where emotional intelligence is essential to solve or ease the patient's situation. Therefore, showing care and compassion towards the patient often shows the patient they are being supported, hence improving the patient's satisfaction towards the support offered by the nurse (Ruddick, 2015). Media are used globally to reach a mass audience. Therefore, the NHS uses the mass media to reach a national audience for their health campaigns. Cutting down the number of smokers in the country is still a high priority to improve public health (NICE, 2015). The NHS using media campaigns for smoking cessation services, and the advice these provide has resulted in an overall positive effect for the incentive, due to the campaign reaching a mass audience (NHS Institute for Innovation and Improvement, 2013). This has been due to the development of diverse and creative advertisements being produced and made available freely to healthcare professionals, organisations and the public (NHS, 2015). These advertisements are not for online or television use only: they are often displayed or given in physical environments where patients and practitioners are present, hence making the delivery of patient care more interesting and more effective in tackling negative habits such as smoking. The extent of influence that the media has on its audience, and their thoughts and beliefs on specific topics, depend on a variety of factors; hence one single theory cannot sum up the impact of media. Using the media to acknowledge successful NHS services is important because often the media report investigations or organisational changes. For example, the BBC reported that over 40% of NHS investigations are not carried out adequately (BBC, 2015). This suggests that the culture of the NHS is one that fails to handle a large number of patient complaints appropriately; the complaint of a patient often suggests that there was a negative event when receiving healthcare within the NHS such as medical negligence. Therefore, failing to acknowledge this can further deteriorate the perception of the NHS to the patient. Furthermore, due to the NHS being a healthcare provider it is expected by society to have a high standard service, yet the demands on the staff to provide this service is often forgotten (Griffin, 2014). The NHS Practitioner Health Programme Team received the 'Innovation in Mental Health in Primary Care' award in 2014; this recognition of high quality practice was reported by various forms of media (NHS, 2014). The public were shown that these practitioners were successful and passionate individuals who were working to improve the Mental Health service within the NHS. Despite this not having a direct impact on the quality of patient care, it positively promoted the NHS and it also recognised that the mental health service in primary care was being recognised as innovative. Healthcare professionals can further promote the NHS culture as positive by using social media to engage with a larger public audience and also to connect with other healthcare professionals by increasing their participation in discussions on healthcare knowledge and alternative techniques (Cooper and Craig, 2013). This engagement can promote self-help techniques to patients and support them to manage their conditions. Self-help and self-care of conditions can reduce hospital admissions, hence directly impacting the number of patients waiting in Accident and Emergency departments, which can then allow clinicians to have more time with patients (The King's Fund, 2010). To summarise, patient experience is central to the quality of patient care. It seems a positive NHS culture is at the core of positive patient experience because it supports the development of relationships between the patient and the healthcare professional: this then can allow the patient to express their thoughts on the healthcare being delivered to them. In addition to this, trusting and respectful relationships can be created between professionals, who can then apply successful multi-disciplinary working to make the quality of care sufficient to meet service demands yet of a high personalised standard for each patient. Sadly, there are constraints in creating a highly positive NHS culture due to the demands put on the NHS service, diverse training of staff and the influence of the media.A

Bibliography

Berwick, D and Department of Health. (2013) Berwick review into patient safety. [Online] Available from: https://www.gov.uk/government/publications/berwick-review-into-patient-safety. [Accessed: 10th May 2015]. Borrill, C.S, Carlette, J, Carter, A.J, Dawon, J.F, Garrod, S, Rees, A, Richards, A, Shapiro, D, West, A.M. (2002) The effectiveness of Health Care Teams in the National Health Service. . [Online] Available from: https://homepages.inf.ed.ac.uk/jeanc/DOH-final-report.pdf. [Accessed: 10th May 2015]. British Broadcasting Corporation. (2015) NHS complaints investigations inadequate, says review. [Online] Available from: https://www.bbc.co.uk/news/health-31168260. [Accessed on: 9th May 2015]. Cooper, A and Craig, M. (2013) Professional reach, the role of social networks and the use of social media in contemporary healthcare. [Online] Available from: https://62c35eb621dd878ea2e9-b943cd9523d92ba087ae15d4d3eb47ce.ssl.cf3.rackcdn.com/Professional%20presence%20social%20media%20AC%20MC%20.pdf. [Accessed on: 8th May 2015]. Department of Health. (2012) The NHS Constitution for England: policy paper. Department of Health: London . [Online] Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/170656/NHS_Constitution.pdf. [Accessed: 10th May 2015]. Equality and Human Rights Commission. (2010) An employer's guide to creating an inclusive workplace. . [Online] Available from: https://www.equalityhumanrights.com/human-rights/human-rights-practical-guidance/area-employment-services/creating-an-inclusive-workplace. [Accessed: 9th May 2015]. Griffin, C. (2014) Improvement of chemotherapy practice and quality of care. Cancer Nursing Practice. 13. (6). p. 35-39. Leape, L.L, Miles, S.F, Dienstag, J.L, Mayer, R.J, Edgman-Levitan, S, Meyer, G.S, Healy, G.B. (2012) Perspective: A culture of Respect, Part 1: The nature and causes of disrespectful behaviour by physicians. The Journal of the Association of American Medical Colleges. 87. (7). p. 845 – 852. National Health Service. (2013) NHS Core Principles. https://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhscoreprinciples.aspx. [Accessed: 9th May 2015]. National Health Service. (2014) Winner of the National Positive Practice Awards. https://php.nhs.uk/winner-national-positive-practice-awards/. [Accessed on: 9th May 2015]. National Health Service. (2015) Smoke Free Resource Centre. https://resources.smokefree.nhs.uk/campaign/. [Accessed on: 9th May 2015]. National Institute of Clinical Excellence. (2015) Smoking Prevention and Cessation Overview. https://pathways.nice.org.uk/pathways/smoking. [Accessed: 9th May 2015]. NHS Institute for Innovation and Improvement. (2010) Joined-up care. https://www.institute.nhs.uk/qipp/joined_up_care/culture.html. [Accessed: 9th May 2015]. NHS Institute for Innovation and Improvement. (2013) Mass Media. https://www.institute.nhs.uk/building_capability/technology_and_product_innovation/mass_media.html. [Accessed on: 10th May 2015]. Ruddick, F. (2015) Customer Care in the NHS. Nursing Standard. 29. (20). p. 37-42. Tapia, A and Hyter, M.C. (2015) Can you teach emotional intelligence? . [Online] Available from: https://www.clomedia.com/articles/6014-can-you-teach-emotional-intelligence. [Accessed: 10th May 2015]. The King's Fund. (2010) Avoiding Hospital Admissions: Lessons from evidence and experience.A [Online] Available from: https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/avoiding-hospital-admissions-lessons-from-evidence-experience-ham-imison-jennings-oct10.pdf. [Accessed on: 10th May 2015]. West, M.A, Dawson, J.F, Admasachew, L. (2011) NHS Staff management and health service quality: results from the NHS staff survey and related data. London: Department of Health. World Health Organisation. (1946) Who Definition of Health. https://www.who.int/about/definition/en/print.html. [Accessed: 9th May 2015].

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Rolfe Reflective Model – Nursing Essay

Contents

Reflective essay on a case scenario - Rolfe reflective model
- What?
- So what?
- Now what?
Appendix
- Scenario:
- References

Reflective essay on a case scenario - Rolfe reflective model

This reflective essay will adopt Rolfe's model of reflection, (Rolfe, G et al. 2001) which was derived from Borton's developmental model. (Boyd E et al. 1983) The scenario is presented as Appendix 1 and the patient has been anonymized as 'Lee' in accordance with the NMC guidelines (NMC 2008)

What?

When analyzed in the overview, one can note that the main issues contained in this scenario are that a schizophrenic patient, who may therefore be psychotic, who is certainly confused due to his metabolic disturbances (hyponatremia) and possibly idiopathic confusion, has made an allegation of physical assault against another staff member. The patient is also forgetful and the event happened three days ago.

Clearly, the incident cannot be confidently verified at this stage and there is a question as to whether the patient is reliable in making this allegation. The analysis revolves around my reflection on the actions that I took and whether they could be considered appropriate or capable of improvement. My role in the situation was that I was the recipient of the allegation. Having heard the allegation, I tried to make sense of it. On the one hand, I was aware of the seriousness of the allegation if it were true, and therefore I was also aware of the potential harm that an untrue allegation could cause to the professional integrity of the ‘Special‘ who was involved. I was obviously aware of Lee's potential for confusion and psychosis, but I was also impressed by the apparent veracity of his recollection and also by the fact that he started to cry when he was recounting it. (Nicol M N et al. 2004)

On balance, I did believe his account of the situation. I, therefore, felt that I had a moral and professional duty to escalate the complaint to the Senior Ward Sister. After a period of discussion with the Ward Sister, I filled in an Incident Report Form (IR1), which was then forwarded to the hospital management. After the event, I experienced a period of prolonged self-examination. I was concerned in case I had inadvertently been party to a false allegation and considered further the consequences for the ‘Special' involved. After a period of intense reflection, I concluded that I was right to take the action that I did, both because of my professional duty to ‘do my best for the patient' but also because I was acting as the patient's advocate in these circumstances, which seemed entirely appropriate. (Brooke C et al. 2007) The response of the Ward Sister seemed entirely appropriate.

I believe that she went and spoke to Lee herself and determined that there was sufficient evidence to make the reporting of the incident (IR1) appropriate. This reassured me greatly. The Ward Sister also discussed the ethics and implications of the situation with me, which was both professionally helpful and considerate, as she could see that I was unclear about what I should do in these circumstances. In any reflective process, one also has to consider the feelings of the patient. In this case, Lee did appear to be pleased that he was being taken seriously, but his fluctuating lucidity meant that further questioning did not clarify the situation any further. He certainly appeared to be pleased when he was told that the ‘special' would not be assigned to him again.

So what?

The theoretical elements of the analysis of this situation are straightforward. Jasper, in his erudite series of analyses (Jasper M 2007), acknowledges that part of the responsibility of being a professional practitioner is to ensure that you give the best care possible to your patients or clients. In an analysis of a similar situation, the author is unequivocal in his assessment that the professional duty of the nurse is to share such reports of possible patient abuse with their immediate superior. Even if the patient is ‘of reduced capacity' or ‘of questionable reliability' (Jasper M 2007 Pg 36), they should therefore consider ‘vulnerable' in the professional sense, and offered greater, not less, protection. An ethical analysis would suggest that the nurse should invoke the Principle of Non-Malificence, which was derived from the often quoted dictum of Hippocrates, which stated that one should “first do no harm”. (Carrick P 2000). This Principle stated that healthcare professionals must ensure that their patients are not harmed, nor will come to harm. (van Uffelen J G Z et al. 2008). I did consider the possibility of speaking to the ‘Special' in an unofficial capacity, but came to the conclusion, that there was nothing that they could say which would change the proper course of action. This concurs with the opinion of Tschudin who analyses a number of similar situations. (Tschudin, V 2003). This level of analysis gave me a deeper insight into the situation and reinforced my initial conclusions relating to the proper and appropriate course of action.

Now what?

Given the fact that Lee had reported a possible episode of abuse, it seems entirely appropriate that it would be properly investigated. The action of the Sister in removing the ‘Special' from caring for Lee also seemed appropriate and proportionate. It may have been considered more appropriate to suspend the ‘Special' from work, but in circumstances when one is dealing with a confused and psychotic patient and there is a significant element of uncertainty about the veracity of the allegations, this might be considered inappropriate and unduly prejudicial to the ‘Special'. (McMillan J 2005) At the time of the reporting of the incident, I apologized to Lee myself and reassured him that such a situation would not be allowed to occur again. I feel that this was also a professionally appropriate course of action, as it not only communicated a professional sense of responsibility to Lee but also it demonstrated the fact that I was taking his complaint seriously and was sorry that it had happened. (Kozier, B et al. 2008) When analyzed in the overview, I effectively had two possible potential outcomes of the situation. Either I believed that Lee‘s story was probably true, or I didn't. This gives rise to a deeper analysis and, in the words of Cruess & Cruess, the evolution of a student into an 'expert practitioner' is judged by the ability to operate from a deep and holistic understanding of the total situation, a concept that is often referred to as ‘professional intuition'. (Baillie L 2005). Cruess et al. suggest that this ‘professional intuition' is better considered as ‘professional expertise', which is generally built up and gained over years of experience and which, when tested in the clinical environment, can become an altogether more robust concept. (Cruess S R et al. 2007). Reflection on this situation, together with the guidance received from the Ward Sister, has helped me to fully understand the main elements of this situation. If I were to encounter such a situation again I would feel more confident in dealing with the situation rather than having to reflect at length after the event. Such analysis has helped me to realize that, to cite Schon, it is one of the ways professionals evolve and move beyond rule-bound behavior and which enables them to function in a world of uncertainty and see problems in a holistic way and act appropriately. (Schön, D A (1987)

Appendix

Scenario:

A 78-year-old gentleman called Lee was admitted to my Ward with schizophrenia and other medical conditions, one of which includes confusion and hyponatremia. It has been explained to the patient and his next of kin that due to the dangerously low sodium level Lee is on a fluid restriction of 750 MLS per day, however, due to the patient's mental statue, he constantly demands fluids and if not given he will start screaming and disturb other patient and can be very aggressive a time. For this reason, the Senior Sister requested a special in order to provide a one to one care for Lee. I supported the patient with personal hygiene care one morning, Lee began to cry, when I asked 'what is the matter Lee?' he said, 'three days ago a special slapped my arm and pinched me. And he said 'I was waiting for her to finish her shift to inform a staff nurse, by then I had forgotten'. I hope when my son will visit me, I will remember to tell him what has happened. I reassured him that this will not happen again and I also apologized on her behalf and told Lee that the particular specialist will not be caring for him anymore. I reported the incident to the Ward Senior Sister and together we filled in an Incident Report Form (IR1).

References

Boyd E & Fales A (1983) reflective learning: the key to learning from experience. Journal of Humanistic Psychology, 23 (2): 99-117 Brooke C; Waugh A Eds (2007) Foundations of Nursing Practice, Fundamentals of Holistic Care. Lond Mosby Elsevier. Carrick P (2000) Medical Ethics in the Ancient World. Georgetown University Press: Philadelphia Jasper M. (2007) Professional Development, Reflection, and Decision – Making. Blackwell Publishing, Singapore. Kozier, B, et al. (2008) Fundamentals of Nursing: Concepts, Process, and Practice. Harlow: Pearson Education. Nicol M N, Bavin B C, Bedford-Turner S B, Cronin P C Rawlings-Anderson K R (2004) “Essential Nursing Skills” 2nd ed. Churchill Livingstone, Mosby NMC (2008) Nurse Midwifery Council: Code of professional conduct: Standards for conduct, performance and Ethics (2008) London: Chatto & Windus 2008 Rolfe, G., Freshwater, D., Jasper, M. (2001). Critical Reflection in Nursing and the Helping Professions: a User's Guide. Basingstoke: Palgrave Macmillan. Schön, D A: (1987), Educating the Reflective Practitioner: Toward a New Design for Teaching and Learning in the Professions, Jossey-Bass Publishers, San Francisco. Tschudin, V (2003). Ethics in Nursing: the caring relationship (3rd ed.). Edinburgh: Butterworth-Heinemann. van Uffelen J G Z, Chinapaw M J M, van Mechelen W, Hopman-Rock M (2008) Walking or vitamin B for cognition in older adults with mild cognitive impairment? A randomized controlled trial. British Journal of Sports Medicine 2008; 42: 344 - 351

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Role and Career Opportunities for a Nurse

Contents

Terms of Reference
Introduction
Qualification, Skills and Experience Required to be a Nurse
Health and Safety Issues
Job Opportunities
Conclusion
- References

Terms of Reference

Accountability: Means that healthcare professionals are accountable to their selves and to others on the care received by the patients. Adverse event: Refers to an incident that occurred in the hospital or any other clinical setting that resulted to harm or could have resulted to the patient's harm. Colleagues: Other healthcare professionals, co-workers, midwifery and nursing students. Patient-centred care: A consideration of patient preferences, engagement and needs when making healthcare decisions. Patient satisfaction: The perceived level of satisfaction on the quality of care they receive from their nurses.

Introduction

This report aims to discuss the role and career opportunities for a nurse. This report will include the qualification, skills and experience that are required to be a nurse in Ireland. A discussion on the daily work of a nurse with reference to health and safety issues will also be presented. Possible job opportunities for nurses in the Irish healthcare system will also be discussed. A conclusion will summarise the key points raised in this report.

Qualification, Skills and Experience Required to be a Nurse

The Code of Professional Conduct and Ethics for Registered Nurses and Registered Midwives (Nursing and Midwifery Board of Ireland, 2014) lays out the skills and professional requirements necessary for registered nurses in Ireland. These skills include the ability to provide safe and quality care for different groups of patients, respecting the dignity of each patient, professional accountability and responsibility, quality care, collaboration and trust and confidentiality. Since nurses continue to professionally develop from newly registered to specialist nurses, it is expected that professional characteristics and skills would be honed as nurses begin their practice. One of the important skills required for quality patient-centred care is the ability to communicate effectively with patients and colleagues. Communication is defined as a two-directional process that could involve transmission and receiving of verbal and non-verbal messages (Kourkouta and Papathanasiou, 2014). Nurses have a crucial role in promoting the health and welfare of patients. Establishing a relationship of trust in the beginning of care is crucial in promoting effective communication (Houghton and Allen, 2005). The first meeting between a nurse and a patient is important since this could either reassure patients or convey fear and indifference (O'Daniel and Rosenstein, 2008). However, communicating with patients who suffer from cognitive impairment or are unable to communicate because of confusion and hypoxia is often difficult and challenging (O'Daniel and Rosenstein, 2008). In patients unable to verbally express themselves, nurses have to recognise non-verbal messages in order to determine the healthcare needs of the patients (Watson, 2008). For instance, facial expressions, body gestures and posture (Houghton and Allen, 2005) could help identity the patient's feelings and needs. Effective communication is important in patient care since this will help facilitate timely and early intervention for the needs of the patients (Watson, 2008). Kourkouta and Papthanasiou (2014) argue that physical space, social and cultural values and psychological conditions have an impact on the communication between the nurse and patient and vice versa. Hence, it is crucial for nurses to identify the factors that promote effective communication and those that deter patients from communicating their needs with the nurses. For instance, a language barrier might lead to miscommunication or misinformation, which in turn, affects the quality of communication of the nurses and patients. Apart from communication skills, healthcare professionals are also bound to provide safe and effective care as stressed in the Code of Conduct for nurses in Ireland (Nursing and Midwifery Board of Ireland, 2014). Avoidance of medication errors does not only promote safe and effective care but also prevents adverse events and death of the patients. Acquiring numeracy skills is a prerequisite in the preparation and safe administration of medications. However, Eastwood et al. (2011) suggest that a number of nursing students have poor numeracy skills. While applicability of the findings of these studies to a larger and more heterogeneous population is limited due to the small sample sizes, findings could show a trend on the numeracy skills of nursing students. These suggest the need to enhance nursing curriculum to ensure that students have sufficient numeracy skills to prepare and administer medications before they become registered nurses. It is noteworthy that these findings are not only seen in nursing students but also in registered nurses (Warburton, 2010). This indicates that there is a continuing need to train nurses on how to safely administer or prepare medications in order to prevent medication errors. Another nursing quality that is associated with quality care is the ability to show empathy to patients. Empathy is described as the ability to share and understand the feelings of other people (Kinnell and Hughes, 2010). Developing this characteristic could calm down patients and let them feel that nurses are willing to listen to their concerns and are available to help them with their needs. Rana and Upton (2009) suggest that patients are satisfied with the care they receive if they perceive nurses to be empathic to their needs, feelings and concerns. Increasing levels of patient satisfaction is important since high levels are associated with better quality care (Rana and Upton, 2009). The Code of Professional Conduct and Ethics (Nursing and Midwifery Board of Ireland, 2014) should also develop skills on how to collaborate effectively with others. This means that individuals also have to learn effective leadership skills in order to lead health care teams, introduce innovations and work in partnership with other agencies in order to improve care. It has been shown that the transformational leadership style is consistent with effective leadership (Bach and Ellis, 2011). This type of leadership requires leaders to develop empathy with their colleagues and patients. These leaders also tend to have high emotional intelligence (Bach and Ellis, 2011). Hence, developing the skills needed to become a transformational leader would be essential as a nurse. Further, collaborating with others requires skills on how to resolve conflicts.

Health and Safety Issues

Nurses working on clinical and primary care settings have some health and safety issues to consider. For example, nurses assigned to patients who are immobile often have to handle these patients manually. Failure to properly handle patients could lead to health issues such as musculoskeletal injuries (Cornish and Jones, 2007; Powell-Cope et al., 2014). The rising incidence of musculoskeletal injuries (Powell-Cope et al., 2014) is a cause of concern since guidelines are available for nurses and students on how to properly handle patients manually. Yet, it has been shown that adherence to these guidelines is not optimal for both students and registered nurses (Powell-Cope et al., 2014). This suggests that translating evidence and uptake of guidelines in actual practice still remains to be low despite aggressive implementation of these guidelines in clinical practice. Health and safety issues are often influenced by the culture present in the clinical setting (Powell-Cope et al., 2014). For instance, student nurses who observe registered nurses not following policies or guidelines might assimilate this bad practice once they become registered nurses (Cornish and Jones, 2007). Apart from developing musculoskeletal injuries, nurses who work long hours are also at risk of nursing burnout. It has been shown that nursing burnout is associated with lower job satisfaction (Mrayyan, 2006). This in turn affects the psychological health of the nurses, their interaction with patients and reduces the quality of care they provide to their patients (Mrayyan, 2006). Hence, it is essential to consider the number of nursing staff and whether this could support the current needs of patients in healthcare settings. Further, nursing burnout also indirectly affects nursing-patient ratio since nurses who report burnout are more likely to leave their jobs (Mrayyan, 2006; Wong et al., 2013). This could lead to a high turnover of nursing, which in turn, affects the quality of care received by the patients. Another important health and safety issue in healthcare setting includes percutaneous and needle-stick and sharp injuries. This health issue is related to poor compliance to universal precaution (Jacob et al., 2010). This is challenging since studies (Gershon et al., 2009; Jacob et al., 2010) have shown that nurses tend to report high knowledge and awareness on universal precaution. The risk associated with failure to observe universal precaution when handling sharp objects in clinical settings include increased risk of acquiring HIV infection, Hepatitis B and C (Mark et al., 2007; Elder and Paterson, 2007). Reporting of injuries is also crucial in maintaining the safety of nurses in clinical settings. However, current data on this type of injuries might not truly reflect actual practice since underreporting is often noted in published studies (Gershon et al., 2009). For instance, Gershon et al. (2009) report that 45% of percutaneous injuries were not reported. The incidence of percutaneous injuries highlights the need for consistent training of the nurses.

Job Opportunities

Nurses in Ireland have many job opportunities as demand of healthcare increases. Incidence of long-term conditions such as obesity, diabetes and heart diseases have increased in the last few decades (DHSSPS, 2012). This requires specialist care from nurses. Further, the ageing population also means that individuals are living longer and hence, might require additional care to ensure longevity or address chronic conditions that affect older persons (DHSSPS, 2012). Newly registered nurses could acquire experience and develop to become specialists in their respective fields. For example, there is a need for specialist nurses such as diabetes nurses to manage patients suffering from type 1 and type 2 diabetes. On the other hand, mental health nurses are required in community and clinical settings to manage patients suffering from schizophrenia, depression, postpartum psychosis, depression and other mental health conditions. Learning disability nurses provide support and care management to patients and their families suffering from learning disabilities. Meanwhile, paediatric nurses provide care to paediatric patients. Nurses could also choose to specialise to become part of surgical theatre teams. Others could also opt to become mentors, cardiology nurses or respiratory specialists. Nurses who are now specialists could also choose to further hone their skills and qualify as a nurse prescriber. These nurses could prescribe medications from their own field of specialty only (Nursing and Midwifery Board of Ireland, 2015). It has been shown that inclusion of nurse prescribers allow continuity of care and higher patient satisfaction (Nursing and Midwifery Board of Ireland, 2015). Patients report that they are also satisfied with the type of care they receive from nurse prescribers and view them as showing more empathy and sensitivity to their situations. However, it should be noted that nurses who choose to become specialists or nurse prescribers have to engage in continuing professional development, earn a Master's degree in nursing or continue to train in their respective fields. Hence, learning is seen as continuous when an individual engages in the nursing profession. Since this is a caring profession, nurses are also expected to show empathy and compassion to their patients. These characteristics are often honed as nurses become highly specialised in their chosen fields.

Conclusion

Nursing is a caring profession that aims to provide quality, patient-centred care to the patients. Preparing to become a registered nurse in Ireland requires earning a nursing degree. The path to becoming an effective nurse begins in the nursing student years. Developing attitudes such as empathy, compassion, responsibility and accountability and practical skills such as numeracy skills could all promote quality care. As patients perceive their nurses to reflect these attitudes and skill, they would be reassured that their nurses truly care and are willing to manage their health condition. This essay also argues the importance of developing communication skills in order to identify the needs of the patient and introduce early interventions. However, becoming a nurse is also challenging because of health and safety issues. These include the risk of musculoskeletal, percutaneous and needle-stick injuries. Some nurses, due to a low nurse-patient ratio, may also suffer from nursing burnout. Once this occurs, this might lead to poor job satisfaction and high nursing turnover. Quality of patient care is affected when there are fewer and dissatisfied nurses. Finally, this essay shows that there are many job opportunities for nurses in Ireland.

References

Bach, S. & Ellis, P. (2011) Leadership, Management and Team Working in Nursing. Exeter: Learning Matters. Cornish, J. & Jones, A. (2007) 'Evaluation of moving and handling training for pre-registration nurses and its application to practice', Nurse Education in Practice, 7(3), pp. 128-134. Department of Health, Social Services and Public Safety (2012) Living with long term conditions: A policy framework. Dublin, Ireland: Department of Health, Social Services and Public Safety. Eastwood, KJ, Boyle, MJ, Williams, B, & Fairhall, R (2011) 'Numeracy skills of nursing students. Nurse Education Today. 31(8) November. pp. 815-818. Elder, A. & Paterson, C. (2006) 'Sharps injuries in UK health care: a review of injury rates, viral transmission and potential efficacy of safety devices', Occupational Medicine, 56 (8), pp. 566-574. Gershon, R., Pearson, J., Sherman, M., Samar, S., Canton, A. & Stone, P. (2009) 'The prevalence and risk factors for percutaneous injuries in registered nurses in the home health care sector', American Journal of Infection Control, 37(7), pp. 525-533. Houghton, A. & Allen, J. (2005) 'Doctor-patient communication', British Medical Journal Career Focus, 330, pp. 36-37. Jacob, A., Newson-Smith, M., Murphy, E., Steiner, M. & Dick, F. (2010) 'Sharps injuries among health care workers in the United Arab Emirates', Occupational Medicine, 6(5), pp. 395-397. Kinnell, D. & Hughes, P. (2010) Mentoring Nursing and Healthcare Students. London: SAGE. Kourkouta, L. & Papathanasiou, I. (2014) 'Communication in nursing practice', Materia Socio Medica, 26(1), pp. 65-67. Mark, B., Hughes, L., Belyea, M., Chang, Y., Hofmann, D., Jones, C. & Bacon, C. (2007) 'Does safety climate moderate the influence of staffing adequacy and work conditions on nurse injuries?', Journal of Safety Research, 38(4), pp. 431-446. Mrayyan, M. (2006) 'Jordanian nurses' job satisfaction, patients' satisfaction and quality of nursing care', International Nurse Review, 53(3), pp. 224-230. Nursing and Midwifery Board of Ireland (2014) The Code of Professional Conduct and Ethics for Registered Nurses and Registered Midwives. Ireland: Nursing and Midwifery Board of Ireland [Online]. Available from: https://www.nursingboard.ie/en/code/new-code.aspx (Accessed: 15 June, 2015). Nursing and Midwifery Board of Ireland (2015) What are NMBI's professional regulations and guidance for nurse/midwife prescribing? [Online]. Available from: https://www.nursingboard.ie/en/prescriptive_authority.aspx#faq2 (Accessed: 15 June, 2015). O'Daniel, https://www.nursingboard.ie/en/prescriptive_authority.aspx#faq2 M. & Rosenstein, A. (2008) Professional communication and team collaboration. In: Hughes, R. (ed.), Patient safety and quality: An evidence-based handbook for nurses. Rockville (MD): Agency for healthcare research and quality. Powell-Cope, G.,Toyinbo, P., Patel, N., Rugs, D., Elnitsky, C., Hahm, B., Sutton, B., Campbell, R., Besterman-Dahan, K., Matz, M., Hodgson, M. (2014) 'Effects of a National Safe Patient Handling Program on Nursing Injury Incidence Rates', The Journal of Nursing Administration, 44(10), pp. 525-534. Rana, D. & Upton, D. (2009) Psychology for nurses. London: Pearson. Warburton, P. (2010) 'Numeracy and patient safety: the need for regular staff assessment', Nursing Standard (Royal College of Nursing, Great Britain), 24(27), pp. 42-46. Watson, D. (2008) 'Pneumonia 2: Effective nursing assessment and management', Nursing Times, 104(5), pp. 30-31. Wong, C., Cummings, G. & Ducharme, L. (2013) 'The relationship between nursing leadership and patient outcomes: A systematic review update', Journal of Nursing Management, 21(5), pp. 709-724.

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Create a Reflective Piece Using the Gibbs Reflective Model

Contents

Create a reflective piece using the Gibbs Reflective Model which identifies an incident in the workplace where there was a lack of leadership.

Create a reflective piece using the Gibbs Reflective Model which identifies an incident in the workplace where there was a lack of leadership.

Use critical analysis of a reflective cycle to explore how this incident has increased your knowledge and understanding of professional practice with respect to the values and behaviour s in the field of nursing, and how future your behaviours will change.

Definition of Gibbs Reflective Cycle

Gibbs' reflective cycle (1988) is a tool used by numerous professionals, including (but not limited to) health professionals, education workers and those in leadership positions: its purpose is to assist practitioners in reflection, which contributes to continuous personal development (CPD) and helps to ensure that a person is continually learning and improving in their role. The idea is to systematically reflect on a particular situation to ensure that all aspects have been considered and evaluated, as this will assist the reflector in understanding what to do next time they are in a similar situation. The process consists of the following steps: Click to Expand

Description: What happened?
Feelings: What were you thinking/feeling?
Evaluation: What was good about the experience? What was bad about it?
Analysis: What sense can be made of the situation? What was really going on, as opposed to what you may have perceived?
Conclusion: What was the end result – how well did you think you managed the situation overall? What else could you have done in the situation?
Action plan: If the situation occurred again, what would you do? Would you act differently? Is there a skill you can develop or something you can learn to help you to be better equipped next time?

Introduction

The incident I will be reflecting on occurred whilst I was placed with the vascular team. We had received a request for a duplex carotid scan for a patient on ITU who had been admitted due to a large stroke. Upon arrival we read her notes which highlighted significant aphasia and difficulties with communication. The nurse also informed us that the patient had a long standing memory problem and as a result of this, she did not remember why she had been admitted and would become very distressed when her stroke was discussed. When we approached her to perform the scan we found that she was under minimal sedation and was having assistance from a ventilator. The scan was completed without difficulty and we began to document our findings in the notes. A nurse came onto the ward with two members of the public in order to show them around ITU before the man's surgery. This has been a long-standing protocol which strives to decrease worry before a planned stay in ITU.

The members of the public were brought to the bedside where the nurse began to explain what the equipment was and what it was used for. The nurse made no effort to introduce the members of the public or herself to the patient. She also glanced at the patient's notes and then informed the members of the public that she had been admitted to ITU because of a stroke. Upon hearing this, the patient became overtly distressed and had to be more heavily sedated after the nurse in charge of her care could not calm her by talking in a soothing manner. This event clearly caused undue anxiety to both the patient and members of the public, in addition to the members of staff who bore witness to the incident. The incident was reported using an in-house critical incident report by both myself and staff from ITU as this was a breach of patient confidentiality and poor practice.

Interpretation of the incident

Before the incident, I was aware that the nurse was showing the members of the public around the ITU in order to familiarise them with the ward. I was very surprised when the nurse did not check the patient's notes beforehand, and the distress caused to both the patient and the members of the public was entirely unnecessary. To critically reflect upon this incident I shall use a well-known reflective cycle from Gibbs (1988). This model is cyclical and is unique because it includes emotions, knowledge, and actions and believes that experiences are repeated, which moves away from the model proposed by Kolb (1984). Some scholars, such as Zeichner and Liston (1996), believe that a wider and more flexible approach is needed by examining values in a critical light and how the practice of this can lead to changes in quality.

Description

The most important factor in this incident was the lack of intervention from myself or the other healthcare professionals. The nurse should have been made aware that this was not a suitable area to bring the members of the public to. I also assumed that there would not be disclosure of specific patient details as this would be a breach of patient confidentiality policies which are covered in numerous guidelines from the Healthcare Professions Council (HCPC, 2012) and the Nursing and Midwifery Council (NMC 2015).

Feelings

The main emotion that I felt in this situation was anxiety. I had been to ITU many times before and it is an environment in which I feel comfortable. I had not been to ITU to perform a carotid ultrasound before and I felt nervous as I wanted to perform the test well. I believe that, as a result of this, I moved some accountability to my senior colleague. I found the incident upsetting to witness as the distress was caused by a member of staff and their actions were avoidable.

Evaluation

My role was to complete the scan and establish the presence or absence of carotid disease, which I did. The results of the scan would have been used to determine the best course of management for this patient. It is important to note that acting in the patient's best interests was also part of my role, and I feel that I did not fulfil this completely. The duty to protect patients and patient confidentiality at all times lies with all staff, including myself, my vascular colleague, and the ITU staff. Our failure to act as a team could be explained by Rutkowski's (1983) theory of group cohesiveness. This theory proposes that altruistic behaviour is dependent upon the social norm, and is defined as people helping those in need, and who are dependent upon them for help. Rutkowski's (1983) showed that the group is more likely to act in accordance with the perceived social norm if there is a high level of group cohesiveness. In the situation that I have described, neither my colleague nor I were familiar with the healthcare professionals on ITU and there may have been a low level of group cohesiveness as a result of this. Further work (Koocher & Keith-Spiegel 2010) has demonstrated that irresponsible professional behaviour can be averted by informal interventions.

People were found to be more likely to take action if they were the senior person in a situation, and most felt that a positive outcome was as a result of their intervention (Koocher & Keith-Spiegel 2010). It is important to note that the way in which this outcome was measured (taken from data described as 'feelings after intervention'), may have introduced bias as it is likely that participants felt pleased with their courage in acting in an appropriate manner, regardless of the outcome of the intervention. It is possible that their intervention garnered no difference in professional behaviour. It is important to note that cases of major misconduct, such as those which could result in harm to patients or damage to the reputation of the Trust, should be dealt with by more formal routes. We completed an internal incident report which automatically flags the incident to senior clinicians and managers which would ensure that this incident was not unheeded. If this incident had not been reported, it would be an indicator of declining professionalism and acceptance of inferior standards of care. Tolerance of poor standards was highlighted by the Francis report (2013) as a consequence of poor staffing, policies, recruitment and training, and leadership.

Analysis

The patient had a jugular line in place, which I had anticipated would make the scan more difficult and therefore probably contributed to my increased level of anxiety. I feel that if I had not been as anxious I would have been more likely to intervene; however it is clear that both my colleagues and I should have intervened more quickly. I believe that an informal intervention as described by Koocher and Keith-Spiegel (2010) would have been appropriate in this situation.

Conclusion

Having witnessed the distress caused to both the patient and members of the public, I am now aware of the important of being more assertive if similar situations were to arise in future. Although I believe I should have intervened at the time, the experience I have gained from this has made me more aware of the important of always acting in the best interests of the patient even when this may take courage. I believe that having greater confidence in my ability to scan would have reduced my diffusion of responsibility and allowed me to act in a more autonomous fashion. There should also be a greater emphasis to establish strong working relationships between healthcare professionals to in turn increase levels of group cohesiveness.

Action plan

My future practice will involve becoming more proactive when I believe that there is a risk to patient confidentiality, and I will not assume that other members of staff will act in a professional manner at all times. I will continue to undertake reflective practice by using the model proposed by Gibbs (1988), and will aim to become confident when protecting patient confidentiality, particularly in situations where I am applying clinical skills which are new to me or that I do not feel completely confident with. As a trainee healthcare scientist, I aim to consistently implement the values and principles as set forth by the HCPC (2012) of a clinical scientist, and although this experience was difficult, I now feel that I have a greater understanding of these principles and values.

Changes in norms and behaviours

Due to the incident, I have formed a new set of behaviours. The first of these is that I will no longer assume that all members of staff will act in accordance with guidelines about patient confidentiality. Tied to this is a conscious effort on my part to refrain from assuming that I can predict the actions of other healthcare workers and I will always prioritise the welfare of patients in my care. Gibb's (1988) model has allowed me to critically reflect on my behaviours and has allowed me to identify aspects of my behaviour which may be detrimental. Critical reflection of this incident has made it clear that there is a deference to those I deem more senior than myself, perhaps due to a subconscious desire to maintain good working relationships. It is possible that the major obstacles which prevented me from speaking out in this incident were my perception of an authority gradient between myself and my colleague and low group cohesiveness. To prevent future events like this occurring I will express any concerns about my clinical skills before beginning any procedures in order to both reduce any authority gradient and to also reduce the diffusion of responsibility as much as possible. I now feel more confident in protecting patient confidentiality and will aim to always embody the values and principles of a healthcare scientist.

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Discuss how Moral Distress Can Affect Nurses and its Impact on Nursing Staff Retention.

Contents

Make recommendations on how the impact of moral distress on nursing staff can be limited.

Make recommendations on how the impact of moral distress on nursing staff can be limited.

What is moral distress?

Moral distress is the state of psychological discomfort and distress that arises when an individual recognises that they have moral responsibility in a given situation, make a moral judgement regarding the best course of action but for a range of reasons are unable to carry out what they perceive to be the correct course of action.A In reference to nursing, it specifically refers to the psychological conflict that occurs when a nurse has to take actions that conflict with what they believe is right, for example, due to restrictions in practice policies within institutions (Fitzpatrick and Wallace, 2011).A A Studies in this area usually use the original definition by Jameton in 1993 "moral distress arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action" (Jameton, 1984).A Further work by Wilkinson in 1987, who published an account of moral distress (Wilkinson, 1989) refined this definition to relate it directly to "psychological disequilibrium and negative feeling" (Wilkinson, 1987).A Common causes cited by nurses for not being able to fulfil their moral responsibility include a lack of confidence in the ability of colleagues, negative attitudes of colleagues towards patients and a team decision on care that does not follow the patients expressed wishes, or fear of reprisal resulting from the course of action they feel is best for the patient (Wojtowicz et al., 2014).A For example, a nurse working in post-operative ward might experience a patient dying as the result of refusing a blood transfusion following surgery due to religious beliefs.A The nurse's personal judgement may be that the patient should receive the blood transfusion to give them the best chance of surviving the surgery.A However, because the patient did not consent, the nurse could not carry out the action they perceived to be correct.A When the patient died, the nurse may have experienced emotional and psychological distress in the form of guilt and anger that they had not saved a life that may have been possible to save, as well as feelings of helplessness that they could not overrule the patient's wishes (Stanley and Matchett, 2014).A A

What situations are more likely to cause moral distress?

In 2015, Whitehead et al carried out a large scale questionnaire based study in the USA on moral distress amongst nurses and other healthcare professionals (592 participants, 395 of which were registered nurses).A The most common causes of moral distress in nurses included frustration at a lack of patient care due to inadequate continuity (rated 6.4 by nurses on a Likert scale of 0-16), poor communication (5.8) or inadequate staffing levels (5.7).A Additionally, nurses reported that giving life supportive therapy when not in a patient's best interest (6.0), or resuscitation only to prolong the process of death (5.8) were also rated highly.A This study also showed that physicians and other healthcare professionals also rated these factors highly, but overall their scores were less than those of nurses.A The authors concluded that nurses are more likely to experience moral distress than other healthcare professionals, possibly due to a discrepancy between levels of responsibility for patient welfare and the required autonomy to make the decisions they believe should be made, as well as feelings of accepting treatment protocols from physicians which they feel are incorrect but unable to challenge or overrule.A Poor team leadership and poor communication was also cited by nurses as a cause of moral distress (Whitehead et al., 2015).A Moral distress appears to be more likely amongst nursing staff who are involved in patient care protocols that are considered to be aggressive and futile e.g. prolonged end of life care, or care protocols that the nurse does not consider to be in the patient's best interest.A For these reasons, moral distress is thought to be particularly prevalent amongst nurses treating patients in palliative care (Matzo and Sherman, 2009), paediatrics, intensive care (Whitehead et al., 2015; Wilson et al., 2013; Ulrich et al., 2010) and neonatal environments (Wilkinson, 1989).A Additionally moral distress is also prevalent amongst psychiatric nurses due to increased feelings of responsibility for vulnerable patients, particularly as these patients are at risk of suffering from ethical mistreatments, e.g. misinformation about drug side effects (Wojtowicz et al., 2014).A Other studies have also identified that issues with the institution itself can cause moral distress, such as inadequate staffing, depersonalisation of staff, inadequate supply of resources and overloading of work (Dalmolin et al., 2014).

How does it affect nursing staff?

Moral distress can have psychological consequences that affect the nurse's performance and wellbeing.A For example, it is thought that nurses experiencing moral distress may self-blame or criticise themselves for an unsatisfactory outcome, and may experience emotions of anger, guilt, sadness or powerlessness (Fitzpatrick and Wallace, 2011; Borhani et al., 2014).A They may shift blame onto others or exhibit avoidance behaviours such as taking time off for illness.A Physical manifestations may also include headaches, diarrhoea, sleep disturbance and palpitations, which may well be interpreted as illness and require time off work, further contributing to low staffing levels, which perpetuates a cycle of understaffing = moral distress / illness = time off = understaffing (Fitzpatrick and Wallace, 2011).A Moral distress is associated with "burnout" (or emotional exhaustion and extreme stress) and with a reduced sense of professional fulfilment (Dalmolin et al., 2014) .A

Moral distress and staff retention

Because experiencing moral distress has been linked to harm and stress to nurses, as well as a reduction in the quality of patient care, many studies have cited it as a reason for nurses to leave the profession, resulting in a reduction in staffing levels and self-perpetuating cycle of staff shortages (Fitzpatrick and Wallace, 2011; Borhani et al., 2014).A Indeed, one study of 102 intensive care nurses in the USA found that as many as 40% had left or had considered leaving a job as the direct result of moral distress (Morgan and Tarbi, 2015), Together, these issues can significantly compromise the quality of patient care and result in "burnout" of nursing staff, causing more to leave the profession to avoid the feelings of guilt that moral distress can cause, particularly in those specialisms typically associated with moral distress such as oncology or paediatrics.A Moral distress also contributes to job dissatisfaction, typically as the result of a discrepancy between the experience the nurse is expecting to have at an institution, and the actual experience (Borhani et al., 2014) This is particularly true of student nurses, who are more likely to have higher expectations of the profession they have worked hard to join, and will be more familiar with the policies and values by which organisations "should" be run rather than the reality, where it is likely that some practices will be sub-optimal or archaic (Wojtowicz et al., 2014; Stanley and Matchett, 2014).A A

Managing and limiting the impact of moral distress

As previously discussed, moral distress is thought to primarily result from either institutional disorganisation (which can be prevented), or distressing ethical situations such as providing futile life prolonging treatment which are unfortunately inevitable (Whitehead et al., 2015).A However, there are ways in which nurses and their management can prepare themselves to deal with these situations effectively, thus reducing the impact of the moral distress (Deady and McCarthy, 2010).A A Although it is important for nursing staff to be supported by their management, ultimately the nurse should be responsible for themselves and their own psychological wellbeing in order to prevent burnout from moral distress (Severinsson, 2003).A Several studies have suggested that the best way to reduce the risk of burnout as a result of moral distress is for nurses to share their feelings and seek support from their peers, ideally in an environment where nurses can share their experiences and discuss ethical implications of specific situations.A It is also important that nurses understand what moral distress is, and can identify the source of negative feelings.A Psychologically it is thought to be important that nurses acknowledge and identify these feelings so that they may be processed in a less damaging manner (Matzo and Sherman, 2009; Deady and McCarthy, 2010; Em Pijl”?Zieber et al., 2008).A Nurses should also be encouraged to challenge treatment protocols they feel are inappropriate without fear of reprisal (Deady and McCarthy, 2010).A Some researchers have advocated approaches such as nurses emotionally distancing themselves from distressing situations, or actively striving to desensitise themselves.A However it is controversial whether or not this actually reduces moral distress, and of course raises questions about patient welfare with some suggesting that it is important that the nurse feels ethically responsible (Whitehead et al., 2015; Severinsson, 2003) and has a degree of emotional involvement in the situation in order to provide best possible care (Bryon et al., 2012; Linnard-Palmer and Kools, 2005; Severinsson, 2003).A The majority of studies in this area recommend that moral distress should be included in the curriculum studied by student nurses, along with practical recommendations regarding measures that can be taken to deal with it as and when it occurs (Wojtowicz et al., 2014; Borhani et al., 2014; Matzo and Sherman, 2009; Stanley and Matchett, 2014; Whitehead et al., 2015), for example in the form of ethical philosophical discussion to facilitate students to explore their individual moral value systems and emotional responses, as well as be more informed regarding the underlying psychological processes involved.A Therefore nurses may better understand the thought processes involved, and be better equipped to identify unhelpful thinking patterns that may result from moral distress, thus limiting stress and avoiding the development of "burnout" (Stanley and Matchett, 2014; Severinsson, 2003).A It has been shown by several studies that moral distress occurs less in institutions and teams where there is a healthy and positive attitude towards ethics and the discussion of the application of ethics (Whitehead et al., 2015).A Therefore, it is important that institutions encourage the development of an ethically healthy environment at all levels of management (Deady and McCarthy, 2010).A A Additionally, many studies highlight that incompetence in colleagues and subsequent errors in patient care is a primary source of moral distress in nursing staff, and as such institutions should ensure that an adequate quality of care monitoring system is in place, preferably where staff are able to raise concerns without fear of reprisal (Whitehead et al., 2015; Stanley and Matchett, 2014).A A Institutions should also strive to reduce factors such as institutional disorganisation, inadequate resource levels and understaffing (Dalmolin et al., 2014).A Anonymous reviews have also identified extreme examples of patient mistreatment and poor care, and a lack of empowerment of student nurses in particular to report or challenge unacceptable behaviour in colleagues.A Universities and institutions should therefore encourage an environment where this is possible (Rees et al., 2015).A Feelings of powerlessness to contest clinical decisions can also be reduced by encouragingA collaborative decision making within teams (Karanikola et al., 2014; Em Pijl”?Zieber et al., 2008).A Healthcare institutions should also recognise their responsibilities in reducing moral distress amongst nursing staff in order to support them correctly and also to retain staff and limit absence due to staff sickness.A For example, an institution could appoint a designated ethics consultant who can offer guidance to nurses, and ensure that staff have access to counselling if required to address any psychological distress.A The institution could also support the setting up of an ethics discussion forum where staff could discuss troubling situations (Matzo and Sherman, 2009), for example using an online forum which would also provide anonymity to facilitate open discussion.A It has been recommended that such groups be cross-disciplinary, as this would allow for potentially valuable differing viewpoints to facilitate discussion and potentially offer different solutions or approaches to those traditionally used by a team (Matzo and Sherman, 2009).A Nursing management staff are thought to experience less moral distress than nurses themselves, presumably as the result of the "distance" perceived between themselves and the questionable moral decision (Ganz et al., 2015).A As a result it may also be beneficial for management staff to receive specific training about moral distress so that they can understand the situation better and provide more effective support to their teams.A

Conclusion

Moral distress is a significant factor for nurses leaving the profession.A Combatting moral distress is important, not only for the welfare of nursing staff but also the patients themselves.A Healthcare institutions have a responsibility to minimise moral distress as much as possible by improving administrative issues such as staffing levels, team organisation and job satisfaction.A However nurses still have a responsibility to themselves and their patients to reduce moral distress and thus negate its impact on patient care (as well as their own health and wellbeing) by actively partaking in activities such as ethical discussion groups and peer support networks.A Together nurses, healthcare institutions and universities can reduce the impact of moral distress by cultivating an environment where nursing staff can participate in controversial care plan discussions.A

References

Borhani, F., Abbaszadeh, A., Nakhaee, N. and Roshanzadeh, M. (2014). The relationship between moral distress, professional stress, and intent to stay in the nursing profession. Journal of Medical Ethics and History of Medicine, 7, p.3. [Online]. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25512824 [Accessed: 25 June 2015] Bryon, E., Dierckx de CasterlA©, B. and Gastmans, C. (2012). 'Because we see them naked' - nurses' experiences in caring for hospitalized patients with dementia: considering artificial nutrition or hydration (ANH). Bioethics, 26 (6), p.285–295. [Online]. Available at: https://www.ncbi.nlm.nih.gov/pubmed/21320145 [Accessed: 25 June 2015] Dalmolin, G. de L., Lunardi, V. L., Lunardi, G. L., Barlem, E. L. D. and Silveira, R. S. da. (2014). Moral distress and Burnout syndrome: are there relationships between these phenomena in nursing workers? Revista Latino-Americana de Enfermagem, 22 (1), p.35–42. [Online]. Available at: https://www.scielo.br/scielo.php [Accessed: 26 June 2015]. Deady, R. and McCarthy, J. (2010). A Study of the Situations, Features, and Coping Mechanisms Experienced by Irish Psychiatric Nurses Experiencing Moral Distress: A Study of the Situations, Features, and Coping Mechanisms Experienced by Irish Psychiatric Nurses Experiencing Moral Distress. Perspectives in Psychiatric Care, 46 (3), p.209–220. [Online]. Available at: https://doi.wiley.com/10.1111/j.1744-6163.2010.00260.xA [Accessed: 26 June 2015]. Em Pijl”?Zieber, Brad Hagen, Chris Armstrong”?Esther, Barry Hall, Lindsay Akins and Michael Stingl. (2008). Moral distress: an emerging problem for nurses in long”?term care? Quality in Ageing and Older Adults, 9 (2), p.39–48. [Online]. Available at: https://www.emeraldinsight.com/doi/abs/10.1108/14717794200800013A [Accessed: 26 June 2015]. Fitzpatrick, J. J. and Wallace, M. (2011). Encyclopedia of Nursing Research, Third Edition. Springer Publishing Company. [Online]. Available at: https://books.google.co.uk/books?id=jAE_s82NjtAC&dq=nursing+moral+distress&hl=en&sa=X&ei=WMiLVfSZE8Ke7gaO4IGIBg&ved=0CD8Q6AEwBQ [Accessed: 25 June 2015]. Ganz, F. D., Wagner, N. and Toren, O. (2015). Nurse middle manager ethical dilemmas and moral distress. Nursing Ethics, 22 (1), p.43–51. [Online]. Available at: https://nej.sagepub.com/cgi/doi/10.1177/0969733013515490 [Accessed: 25 June 2015]. Jameton, A. (1984). Nursing practice: The ethical issues. 1st ed. Englewood Cliffs. [Accessed: 25 June 2015]. Karanikola, M. N. K., Albarran, J. W., Drigo, E., Giannakopoulou, M., Kalafati, M., Mpouzika, M., Tsiaousis, G. Z. and Papathanassoglou, E. D. (2014). Moral distress, autonomy and nurse-physician collaboration among intensive care unit nurses in Italy. Journal of Nursing Management, 22 (4), p.472–484. [Online]. Available at: https://doi.wiley.com/10.1111/jonm.12046 [Accessed: 26 June 2015]. Linnard-Palmer, L. and Kools, S. (2005). Parents' refusal of medical treatment for cultural or religious beliefs: an ethnographic study of health care professionals' experiences. Journal of Pediatric Oncology Nursing: Official Journal of the Association of Pediatric Oncology Nurses, 22 (1), p.48–57. [Online]. Available at: https://www.ncbi.nlm.nih.gov/pubmed/15574726. [Accessed: 25 June 2015] Matzo, M. L. and Sherman, D. W. (2009). Palliative Care Nursing: Quality Care to the End of Life, Third Edition. Springer Publishing Company. [Online]. Available at: https://books.google.co.uk/books?id=rTexGiX5bqoC&pg=PA121&dq=nursing+moral+distress&hl=en&sa=X&ei=cciLVbDDK-fd7QbR6q3oDQ&ved=0CEMQ6AEwBjgK#v=onepage&q=nursing%20moral%20distress&f=false [Accessed: 25 June 2015]. Morgan, B. and Tarbi, E. (2015). A Survey of Moral Distress Across Nurses in Intensive Care Units (FR416-A). Journal of Pain and Symptom Management, 49 (2), p.360–361. [Online]. Available at: doi:10.1016/j.jpainsymman.2014.11.091 [Accessed: 25 June 2015]. Rees, C. E., Monrouxe, L. V. and McDonald, L. A. (2015). 'My mentor kicked a dying woman's bed…' Analysing UK nursing students' 'most memorable' professionalism dilemmas. Journal of Advanced Nursing, 71 (1), p.169–180. [Online]. Available at: https://doi.wiley.com/10.1111/jan.12457 [Accessed: 26 June 2015]. Severinsson, E. (2003). Moral stress and burnout: Qualitative content analysis. Nursing and Health Sciences, 5 (1), p.59–66. [Online]. Available at: https://doi.wiley.com/10.1046/j.1442-2018.2003.00135.xA [Accessed: 26 June 2015]. Stanley, M. J. C. and Matchett, N. J. (2014). Understanding how student nurses experience morally distressing situations: Caring for patients with different values and beliefs in the clinical environment. Journal of Nursing Education and Practice, 4 (10), p.p133. [Online]. Available at: https://www.sciedu.ca/journal/index.php/jnep/article/view/5139 [Accessed: 25 June 2015]. Ulrich, C., Hamric, A. and Grady, C. (2010). Moral Distress: A Growing Problem in the Health Professions? Hastings Center Report, 40 (1), p.20–22. [Online]. Available at: https://muse.jhu.edu/content/crossref/journals/hastings_center_report/v040/40.1.ulrich.html [Accessed: 26 June 2015]. Whitehead, P. B., Herbertson, R. K., Hamric, A. B., Epstein, E. G. and Fisher, J. M. (2015). Moral Distress Among Healthcare Professionals: Report of an Institution-Wide Survey: Moral Distress. Journal of Nursing Scholarship, 47 (2), p.117–125. [Online]. Available at: https://doi.wiley.com/10.1111/jnu.12115 [Accessed: 25 June 2015]. Wilkinson, J. M. (1987). Moral Distress in Nursing Practice: Experience and Effect. Nursing Forum, 23 (1), p.16–29. [Online]. Available at: https://onlinelibrary.wiley.com/doi/10.1111/j.1744-6198.1987.tb00794.x/abstract [Accessed: 25 June 2015]. Wilkinson, J. M. (1989). Moral Distress: A Labor and Delivery Nurse's Experience. Journal of Obstetric, Gynecologic, Neonatal Nursing, 18 (6), p.513–519. [Online]. Available at: https://doi.wiley.com/10.1111/j.1552-6909.1989.tb00503.x [Accessed: 26 June 2015]. Wilson, M. A., Goettemoeller, D. M., Bevan, N. A. and McCord, J. M. (2013). Moral distress: levels, coping and preferred interventions in critical care and transitional care nurses. Journal of Clinical Nursing, 22 (9-10), p.1455–1466. [Online]. Available at: https://doi.wiley.com/10.1111/jocn.12128 [Accessed: 26 June 2015]. Wojtowicz, B., Hagen, B. and Van Daalen-Smith, C. (2014). No place to turn: Nursing students' experiences of moral distress in mental health settings: Moral Distress in Mental Health Settings. International Journal of Mental Health Nursing, 23 (3), p.257–264. [Online]. Available at: https://doi.wiley.com/10.1111/inm.12043 [Accessed: 25 June 2015].

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How the Beliefs, Values and Attitudes of the Nurse May Impact Upon the Provision of Person-centred Care

Contents

Introduction
Conclusion
References/Bibliography:

Provide a critical analysis of how the beliefs, values and attitudes of the nurse may impact upon the provision of person-centred care

Introduction

The person-centred care approach focuses holistically on the patient as an individual, rather than their diagnosis or symptoms, and ensures that their needs and choices are heard and respected. According to Draper & Tetley (2013: n.p.), person-centred care is defined as “an approach to nursing that focuses on the individual’s personal needs, wants, desires and goals, so that they become central to their care and the nursing process. This can mean putting the person’s needs, as they define them, above those identified as priorities by healthcare professionals.” Theoretically, this is an achievable aim – nursesas a matter of principle should provide care that respects the diversity of the values, needs, choices and preferences of those in their care – but how can any incongruity between the values, beliefs and attitudes of the patient and those of the nurse be reconciled? Is it inevitable that this dissonance will have a negative impact on the quality of person-centred care being provided?

This essay will examine the beliefs, values and attitudes of nurses planning and delivering person-centred care, and the impact these issues can have on the provision of that care.

Nurses are expected to practice in a caring, knowledgeable, professional, courteous and non-judgemental manner, and the majority do this as a matter of principle, displaying unconditional positive regard for their patients at all times. However, values, beliefs and attitudes are, of course, subjective to each individual, and in the context of delivering person-centred nursing care, it is important to identify those that are holistic and therapeutic, rather than focussing only on those that are not. According to Brink & Skott (2013), some diagnoses lead to preconceptions about the individuals receiving them, which subsequently negatively influence their care and treatment. This can be particularly evident in the case of mental illness, which is often mired in stigma, fear, ignorance and discrimination.

Research undertaken by Chambers et al (2010: pp. 350) found that “Stigma on the part of mental health professionals affects the quality of care provided for those with mental health problems, as well as their rates of recovery.” Although nurses working within the field of mental health will obviously have more developed skills and knowledge in this subject than those in other specialities of nursing, it is not inconceivable that nurses may harbour some preconceptions about mental illnesses and those diagnosed with them, which may impact on how positively they deliver care to those patients.

Those requiring treatment for alcohol abuse or substance misuse may also experience a less empathetic experience in the care of nurses, who may feel that the condition is self-inflicted, or that resources may be better utilised elsewhere. This attitude may be even more prevalent in cases of liver transplant due to alcoholic cirrhosis of the liver, when there may be a misplaced belief that another recipient is more ‘deserving’ of the organ.

Other morbidities which can be perceived as having a self-inflicted element (e.g. obesity, smoking-related illnesses, type-II diabetes, addictions) also have the potential to be perceived negatively by nursing staff, who may lack an appropriate level of empathy and compassion, or make assumptions and pre-conceptions about these patients based on their diagnoses.

In a similar manner, patients attempting suicide or deliberately self-harming, may experience stigma, a lack of sympathy and a lack of understanding from nursing staff, especially if the nurse managing their care is also involved in the care of patients suffering from serious illnesses or conditions. Caring for patients attending accident and emergency departments due to para-suicide or deliberate self-harm can evoke extremely negative emotions and attitudes amongst the nursing staff caring for them. Nurses working with such patients report experiencing high levels of ambivalence and frustration.

Additionally, deliberately self-harming patients may evoke negative attitudes such as anxiety, anger, and lack of empathy (Ouzouni & Nakakis 2013).

A suicidal patient voicing their desire to end their life is expressing a wish. However, in the context of person-centred care, it would be difficult to agree that this wish should be considered as a person-centred need. This could be a source of conflict, difficulty and dissonance as balancing the needs and wishes of the patient in this situation, contradicts entirely the nurse’s duty of care. In such circumstances, it could be argued that the care provided cannot be person-centred, as it is not in line with the patient’s wishes. Obviously it would be neither legal nor ethical for the nurse to allow a suicidal patient to actively attempt to end their life whilst under their care, or to comply with the patient’s wishes not to receive treatment if suicide had been attempted.

Similar ethical considerations may also influence the treatment of patients undergoing procedures to terminate pregnancy, and may negatively influence the extent to which the care received by the patient is truly person-centred. There have been well-documented cases of nurses refusing to assist with these procedures, or to treat patients who have undergone them post-operatively.

Predominantly such cases arise due to a conflict with the religious beliefs, moral convictions and ethical stance of the nurses being asked to assist with these procedures. The Nursing & Midwifery Council (2015) states that “Nurses and midwives must at all times keep to the principles contained within The Code: Professional standards of practice and behaviour of nurses and midwives (2015: n.p.). This code states that nurses and midwives who have a conscientious objection must tell colleagues, their manager and the person receiving care that they have a conscientious objection to a particular procedure.

They must arrange for a suitably qualified colleague to take over responsibility for that person’s care. Nurses and midwives may lawfully have conscientious objections in two areas only. Firstly, Article 4(1) of the Abortion Act 1967 (Scotland, England and Wales). This provision allows nurses and midwives to refuse to participate in the process of treatment which results in the termination of a pregnancy because they have a conscientious objection, except where it is necessary to save the life or prevent grave permanent injury to the physical or mental health of a pregnant woman.

Secondly, Article 38 of the Human and Fertilisation and Embryology Act (1990). This provision allows nurses and midwives the right to refuse to participate in technological procedures to achieve conception and pregnancy because they have a conscientious objection.

This is a highly contentious and emotive issue, and one which attracts much ongoing debate and argument, and is significant as it can be asked at what point does a nurse’s own beliefs and values take precedence over their responsibility and duty to care for their patients’ needs, whatever they might be? Should nurses be permitted to refuse to participate in care procedures that contradict their values or beliefs, or to refuse to provide care to those they deem ‘undeserving’? Does this set a worrying precedent for other contentious procedures to be added to the list (gender reassignment surgery for example)? It could be argued that the nurse’s first responsibility should be their duty of care to their patient, and this surely requires them to take a holistic and person-centred view; a view that should not be clouded by the nurse’s own values system or moral standpoint.

The aspects of person-centred care discussed so far in this essay have been those of a contentious and perhaps, more exceptional nature. However, the more routine, day-to-day aspects of nursing are also susceptible to the influence of nurses’ values, beliefs and attitudes negatively impacting on the quality of person-centred care provision.

Giving patients a greater degree of autonomy over their care can lead to some discord as nurses may feel that their professional expertise is being disregarded, and may be concerned that patients’ informed opinions and decisions about their care may be detrimental to recovery or good health. This could lead to nurses adopting a didactic attitude in the belief that they know best, when the patient is equally certain that their decision is the right one for them. Nurses must always ensure that they are viewing the patient as a whole person, and not merely an illness or condition to be treated or managed, as this can lead to ambivalence as nurses attempt to reconcile their desire to deliver effective, evidenced-based care, knowing that patients’ stated wishes or preferences are contrary to this aim.

However, if the patient is deemed to have capacity to make informed decisions about their care and treatment, with all the facts at their disposal, nurses must accept this if good, person-centred care is to be delivered (NHS Choices 2014). In the event that the patient does not have the capacity to make informed decisions (e.g.

patients suffering from more advanced forms of dementia), then any known pre-morbid preferences and choices should be documented and adhered to where this is practicable. There is always a danger that individuals with dementia receive care that is task-orientated rather than person-centred. Again, nurses may make assumptions regarding what is best for the patient, rather than respecting their choices and preferences.

One of the easiest ways to ensure that care is person-centred is to gather collateral about each patient prior to care or treatment commencing, so a more rounded picture can be formed. This is particularly important when dealing with people from diverse cultural backgrounds, as lack of cultural understanding and tolerance can lead to damaging misconceptions, misunderstandings and unintentional offence, which will not engender good person-centred care. Having some knowledge of patients’ history and background prior to treatment can be a useful tool in terms of developing appropriate care.

The flip-side to this however is that unhelpful stereotypes or prejudices may be formed by nursing staff, based on the current or historical background of the patient.

Gender (including gender identify), race, age, religious affiliation, employment status, marital status, and educational and socio-economic background can lead to assumptions (both positive and negative) being formed by nursing staff. Whilst the majority of nurses will treat their patients with unconditional positive regard and courtesy, regardless of issues that may be at odds with their own beliefs, values and attitudes, there will always be a minority who will be affected by such issues, and who will allow it to influence the care they provide. The scale of this issue is difficult to quantify, due to a lack of available evidence-based research, but it could be said that one nurse whose attitude negatively impacts on person-centred care is one nurse too many.

Conclusion

We have explored some of the more contentious issues that can and do arise when nurses’ beliefs, values and attitudes do not correspond with those of their patients, and have examined the potential impact this can have on the quality of person-centred care provided. As little research has been carried out into this subject, it is not possible to quantify the scale of the problem, nor to accurately identify where it is most prevalent.

However, it is safe to say that the dichotomy between delivering truly person-centred care, whilst reconciling challenges to the nurse’s own core beliefs and values is not one easily solved. Modern nurses are extensively trained and highly skilled professionals, with a wider remit and range of responsibilities than their predecessors. They are however fundamentally human, with the same character flaws and failings as anyone else. It is a completely human trait to be influenced by the information we perceive or receive about others, and everyone has innate beliefs and value systems and, whether we like it or not, innate prejudices.

Although it would seem logical that professional nurses have a well-developed sense of understanding and equality, they also deal with a magnitude of very diverse people on a daily basis, generally having very limited time with each. Despite this, the majority of nurses deliver excellent, patient-focussed and person-centred care as a matter of course.

Unfortunately there will always be a minority who do not. Nurse education programmes are constantly evolving to meet the shifting demands of health care, so it can only be hoped that recognising, challenging and improving unhelpful attitudes becomes an accepted part of nurse education, and becomes core to person-centred care provision.

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Factors Impacting on the Effectiveness of Palliative Care

Palliative care can vary significantly in its effectiveness according to condition, location, and type of patient. This has long been recognised as an issue: Higginson et al. (2003) suggested that it has been difficult to prove the effectiveness of palliative care given the broad range of providers and the diverse nature of the clients. The World Health Organisation has argued that palliative care has generally been unduly focused on the needs of cancer patients and is unsuited for the increase in older patients with diverse needs that are more common in many parts of the world. Part of this variation is the differences between the type of care required for various conditions and the fact that sometimes specialised care for a variety of conditions is required. There are also challenges posed to meeting patients' wishes for palliative care through patient-centred care, and Gomes et al. (2013) suggest that the desire of most patients to die at home can stretch resources or result in palliative care provision not reaching the wishes of their clients.

Likewise, the extent to which palliative care can be effectively provided through interaction with other care providers, and the role of family or informal carers is often unclear. This has led to a range of views on the effective provision of palliative care. In this essay, first the challenges posed by an aging population and the challenge of providing specialist care to specific population groups will be considered. Second, the challenge of providing home-based palliative care will be discussed. Third, the challenges of developing effective communication between caregivers and the family will be evaluated. Fourth, ways in which informal caregivers may be involved in palliative care will be discussed. Finally, the arguments for earlier intervention in some cases will be evaluated. The World Health Organisation argues that an important factor impacting upon the effectiveness of palliative care is the aging population in most countries that is coupled with a lack of attention to their complex needs.

Older people more commonly experience multiple health problems, resulting in the need for such complex health needs to be more effectively supported (WHO, 2011). The model for palliative care traditionally focuses upon support for single diseases such as cancer, whereas people aged over 85 years are more likely to die from cardiovascular disease. There are also multiple debilitating diseases, such as dementia, osteoporosis and arthritis, and may require palliative care at any point in their illness trajectory. WHO (2011) indicate that palliative care does not usually form a part of traditional disease management, and with a combination of diseases the point at which palliative care is needed may become increasingly difficult to determine. The need for integration between different agencies is also cited as an important factor affecting older people (WHO, 2011). As such, palliative care for older adults must take into account the increasing variety of conditions that may develop, which is something that is not yet common amongst many care providers.

Solutions to these issues proposed by WHO (2011) include the need for palliative and primary care providers to receive more effective training in the needs of older people, and to gain a clearer understanding of the syndromes that affect this population group. This also includes a more effective understanding of the pharmacokinetics of opiates for pain management, and issues that are caused by comorbidity (Gardiner et al., 2011). Palliative physicians also need to improve their understanding of long-term care, including the administrative and clinical issues that are associated with older people dying in care homes. Likewise, inter-agency collaboration in palliative care is required to ensure that diverse needs are met through carers with different specialisms (Neilson et al., 2013). This means that palliative care needs to adopt a more personalised approach that takes into account the specific needs of clients, making collaborative approaches more common (Vitillo & Puchalski, 2014).

As such, partnership working is likely to play an increasingly prominent role in palliative care provision in the future. Similar concerns involving the specialised care for specific groups is identified by Vollenbroich et al. (2012), who investigate the potential for providing home care for children. These results suggested that where a specialised paediatric care team was used, there were high improvements in the children's symptoms and quality of life. Additional benefits were seen as the reduction of the administrative barriers and improvement in aspects of communication between the care teams and the family. This supports arguments made by WHO (2011) which suggests greater specialisation is required to take into account the different diversities of patients who need palliative care. However, one aspect that is not identified by Vollenbroich et al. (2012) is the challenge posed by whether the condition should be considered as of greatest importance or whether the demographic considerations are needed. This suggests that perceptions of the age at death can significantly affect the patients' needs in palliative care, and further research may be required to investigate the extent to which such suppositions are borne out in practice. The place in which palliative care is provided is also a significant factor when considering how far the care meets the wishes of the patients.

The extent to which people can opt for their place of death is an important factor affecting the effectiveness of palliative care. In the European Union, most people do not die at home (WHO, 2011). However, this is the preferred place of death for most people. In England, 58% of deaths occur in NHS hospitals, 18% at home, 4% in hospices, and 3% in other places. There is clearly an interest amongst many patients for dying at home. JordhA¸y et al. (2010) report on an intervention programme staged by the University Hospital of Trondheim, Norway, which was intended to enable patients to spend more time at home and for them to die there should they prefer. This demonstrates that in order to achieve this end, close cooperation was necessary with the community health-care providers, and a multidisciplinary consultant team was needed to coordinate the care provision. This research demonstrated that intervention patients spent a smaller proportion of the last month of life in nursing homes than was possible for the control sample (JordhA¸y et al. 2010). This illustrated that to increase the proportion of patients who were able to die at home, a significant investment of resources would be needed.

This manifested itself in the need for greater levels of training in palliative care for community care staff, thus increasing the costs associated with the provision of care. Similar considerations were made by Gomes et al. (2013), who argue that providing palliative care at home increases the chances of dying at home, while reducing symptom burden that people experience as a part of an advanced illness. This also reduces the intensity of grief for family members if the patient dies. However, Gomes et al. (2013) suggest that it is possible to provide home palliative care without significantly raising costs, but this is challenged by reports such as WHO (2011) who argue that for many patients, the complexity of the conditions experienced undermine the potential for home care to be effectively provided. Smith et al. (2014) suggest, however, that the context of increasing costs of healthcare means that the potential for palliative care to be provided in the home environment should be more closely investigated. In particular, this outlines that the quality of care can be significantly improved for home-based care, and in some cases the costs may be reduced by the fact that they may be spread between existing caregivers.

Communication between the patients and family members is often cited as an important factor leading to improved palliative care. Hannon et al. (2012) suggest that in contexts where family members are taken into account and given a role, family meetings can account for a significant improvement to the weekly workload for staff members. The study suggested that such meetings improved the particular areas of concern and worry for family members. This demonstrates that such meetings can play an important role improving the experience of palliative care and indicate that one of the important roles of caregivers lies in the support that is given to the families of the patients as well as to the patients themselves. However, although such meetings are considered appropriate and effective they may be undermined by the time constraints, the availability of appropriate staff, and the limitations of resources. This may lead to less emphasis being placed on such aspects of palliative care, particularly where the benefit is not directed wholly towards the patient. Nevertheless, against this criticism is the extent to which such issues may result in the needs of the patient being better identified by consultation with family members.

It can be argued that this would represent an area of particular benefit to the provision of palliative care. Harding et al. (2011) point out that informal caregivers are of significance in providing effective palliative care. Given the diversity of the care provided by this group, there is a need for a range of intervention strategies to provide appropriate support, depending on the needs of the patient. However, Harding et al. (2011) suggest that the range of models that are available to meet caregivers' needs. Likewise, Harding et al. (2012) emphasise the significant costs to informal caregivers in terms of the emotional, physical and financial demands that informal caregiving places upon them. The conclusions of these studies indicate that support should be provided specifically to the caregiver and tailored closely to their needs, and the drawback of many existing approaches was the fact that interventions were not tailored to the caregivers' needs. This is an important aspect for improving palliative care, as many patients prefer the services of informal caregiving, and this can also reduce the burden on professional healthcare if appropriate.

The potential for providing support that is tailored to the needs of the informal caregivers would seem an important and effective means by which the quality of palliative care can be improved. Zimmerman et al. (2014) identify that there are limitations to the provision of palliative care in home settings that depend upon the condition of the patient. In their study, patients with advanced cancer tend to have a much lower quality of life that worsens as their condition progresses. This suggests that for some patients, palliative care should be provided at an earlier stage than is usually the case. However, such developments would depend upon the prognosis, and in such cases it is important to avoid premature judgment. Yoong et al. (2013) also suggest that early palliative care can prove beneficial in situations where patients have advanced lung cancer. This suggests that the benefits allow the palliative care teams to focus on fostering relationships with patients and their families, and improving illness understanding amongst patients and caregivers.

The potential for adopting a comprehensive approach in this case provided psychosocial benefits, such as improving the coping mechanisms for patients alongside the management of medical treatment. The research thus indicates that the involvement of palliative care teams at an earlier stage in the treatment may be appropriate for some conditions and may provide significant benefits to the quality and effectiveness of care. In conclusion, many of the arguments discussed suggest that there is an important case to be made for a greater diversity in approaches to palliative care. The need to take into account the diversity in the psychosocial needs of different population groups illustrate the importance of a more personalised approach to palliative care.

Likewise, the challenge in meeting patients' wishes to die at home requires significant attention as this can clearly provide significant benefits to patients. The research also indicates that greater engagement with family members can help support patients and prove of wider benefit to the carers. This also indicates that the involvement of informal caregivers is also a significant area of development, given the wide-ranging role they can play in the provision of palliative care. The introduction of palliative care at an earlier stage may allow benefits to the care process, particularly where the patient is cared for at home, as it helps foster an effective working relationship between different parties. Thus far, the key deficiencies of palliative care are largely that it appears to be focused on particular conditions and specific locations; the challenge is to broaden the type of patient that can be cared for, provide greater support to informal carers and family members, and be more responsive to the wishes of the patient.

References

Aslakson, R., Cheng, J., Vollenweider, D., Galusca, D., Smith, T. J., & Pronovost, P. J. (2014). Evidence-based palliative care in the intensive care unit: a systematic review of interventions. Journal of Palliative Medicine, 17(2), 219-235. BrandstA¤tter, M., KAgler, M., Baumann, U., Fensterer, V., KA¼chenhoff, H., Borasio, G. D., & Fegg, M. J. (2014).
Experience of meaning in life in bereaved informal caregivers of palliative care patients. Supportive Care in Cancer, 22(5), 1391-1399. Bajwah, S., Higginson, I. J., Ross, J. R., Wells, A. U., Birring, S. S., Patel, A., & Riley, J. (2012). Specialist palliative care is more than drugs: a retrospective study of ILD patients. Lung, 190(2), 215-220. Bruera, E., & Yennurajalingam, S. (2012). Palliative care in advanced cancer patients: How and when?. The Oncologist, 17(2), 267-273. Gardiner, C., Cobb, M., Gott, M., & Ingleton, C. (2011). Barriers to providing palliative care for older people in acute hospitals.
Age and Ageing, 40(2), 233-238. Gomes, B., Calanzani, N., Curiale, V., McCrone, P., & Higginson, I. J. (2013). Effectiveness and cost”effectiveness of home palliative care services for adults with advanced illness and their caregivers. The Cochrane Library. https://www.update-software.com/BCP/WileyPDF/EN/CD007760.pdf Hannon, B., O'Reilly, V., Bennett, K., Breen, K., & Lawlor, P. G. (2012). Meeting the family: measuring effectiveness of family meetings in a specialist inpatient palliative care unit. Palliative and Supportive Care, 10(1), 43-49. Hannon, B., Swami, N., Pope, A., Rodin, G., Dougherty, E., Mak, E., ... & Zimmermann, C. (2014).
The oncology palliative care clinic at the Princess Margaret Cancer Centre: an early intervention model for patients with advanced cancer. Supportive Care in Cancer, 23(4), 1073-1080. Harding, R., Epiphaniou, E., Hamilton, D., Bridger, S., Robinson, V., George, R., ... & Higginson, I. J. (2012). What are the perceived needs and challenges of informal caregivers in home cancer palliative care? Qualitative data to construct a feasible psycho-educational intervention. Supportive Care in Cancer, 20(9), 1975-1982. Hanson, L. C., Rowe, C., Wessell, K., Caprio, A., Winzelberg, G., Beyea, A., & Bernard, S. A. (2012).
Measuring palliative care quality for seriously ill hospitalized patients. Journal of Palliative Medicine, 15(7), 798-804. Harding, R., List, S., Epiphaniou, E., & Jones, H. (2011). How can informal caregivers in cancer and palliative care be supported? An updated systematic literature review of interventions and their effectiveness. Palliative Medicine, 26(1), 7-22. Higginson, I. J., Finlay, I. G., Goodwin, D. M., Hood, K., Edwards, A. G., Cook, A., ... & Normand, C. E. (2003). Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers?. Journal of Pain and Symptom Management, 25(2), 150-168. JordhA¸y, M. S., Fayers, P., Saltnes, T., Ahlner-Elmqvist, M., Jannert, M., & Kaasa, S. (2010).
A palliative-care intervention and death at home: a cluster randomised trial. The Lancet, 356(9233), 888-893. Neilson, S. J., Kai, J., McArthur, C., & Greenfield, S. (2013). Using social worlds theory to explore influences on community nurses' experiences of providing out of hours paediatric palliative care. Journal of Research in Nursing, 18(5), 443-456. Preston, N., Dunleavy, L., Rigby, J., Griggs, A., Salt, S., Parr, A., & Payne, S. (2014). Overcoming barriers to research in palliative care: results from a consensus exercise.
Palliative Medicine, 28(6), 745-745. Smith, S., Brick, A., O'Hara, S., & Normand, C. (2014). Evidence on the cost and cost-effectiveness of palliative care: A literature review. Palliative Medicine, 28(2), 130-150. Vitillo, R., & Puchalski, C. (2014). World Health Organization authorities promote greater attention and action on palliative care. Journal of Palliative Medicine, 17(9), 988-989. Vollenbroich, R., Duroux, A., Grasser, M., BrandstA¤tter, M., Borasio, G. D., & FA¼hrer, M. (2012).
Effectiveness of a pediatric palliative home care team as experienced by parents and health care professionals. Journal of Palliative Medicine, 15(3), 294-300. Yoong, J., Park, E. R., Greer, J. A., Jackson, V. A., Gallagher, E. R., Pirl, W. F., ... & Temel, J. S. (2013). Early palliative care in advanced lung cancer: a qualitative study. JAMA Internal Medicine, 173(4), 283-290. Zimmermann, C., Swami, N., Krzyzanowska, M., Hannon, B., Leighl, N., Oza, A., ... & Lo, C. (2014). Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. The Lancet, 383(9930), 1721-1730.

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Safeguarding Dementia Patients

Contents

Introduction
Dementia: Cause of Vulnerability
Safeguarding: Duties and Expectations
Dementia Specific Issues
Steps a Nurse Can Take: Identification
Steps a Nurse Can Take: Prevention
Conclusion
References

Introduction

All nurses have a duty of care to their patients (Brooker and Waugh, 2013). Nurses are expected to play a safeguarding role, recognising vulnerable patients and protecting them from harm, abuse and neglect. Elderly patients are at especial risk due to their poor health, disabilities and increased frailty (de Chesnay and Anderson, 2008). Of concern here, is the higher than average incidence of abuse in elderly people with dementia (Cooper et al., 2008). Nurses play an important role in recognising signs of abuse and acting as advocates for their dementia patients. Here, the principles of safeguarding and how they are applied in dementia nursing are presented.

Dementia: Cause of Vulnerability

Dementia is a group of symptoms that are associated with declining functionality and physical health of the brain (NHS Choices, 2015). This decline in mental function makes a person increasingly vulnerable (de Chesnay and Anderson, 2008). Dementia is typically seen in elderly people with one in every three people over 65 having dementia, and two-thirds of these will be women (Alzheimer's Society, 2014). The signs and symptoms of dementia demonstrate how this condition makes someone vulnerable to harm, abuse or neglect (Hudson, 2003) as they include: memory loss, reduced thinking speed, reduced mental agility, language difficulties, lower levels of understanding and reduced judgement. Furthermore, as dementia develops people become more apathetic and isolated as they lose interest in socialising, putting them at increased risk. Dementia can alter a person's personality (Hudson, 2003). They may find it difficult to control their emotions and hard to empathise. They may appear more self-centred, suffer from hallucinations and even make false claims or statements. All of these factors make it difficult for relatives and carers to interact with the dementia patient especially when offering very personal care (Adams and Manthorpe, 2003). Dementia reduces a person's ability to live independently and, as the condition progresses, they will increasingly need support and assistance. Their lack of mental capacity makes dementia patients vulnerable to the actions of others (Hudson, 2003). They will require assistance with decisions and gradually lose their autonomy as the dementia progresses, eventually relying on others for even the most simplistic decisions. Depending upon the stage and severity of their dementia, they may be living at home with support from relatives, or they may be in residential care.

Safeguarding: Duties and Expectations

Safeguarding adult patients means to protect those at risk of harm from suffering any abuse or neglect (Tidy, 2013). The CQC (2015) defines safeguarding people as "protecting people's health, wellbeing and human rights, and enabling them to live free from harm, abuse and neglect". Safeguarding is seen as an essential component of high quality health and social care. The healthcare provider is expected to minimise the risk of any abuse or neglect befalling a patient, identifying any potential causes and taking steps to mitigate them. A patient's right to live safely and free from abuse or neglect must be protected, and their wellbeing promoted with ample consideration for their own views and beliefs. The overall responsibility for safeguarding vulnerable adults lies with Adult Social Care (Dementia Partnerships, 2015). They receive and process and safeguarding issues from their partner agencies. However, each partner agency is expected to have its own procedures and practices to recognise and respond to any safeguarding alerts. This means that all staff employed by a health or social care provider has a duty to identify and report any safeguarding issues. Nurses caring for patients with dementia therefore have a duty to identify and report any signs of abuse or neglect (Hudson, 2003). Furthermore, they must have the knowledge and skills necessary to provide quality care to these patients with reduced mental capacity. Abuse of a vulnerable adult can occur anywhere: at their home, in a hospital or a residential care setting (Tidy, 2013). Abuse can include physical actions, sexual abuse, mental or emotional abuse, neglect and also financial abuse. Often, the abuser is well known to the victim (de Chesnay and Anderson, 2008). They could be a neighbour, relative or friend, carer, nurse or social worker, a fellow resident or service user. The adults most at risk of abuse are the frail elderly people who either live alone, or live in residential care, but without any family support (Mandelstam, 2008). In terms of suffering physical harm, the most at risk are those adults with mental or physical disabilities.

Dementia Specific Issues

Dementia patients are vulnerable adults, their degree of vulnerability dependant on the stage and severity of their condition (Tidy, 2013). The Department of Health describes vulnerable adults as those who are unable to take care of themselves, or who are unable to protect themselves from harm (DH, 2000). People with care and support needs require help and assistance from both the nursing and social care disciplines. Part of the nurse's duty is to safeguard their vulnerable patient from abuse and neglect (SCIE, 2015). The Care Act (HM Government, 2014) requires local authorities to perform safeguarding duties. This stipulates a multiagency approach where any safeguarding concerns are recognised, acknowledged and addressed. Dementia patients are especially vulnerable as they increasingly lack the mental capacity to participate in the decision-making process that will ultimately protect and promote their own interests (BMA, 2011). This means that any decisions made regarding their care or treatment are made on their behalf. This loss of autonomy disempowers them and makes them subject to others' will. Coupled with the ageing process, declining physical health and increased frailty, this puts dementia patients in a highly vulnerable position.

Steps a Nurse Can Take: Identification

Safeguarding adults with dementia is a difficult task. It is widely acknowledged that it is difficult for the nurse to spot signs of abuse in dementia patients due to similarities between signs of abuse and symptoms of their underlying condition. General signs of abuse can include frequent arguments between the caregiver and the patient, and changes in the dementia patient's personality or behaviour (Tidy, 2013). Yet, as noted above, these are also signs and symptoms of the progressive disease. Furthermore, spotting such trends requires the nurse to have good knowledge of both patient and carer. Recognised signs of emotional abuse such as rocking, sucking and/or mumbling to themselves are also dementia-like (Tidy, 2013). Often professionals can only detect the signs of physical abuse and neglect by way of a detailed physical examination. The nurse should look for signs of physical and sexual abuse such as physical injury, bruising and bleeding. These may seem more easily detectable, but can be concealed or explained away as accidents. Signs of neglect, including weight loss, dirty living conditions, poor personal hygiene and untreated physical problems, should be identified by the nurse. Again, factors associated with dementia such as increasing apathy, reduced taste / appetite may be the underlying cause and will need to be explored. Effective safeguarding requires the nurse needs to get to know their patient, discussing all aspects of their well being with them and/or their carer. People with dementia are especially vulnerable to abuse being less able to remember or describe what has occurred (Alzheimer's Society, 2014). Victims, whether they have dementia or not, find it difficult to tell anyone what has happened. Added to this general reluctance, are issues specific to dementia: patients may feel that they will not be believed, have difficulties recalling and communicating events. The distress caused by the abuse may exacerbate these difficulties. Dementia patient are often not believed, being discredited and thought of as confused and unreliable. Therefore, to protect their patients and best represent their interests it is essential that the nurse understands them and establishes a good trusting relationship. Dementia patients are also at increased risk of financial abuse. This can include sales-people taking advantage of them, relatives or carers accessing their bank details or causing them to alter their will and/or gain power of attorney (Adams and Manthorpe, 2003). Yet, the nurse should remember that some of these actions may be necessary steps so as to provide care to elderly dementia sufferers. For example, a carer may need to pay for some goods or services for the patient, and, in cases of significant reductions in mental capacity, power of attorney has to be awarded to ensure that all aspects of the dementia patient's life are managed. Nurses should be aware of the Mental Capacity Act (HM Government, 2005). This was introduced to help protect the rights and wellbeing of those who lack capacity. It governs the responsibilities and jurisdiction of those making decisions on another's behalf. It aims to ensure that people's autonomy is protected, but where they cannot make a decision, they are not ignored and any actions are in their best interest (Adams and Manthorpe, 2003). The demanding care needs of dementia patients can result in high levels of 'carer stress' to be experienced by relatives and friends. This may cause that individual to do abusive things and behave out-of-character. Nurses should recognise that carers of dementia patients experience greater strain and distress compared to carers of other elderly people (Alzheimer's Society, 2014). The enforced change of lifestyle resulting from caring full time can manifest as resentment and dislike. External pressures and stress can make people abuse others, as can a history of being abused themselves, previous violent or antisocial behaviour. Nurses should endeavour to develop a good relationship with both patient and carer(s). They should seek to establish trust and empathy and learn about the people behind the condition. This will enable the nurse to offer high quality care as described in the next section.

Steps a Nurse Can Take: Prevention

Nurses should recognise that abuse can take place in all settings and be performed by all people (Tidy, 2013). Abuse of dementia patients in formal residential or hospital care settings is usually a sign of an overall poor quality of care. It signifies that staff are not appropriately trained and skilled in dementia care. They do not understand the complex needs of these patients and therefore cannot adequately address them. Thus, where a nurse identifies abuse at an organisational level, the situation should be reported so the necessary systems and training can be put in place. Remedial action on this scale is outside the scope of this essay, but where a colleague or individual carer acts inappropriately, the nurse can intervene to educate and train them. The communication difficulties posed by dementia patients does mean that it is more difficult to offer person-centred care. This results in an individual's needs not being met. This is further exacerbated where the dementia patient exhibits behavioural and psychological symptoms such as restlessness, shouting and aggression. These can result in the patient being restrained or medicated inappropriately. Therefore, nurses should ensure that they have the knowledge and skill to work with dementia patients so as to act in their best interests. On occasion, the requirements of the Mental Capacity Act are not followed appropriately: Staff assume that all dementia patients lack capacity and therefore don't involve them in decisions. Nurses should be aware of, and understand, the Act. They should know how to implement it and where to gain advice if necessary. Ideally, there should be continuity of care. The same nurse should work with the patient and their carer(s) throughout the progression of the condition. By knowing the patient well, they will be better able to facilitate person-centred care, upholding the patient's interests and best representing their views. The nurse also has safeguarding duties with regards to home-based care. Improving the emotional and practical support given to family carers of dementia patients is recognised as key to safeguarding patients. These carers have little or no training and often do not feel adequately prepared (Alzheimer's Society, 2014). They often find the situation stressful and demanding: circumstances that could lead to abuse or neglect. The nurse should therefore ensure that they are approachable and inspire confidence in the patient and carer. They should provide education and advice to carers and ensure that back-up support and resources are available to those who need it at all times. Developing a good relationship between all parties is essential in preventing abuse from occurring, ensuring the patient's needs are met and their interests respected.

Conclusion

Nurses play a key role in protecting dementia patients from abuse. In order to effectively safeguard their patients, it is essential for nurses to understand the types of abuse, how and why it may occur. Dementia patients are at especial risk due to their declining mental capacity and reliance on others. Nurses are well placed to identify and prevent abuse through establishing close, open and trusting relationships with both patient and carer. Nurses can act as advocates for their patients, representing their best interests and facilitating person-centred care. Through providing education and support for carers, nurses can ensure that all the dementia patient's needs are met.

References

Adams, T., Manthorpe, J., (2003). Dementia Care: An evidence based textbook. Boston, CRC Press Alzheimer's Society, (2014). Dementia 2014 Infographic [on-line]. London, Alzheimer's Society via: https://www.alzheimers.org.uk/infographic BMA, (2011). Safeguarding Vulnerable Adults – A toolkit for general practitioners. London, British Medical Association Brooker, C., Waugh, A., (2013). Fundamentals of Nursing Practice: Fundamentals of Holistic Care. New York, Elsevier Cooper, C., Selwood, A., Livingstone, G., (2008). The prevalence of elder abuse and neglect: A systematic review. Age and Ageing, 37(2): 151-160 CQC, (2015). Safeguarding People [on-line]. London, Care Quality Commission https://www.cqc.org.uk/content/safeguarding-people de Chesnay, M., Anderson, B.A., (2008). Caring for the Vulnerable: Perspectives in Nursing Theory, Practice and Research. London, Jones and Bartlett Learning Dementia Partnerships, (2015). Safeguarding vulnerable adults [on-line]. Ashburton, Dementia Partnerships https://www.dementiapartnershipd.org.uk/archive/primary-care/primarycaretoolkit/1-dementia-care/managing-a-long-term-condition/safeguarding/ DH, (2000). No Secrets: guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse. London, Department of Health HM Government, (2014). The Care Act. London, The stationary office HM Government, (2005). The Mental Capacity Act. London, The stationary office Hudson, R., (2003). Dementia Nursing: A guide to practice. Oxford, Radcliffe Publishing Mandelstam, M., (2008). Safeguarding Vulnerable Adults and the Law. London, Jessica Kingsley Publishers NHS Choices, (2015). Dementia [on-line]. London, Department of Health https://www.nhs.uk/Conditions/dementia-guide/Pages/about-dementia.aspx SCIE, (2015). Adult Safeguarding [on-line]. London, Social Care Institute for Excellence https://www.scie.org.uk/adults/safeguarding Tidy, C., (2013). Safeguarding Adults. Leeds, Emergency Medical Information Service

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Deathography Reflective Essay

Contents

References
Bibliography

>Deathography Reflective Essay

In life nothing is more inevitable than death, it simply cannot be avoided. Despite advances in medical sciences and increased longevity in the Western world, human life remains fragile as death can occur at any age in a myriad of circumstances. Grief follows the death of a loved one, is often cited as being a ‘universal’ response to loss (Davidson, 1988) and can be defined as ‘intense sorrow’ (Oxford English Dictionary, 2013).

Each bereaved person will experience and respond to grief in a unique way, underpinned by social, cultural and religious factors, further influenced by the individual’s personality and coping mechanisms. Grief reactions are widely acknowledged to vary in length and severity and to have physical, emotional, cognitive, behavioural and spiritual components (Rosenblatt, 1993: Archer, 1999: Parkes, 2001). On the 18th September 1989 I gave birth to a beautiful, healthy baby girl weighing 8lbs and 11 ounces. As a parent I had such high hopes and expectations for the future but on 23rd February 2002, aged 12 years, her life was drastically cut short following a tragic accident. She was excited as she set off for her first ever sleep over at her best friend’s house, I was anxious as this was the first time she had been away from home without me.

On that cold, damp Saturday afternoon they had decided to go out for a bike ride (my daughter had borrowed an old bike belonging to her friend’s brother).Whilst out riding the chain came off, as she fell to the ground the bike landed on top of her abdomen causing her liver to rupture. My daughter died within minutes from a massive internal haemorrhage, in severe pain and all alone at the road side as her friend had gone to get help.

Oblivious to what had happened; I received a telephone call from her friend’s mother stating that Gemma had been in an accident and to meet her at the Birmingham Children’s Hospital. Assuming that she had experienced relatively minor injuries (I was told not to worry), I was ill prepared for the scene that unfolded before me as I entered the Multiple Injuries Unit in Accident and Emergency. Gemma lay motionless on a trolley, her body covered with a white sheet. The room was full of nurses and doctors who had attempted to resuscitate her, all of whom appeared shaken and emotional but no one was able to provide an explanation or answer my questions as there were no signs of injury or trauma to her body.

It was only after the post mortem that the cause of her death was identified. I left the hospital that evening with a carrier bag containing her personal possessions and a leaflet explaining ‘what to do when a child dies in hospital’, barely able to comprehend what had just happened or the magnitude of my loss. The loss of a child is the most devastating loss of all. It defies the natural order of events as parents do not expect to mourn their children, causing heartbreak and trauma like no other. Parental grief is different from other losses in both intensity and length.

Sudden death robs the bereaved of preparatory grief, is more common in young people and often occurs in clinical environments. There is a well-established theory base relating to issues of loss. Early theories include Freud’s (1917) grief work perspective and Bowlby’s (1969) early attachment model. Freud’s work led to grief being conceptualised as both a pathological condition requiring psychological intervention and a linear process.

The individual must ‘work through’ it in order to detach the memories and thoughts associated with the deceased love one. Both Bowlby (1980) and Parkes and Brown (1972) suggest that grief follows a predictable pattern. A well-known five stage grief model developed by Kübler-Ross (1969) depicts grief as passing through phases of shock and denial, anger, depression, bargaining and eventual resolution and acceptance. Terms such as ‘normal’ and ‘complicated’ grief (Engel, 1961) were developed as a way of distinguishing grief that had not resolved within a given time frame. Recent years have seen the development of a number of new theories and approaches to loss and grief.

Stroebe and Schut (1999) explain grief reactions in terms of two concurrent processes or ‘orientations’ (also known as the dual process model). Loss orientation is described as a traditional grief reaction, characterised by despair, sadness and anger, whilst restoration orientation is characterised by attempting to rebuild one’s life and move on.

Klass et al (1996) emphasises the importance not of letting go but of holding on even after the loss has occurred to maintain continuing bonds. Worden (1991) described four overlapping stages and tasks which the bereaved work through in order to relocate the deceased by redefining the relationship in the new context of the loss to invest in the future. People who are suddenly bereaved often require more support and counselling than those who have the time to prepare for the death of a loved one. Without such support, unresolved grief reactions may occur along with a life time risk for psychiatric diagnosis (Keyes et al, 2014).Unexpected death is associated with Post Traumatic Stress Disorder (PTSD), panic disorder and depression regardless of when the death occurred in the life of the bereaved person.

The incidence of generalised anxiety disorder, social phobia, mania and alcohol abuse is greater if the death occurred after the age of 40 in the bereaved person’s life. Thus, whilst extreme sadness and despair are normal reactions to loss which usually dissipate over time, some grief reactions are so severe they give rise to psychiatric disorders requiring medical intervention (Worden, 2003). On that fateful day in 2002, my whole life’s purpose changed and everything that I had lived for now ceased to be. Neimeyer (2000) maintained that major losses challenge a person’s sense of identity. In the immediate days and months that followed I strongly identified with the initial stages outlined by Kübler – Ross of shock and denial.

As a mental health professional I was familiar with the model and knew the predicted pattern that my grief would likely follow. I would ask myself over and over again, how could my only child be dead? How can someone die falling off a bicycle? Catapulted into the depths of despair, no longer a mother, all my hopes and plans for the future had become futile and irrelevant. A major task of grief requires refocusing one’s life story to rebuild and maintain a semblance of continuity between what has gone before and what lies ahead (Neimeyer, 2006). The foundations of my belief system had been called into question; why Lord did you have to take my daughter who had so much to live for when there is so much human suffering in the world.

I was consumed with anger whilst having to support my husband, parents and other family members alongside coping with returning to work. My colleagues would avoid me in the corridor, not knowing how to approach me or what to say. Barely able to function, I felt lost, alone, hopeless and worthless. Overwhelmed by guilt, I felt that I should be blamed for failing to protect my daughter as I had not fulfilled my duty as a mother. The months turned to years, my frustration grew as I waited for the time that I would achieve resolution and acceptance.

I lost motivation and became anxious, living in fear that I would lose another family member in such sudden and dreadful circumstances. I experienced flashbacks and actively avoided seeing friends and family as their children reached major milestones such as learning to drive or graduation.

Loss orientation and concurring loss restoration would have been incomprehensible for me at this time. Instead, I chose to keep her memory alive by raising money for the Birmingham Children’s Hospital, publishing a diary of a bereaved mother, sponsoring an award in her name at the school she had previously attended, making frequent visits to her grave and commissioning a large portrait of her to hang in the lounge (continuing bonds). Five years on, I was still unable to contemplate resolution and the trajectory of my grief wasn’t following a staged or linear process but zig zagged erratically back and forth between stages. This was unsettling and uncomfortable and went against everything that I had been taught as a mental health professional.

Not only had the prescriptive linear and staged models been unhelpful (Sheehy, 2013) but had led professionals to conclude that I experienced a complicated grief reaction as resolution didn’t come within a given time frame. I gave up engaging with health care professions as I felt the template they were adhering to didn’t fit my unique situation. I still felt the physical pain of losing her as I acknowledged that my loss had pervaded every area of my life and completely changed my personality. Finally, I knew that it was up to me to find meaning in my life in order to have a future. That meaning came six years later when I became the mother of a baby boy in 2008.

The experience of losing Gemma was devastating and remains immensely painful but I now accept that the pain is an intrinsic part of me. I have simply learnt to live with it. The loss and trauma I have experienced has defined the person I am today, however, it must be stated that it has also positively influenced my attitudes and beliefs about life in many ways. Over the thirteen years, I have gained inner strength and I now appreciate just how precious life is.

I take nothing for granted, knowing only too well how quickly a life can be taken away. I don’t plan for next year or too far into the future but I prefer to live in the moment and try to find something positive in each day. I am more tolerant and forgiving of others, whilst making a conscious effort to regularly remind relatives and friends how important they are to me and how much they are loved. If something is wrong in my life, I now have the courage to change it. I am not afraid of my own mortality, my faith has now been fully restored and I believe that one day I will be with her again when it is my turn to cross to the other side.

Furthermore, the way in which I interact with bereaved people as a mental health professional has changed, shaped by my own experiences and the need to understand each individual in the context of their reality. The hardest thing to do was to forgive myself and to realise that I am not to blame for her death.

I have survived life’s cruellest blow and although life will never be the same, I am now able to experience happiness again. Gemma will always have a presence in my life as she is spoken about lovingly and frequently as a household name, her portrait remains over the fire place as a reminder of her wonderful contribution to my life. In conclusion, whilst models and theories offer helpful frameworks and insights into the grieving process an individual’s unique response cannot be overstated. Many factors influence how an individual grieves, the dominance of linear or staged processes are too prescriptive.

In supporting the bereaved, the task of the health care professional is not to favour or propose one model over another but to challenge assumptions and listen to the bereaved in order to facilitate an accurate reconstruction of the individual’s inner self and outer world. Thus, adopting broad concepts facilitates a more holistic understanding of the needs of the individual. Failure to do so will result in a continued theory/practice gap and those bereaved individuals who do not come through may remain prone to a range of long lasting psychiatric disorders. Further research is required into bereavement related contextual factors and the development of effective interventions in helping the bereaved to cope and such an approach is relevant in a wide variety of situations.

References

Archer, J. (1999) The Nature of Grief: The Evolution and Psychology of Reactions to Loss. New York: Routledge.

Bowlby, J. (1969) Attachment and Loss. London: Hogarth. Bowlby, J. (1980) Attachment and Loss.

Volume 3: Loss, Sadness and Depression. London: Hogarth.

Davidson, P. (1988) Grief a Literary Guide to Psychological Realities. New Zealand Family Physician 15(4): 138-46 Engel, G. (1961) Is Grief a Disease? A Challenge for Medical Research.

Psychosomatic Medicine 23(1): 18-22 Freud, S. (1917) Mourning and Melancholia. Edited and translated in Strachey.J. Standard Edition of the Complete Works of Sigmund Freud. London: Hogarth Press.

Keyes, K.M, et al. (2014) The Burden of Loss: Unexpected Death of a Loved One and Psychiatric Disorders Across the Life Course. American Journal of Psychiatry 171:864-71 Klass, D., Silverman, P.R. and Nickman, S.L.

(eds.) (1996) Continuing Bonds: A New Understanding of Grief .London: Taylor and Francis. Kübler – Ross, E. (1969) On Death and Dying. New York: Macmillan. Neimeyer, R.A.

(2000) Searching for the Meaning of Meaning: Grief Therapy and the Process of Reconstruction. Death Studies 24(6):541-48 Neimeyer, R.A.

(2006) Widowhood as a Quest for Meaning. A Narrative Perspective on Resilience. In Carr, D., Nesse, R.M., and Wortman, C.B., (eds.), Spousal Bereavement in Later Life (pp 227-252).New York: Springer. Oxford English Dictionary.

(2013) Oxford University Press: Oxford. Parkes, C.M. and Brown, R.J. (1972) Health after Bereavement. A Controlled Study of Young Boston Widows and Widowers.

Psychosomatic Medicine 34(5): 449-61 Parkes, C.M. (2001) Bereavement Dissected: A Re-examination of the Basic Components Influencing the Reaction to Loss. Israel Journal of Psychiatry and Related Sciences 38(3-4): 150-6 Rosenblatt, P. C.

(1993) Cross -Cultural Variation in the Experience, Expression and Understanding of Grief, in Irish et al (1993). Sheehy, L (2013) Understanding Factors that Influence the Grieving Process. End of Life Journal.3 (1) Stroebe, M. and Schut, H (1999) The Dual Process Model of Coping with Bereavement: Rationale and Description. Death Studies, 23 (3) Worden, W.J.

(1991) Grief Counselling and Grief Therapy: A Handbook for the Mental Health Practitioner.2nd edn. London: Routledge.

Worden, W. J. (2003) Grief Counselling and Grief Therapy: A Handbook for the Mental Health Practitioner.3rd edn. New York: Routledge.

Bibliography

Archer, J. (1999) The Nature of Grief: The Evolution and Psychology of Reactions to Loss. New York: Routledge.

Balk, D.E.(2004) Recovering Following Bereavement: An Examination of the Concept. Death Studies 28 (4): 361-74 Bowlby, J. (1969) Attachment and Loss. London: Hogarth. Bowlby, J.

(1980) Attachment and Loss. Volume 3: Loss, Sadness and Depression.

London: Hogarth. Corr, C.(1993) Coping with Dying: Lessons that we should learn from the work of Elizabeth Kübler – Ross . Death Studies 17 (1): 69-83 Davidson, P. (1988) Grief a Literary Guide to Psychological Realities.

New Zealand Family Physician 15(4): 138-46 Engel, G. (1961) Is Grief a Disease? A Challenge for Medical Research. Psychosomatic Medicine 23(1): 18-22 Freud, S. (1917) Mourning and Melancholia. Edited and translated in Strachey.J.

Standard Edition of the Complete Works of Sigmund Freud. London: Hogarth Press. Keyes, K.M, et al. (2014) The Burden of Loss: Unexpected Death of a Loved One and Psychiatric Disorders Across the Life Course.

American Journal of Psychiatry 171:864-71 Klass, D., Silverman, P.R. and Nickman, S.L. (eds.) (1996) Continuing Bonds: A New Understanding of Grief .London: Taylor and Francis. Kübler – Ross, E. (1969) On Death and Dying.

New York: Macmillan. Neimeyer, R.A.

(2000) Searching for the Meaning of Meaning: Grief Therapy and the Process of Reconstruction. Death Studies 24(6):541-48 Neimeyer, R.A. (2006) Widowhood as a Quest for Meaning. A Narrative Perspective on Resilience.

In Carr, D., Nesse, R.M., and Wortman, C.B., (eds.), Spousal Bereavement in Later Life (pp 227-252).New York: Springer. Oxford English Dictionary. (2013) Oxford University Press: Oxford. Parkes, C.M. and Brown, R.J.

(1972) Health after Bereavement. A Controlled Study of Young Boston Widows and Widowers. Psychosomatic Medicine 34(5): 449-61 Parkes, C.M. (2001) Bereavement Dissected: A Re-examination of the Basic Components Influencing the Reaction to Loss.

Israel Journal of Psychiatry and Related Sciences 38(3-4): 150-6 Rosenblatt, P. C. (1993) Cross -Cultural Variation in the Experience, Expression and Understanding of Grief, in Irish et al (1993). Sheehy, L (2013) Understanding Factors that Influence the Grieving Process. End of Life Journal.3 (1) Stroebe, M.

and Schut, H (1999) The Dual Process Model of Coping with Bereavement: Rationale and Description. Death Studies, 23 (3) Worden, W.J.

(1991) Grief Counselling and Grief Therapy: A Handbook for the Mental Health Practitioner.2nd edn. London: Routledge. Worden, W. J.

(2003) Grief Counselling and Grief Therapy: A Handbook for the Mental Health Practitioner.3rd edn. New York: Routledge.

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The Treatment of Organ Rejection with Immunosuppressive Medication: a Discussion

Since the pioneering experiments of allograft heart transplantation by Christiaan Barnard in 1967, there have been significant advances in the development of human organ transplantation. Indeed, over 35,000 patients in both the US and Europe benefit annually from organ transplantation (Hampton, 2005). Through the transplantation and engraftment of these organs, not only can biological function of organs be restored, but also the quality of life of recipients can be greatly increased. As a result the number of transplantation operations carried out each year has increase exponentially over the past decades. Despite improvements in surgical techniques, the hurdle of immunological rejection by the host of transplanted organs still remains a current obstacle.

This represents a challenge both scientifically and clinically and, as a result, is a focus of both the medical and scientific communities. Over the past 60 years, there has been an exponential increase in the development of immunosuppressive drugs in order to treat organ rejection, as well as autoimmune diseases (Gummert et al. 1999). These drugs seek to suppress various components of the immune system in order to prevent rejection in the context of organ transplantation. This essay seeks to examine the broad immunology of transplantation as well as the different classes of immunosuppressive drugs and their associated benefits and side effects. Transplantation is broadly defined as the act of transferring cells, tissues, or organs from one site to another. In the context of organ transplantation, this is generally from one person to another, with transplantation classed as either from a living donor or cadaveric. Although less common, there has been some attempt to transplant organs from other animals, known as xenografts. This was initially attempted given the lack of availability of human donor organs. However, as transplantation occurs between two immunologically distinct persons, a degree of immunological mismatch occurs.

Due to this mismatch, the host immune system recognises the donor organ as ‘foreign’ and, as a result, activates various arms of the immune system. Several types of immune rejection can occur in individuals undergoing organ transplantation. Hyperacute rejection occurs when pre-existing antibodies within the host against donor antigens attack the graft and result in rapid rejection of the graft, typically within a few hours (Murphy et al. 2010). This results in rapid declining function of the graft and is often non-reversible, thereby causing the recipient to lose the graft. In contrast, acute rejection occurs within six months following transplantation and is the result of activated T cells against donor antigens (Murphy et al. 2010). The third type of rejection is known as chronic rejection and, as the name suggests, occurs years after transplantation and is mediated by both antibodies and T cells. In order to encourage graft survival, and prevent the aforementioned from occurring, effective regimes in order to suppress these immune responses have been developed, although as outlined, they often come with significant side effects. Glucocorticoids, such as prednisone, are commonly used in immunosuppressive regimes.

These drugs seek to prevent rejection by suppressing various arms of the immune system including T cells, B cells, macrophages, granulocytes and monocytes (Steiner and Awdishu, 2011). These drugs are, therefore considered to be relatively non-specific and highly potent leading to a range of side effects. Glucocorticoids exert their effects by regulating the activity and expression of various cytokines through inhibition of intracellular signalling pathways such as NF-kB. Through modulation of this complex signalling pathway, the production of pro-inflammatory cytokines such as IL-1, IL-6 and TNF-alpha are greatly reduced (Schacke et al. 2002). Although these drugs feature heavily in clinical practice, they are associated with a significant number of side effects. Prolonged glucocorticoid use can lead to Cushing’s syndrome: a constellation of symptoms characterised by increased central adiposity, ‘buffalo hump’, osteoporosis and a round face (Schacke et al. 2002). These symptoms are due to excess exogenous cortisol within the body and therefore have multiple endocrinological effects on various physiological processes. The concentration of such drugs are therefore closely monitored and patients are encouraged to monitor for symptoms suggestive of Cushing’s syndrome. As well as glucocorticoids, drugs known as antimetabolites are frequently used in immunosuppressive regimes.

These drugs, such as azathioprine and mercaptopurine, amongst others, were originally developed in the 1950s, but remain used to this day. Azathioprine is commonly used for liver and kidney transplantation (Germani et al. 2009), as well as for the treatment of autoimmune conditions such as rheumatoid arthritis (Whisnant and Pelkey, 1982). Antimetabolites exert their immunosuppressive effects by blocking the synthesis of purine within cells (Murphy et al. 2010). Through the blockage of purine synthesis, DNA replication is unable to take place, thereby preventing expansion of rapidly dividing cells within the immune system. Through the blockade of T and B cell expansion, the level of rejection against organ transplants can be controlled. One considerable side effect associated with the use of azathioprine is the increased risk of skin cancer. A relatively recent review by Ulrich and Stockfleth (2006) has shown that sunlight exposure, pre and post transplantation in patients using azathioprine, correlates with an increased incidence of skin cancer. As exposure to UVA light damages skin cells: these cells are unable to undergo repair following damage, due to inhibition of DNA replication from azathioprine. In the long term, this accumulation of damage results in the increased propensity for patients to develop skin cancer. Current clinical guidelines suggest that clinicians discourage patients in spending prolonged periods of time in the sun following transplantation (Perrett et al. 2008). Along with these classes, of drugs, another category of immunosuppressive medications, known as calcineurin inhibitors, also work efficaciously in organ transplantation. These drugs, which include tacrolimus and cyclosporine, act by inhibiting the protein calcineurin.

Calcineurin in activated following the presentation of an antigen by an antigen presenting cell, such as a dendritic cell or macrophage, to a T cell, resulting from an increase in the concentration of intracellular calcium (Reynolds and Al-Daraji, 2002). Following the activation of calcineurin, there is an increase in the production of interleukin 2 (IL-2), which causes the activation of T cells. As a result, this further propagates an immune response. Calcineurin inhibitors are, therefore, useful in dampening an immune response, preventing the activation of T cells against a transplanted organ. Calcineurin inhibitors are popular drugs used in renal transplantation. However, evidence over the past decade has suggested that drugs such as tacrolimus may induce renal failure in some patients (Ponticelli, 2000). Obviously this a key consideration when considering patients who already have poor renal function to being with. As a result, these drugs are often combined with other immunosuppressive agents and tailored to the lowest dosage possible. The understanding into the way in which the immune system functions has been exploited over the past thirty years with the development of monoclonal antibodies.

Monoclonal antibodies were first developed in the 1970s through the fusion of rapidly proliferative myeloma cells with B cells to produce hybridomas (Liu, 2014). Antibodies are protein molecules that have a specific antigen-binding region enabling them to have a high degree of specificity. Antibodies have, therefore, been exploited therapeutically in order to target pathogenic molecules within the body. Recently, monoclonal antibodies have been developed to target various components of the immune responses in order to modulate organ rejection seen in patients. In particular, monoclonal antibodies have been developed to target T and B cells. Some examples of these therapeutics are discussed below. Muromonab is a monoclonal antibody, which is specific for cluster of differentiation 3 (CD3), a molecule found primarily on T cells (Murphy et al. 2010). By targeting T cells and preventing their activation against the transplanted organ, there is considerable evidence to show that this can significantly prolong the survival of the organ following transplantation, compared to glucocorticoid steroids (Authors not listed, 1985). However, despite the success of anti-CD3 therapy, there are substantial side effects associated with clinical use. Use of anti-CD3 has been associated with severe fever in patients, as well as the unwanted release of pro-inflammatory cytokines (Norman et al. 2000). As a result the use of anti-CD3 has declined in clinical practice and is reserved for treatment resistant cases of organ rejection. As well as muromonab, another mainstay treatment for organ rejection are antibodies directed against cluster of differentiation number 25 (CD25). Organ rejection is heavily mediated by T cells, in combination with other arms of the immune system (Ingulli, 2010). When activated, T cells produce large amounts of IL-2, a cytokine that acts in an autocrine fashion to further expand T cells via the IL-2 receptor CD25. Therefore, blockade of CD25 with a monoclonal antibody was hypothesised to offer a novel target in treating immunological rejection by T cells. As a result, daclizumab was developed and was shown by Vincenti et al. in 1998 to be a successful tool in treating renal transplantation compared to using a combination therapy of cyclosporine, azathioprine and corticosteroids. Furthermore, more long term studies have examined the function of renal transplants and concluded that patients on daclizumab showed improved renal function, as established by estimated glomerular filtration rate (GFR) (Ferran et al. 1990). However, like other pharmacological treatments, daclizumab has also been shown to cause a significant number of side effects such as hypertension and insomnia (EPAR for Zenapax). More recently, the scientific community has sought to develop more refined immunological tools in order to modulate rejection.

Through the development of monoclonal antibodies targeting cluster of differentiation 52 (CD52), clinicians are able to target lymphocytes for destruction, sparing the destruction of resident haematopoetic stem cell populations (Flynn and Byrd, 2000). Anti-CD52 drugs were originally developed for multiple sclerosis (Coles et al. 2008) and trials are currently being undertaken to establish their efficacy in organ transplantation. The overarching side effect with immunosuppressive regimes is the relatively blanket level of immunosuppression which they cause. Although immunosuppression is required to maintain organ survival, immunosuppression also results in a reduced ability to fight infections. In particular, pulmonary infections are common in organ transplant patients, with Hoyo et al. (2012) detailing that around 1 in 5 patients in their study developed pulmonary infections. It is clear that clinicians dealing with organ transplantation patients must remain vigilant for infections. It is similarly clear, therefore, that a fine balance of the level of immunosuppression should be reached: a heavily weighted level will pre-dispose to opportunistic infections, and, conversely, a lightly weighted level will result in organ rejection. With respect to future outlooks in transplantation immunology, the development of pluripotent stem cells has been hypothesised to overcome immunological issues associated with organ transplantation.

Through the use of induced pluripotent stem cells (iPS cells) developed by Takahashi et al. (2006) it has been shown that it is possible to differentiate nearly all existing cell types. As these cells are derived from the patient, they are immunologically matched to the individual and, as a result, patients would not require harsh immunosuppressive regimes. Although this technology has not been tested clinically in patients extensively yet, it is hoped that within the next twenty years this method will provide an unlimited source of organ replacement for patients. Use of such cells is currently being explored for regeneration of certain organs such as the heart (Masumoto, 2014). Use of these cells will require a significant amount of clinical testing to determine their immunological properties, as well as their propensity to develop into tumours. It is likely, therefore, that the clinical applications of stem cells are still many years away. In conclusion, despite significant improvements in targeted immunosuppressive regimes, significant side effects are associated with current pharmacological treatments. Clearly, as patients treated with these agents are often susceptible to opportunistic infections, their progress must be monitored closely by a clinician who is familiar with such patients, and the complications they can present with.

Through our increased understanding of the immune system, alongside new technologies such as stem cell replacement therapy, it is hoped that the immunological issues associated with organ transplantation will in the near future be overcome.

Bibliography

Authors not listed (1985) A randomized clinical trial of OKT3 monoclonal antibody for acute rejection of cadaveric renal transplants. Ortho Multicenter Transplant Study Group. N Engl J Med. 313:337–342 Coles, A., Lake, S. and Moran, S. (2008) Alemtuzumab vs. interferon beta-1a in early multiple sclerosis. NEJM. 359: 1786-1801. EPAR for Zenapax”. European Medicines Agency. 2007. https://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Summary_for_the_public/human/000198/WC500057570.pdf Gummert, J., Ikonen, T. and Morris, R. (1999) Newer immunosuppressive drugs: a review. J Am Soc Nephrol. 10(6):1366-80. Hoyo, I. Sanclemenete, G., Cervera, C. (2012) Opportunistic pulmonary infections in solid organ transplant recipients. Transplant Proc. ;44(9):2673-5 Ferran, C., Dy, M., Merite, S., Sheehan, K., Schreiber, R., Leboulenger, F. (1990) Reduction of morbidity and cytokine release in anti-CD3 MoAb-treated mice by corticosteroids.

Transplantation. 50:642–648. Flynn, J. and Byrd, J. (2000) Campath1H monoclonal antibody therapy. nn rheu. Opinion in Oncology. 12(6) 574-581. Germani, G., Tschochatiz, E., Adreana, L. and Burroughs, A. (2009) Azathioprine in liver transplantation: a reevaluation of its use and a comparison with mycophenolate mofetil. Am J Transplant. 9(8):1725-3 Hampton, T. (2005) Skin cancer’s ranks rise: immunosuppression to blame. JAMA. 294: 1476-1480. Ingulli, E. (2010) Mechanism of cellular rejection in transplantation. Pediatr Nephrol. 25(1): 61–74. Liu, J. (2014) The history of monoclonal antibody development – Progress, remaining challenges and future innovations. Ann Med Surg (Lond). 3(4): 113–116. Masumoto, H., Ikeda, T., Okano, T., Sakata, R. and Yamashita, J. (2014) Human iPS cell-engineered cardiac tissue sheets with cardiomyocytes and vascular cells for cardiac regeneration.

Scientific Reports. 4: 6716/ Murphy KM, P Travers, M Walport (Eds.) (2010) Janeway’s Immunobiology. 8th Edition. New York:Taylor & Francis, Inc. Norman, D. J., Vincenti, F., de Mattos, A.M., Barry, J.M., Levitt, D.J., Wedel, N.I. (2000) Phase I trial of HuM291, a humanized anti-CD3 antibody, in patients receiving renal allografts from living donors.

Transplantation. 70:1707–1712 Perrett, C., Walker, S., Warwick, J., Harwood, C., Karran, P. and McGregor, J. (2008) Azathioprine treatment photosensitizes human skin to ultraviolet A radiation. BJD. 159(1): 198-204. Ponticelli, C. (2000) Calcineurin”?inhibitors in renal transplantation. Too precious to be abandoned. n Rheum. Dial. Transplant. 15 (9): 1307-1309. Reynolds, N. and Al-Daraji, W. (2002) Calcineurin inhibitors and sirolimus: mechanisms of action and applications in dermatology.

Clin Exp Dermatol. 27(7):555-61. Schacke, H., Docke, W. and Asadullah, K. (2002) Mechanisms involved in the side effects of glucocorticoids. Pharmacology and Therapeutics. 96(1): 22-43. Steiner, R. and Awdishu, L. (2011) Steroids in kidney transplantation. Semin. Immunopathol. 33(2): 157-167. Takahashi, K. and Yamanaka, S. (2006) Induction of Pluripotent Stem Cells from Mouse Embryonic and Adult Fibroblast Cultures by Defined Factors. Cell. 126(4): 663-676. Ulrich, C. and Stockfleth, E. (2007) Azathioprine, UV light, and skin cancer in organ transplant patients—do we have an answer? Nephrol. Dial. Transplant. 22 (4): 1027-1029 Vincenti F, Kirkman R, Light S, Bumgardner G, Pescovitz M, Halloran P. (1998) Interleukin-2-receptor blockade with daclizumab to prevent acute rejection in renal transplantation.

Daclizumab Triple Therapy Study Group. N Engl J Med. 338:161–165 Whisnant, J. and Pelkey, J. (1982) Rheumatoid arthritis: treatment with azathioprine (IMURAN (R)). Clinical side-effects and laboratory abnormalities. Ann Rheum Dis. 41(Suppl 1): 44–47.

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Stiffness Car Chassis

Contents

Introduction
Why is it so important to increase the stiffness and reduce the weight of the chassis?
Background to project
History
Structural efficiency
Literature Review
Introduction:
Bending case
Torsion case
Combined bending and torsion
Lateral loading
Fore and aft loading
Longitudinal loading
Allowable stresses
Bending stiffness
Torsion stiffness
Chassis types
Space frame
Space frame principles
AIMS
Weight
Stiffness
Size
Requirements
Project Objectives
Research Questions
Research Approach and Design
Approach and design
Experiment design
Response variable
Independent variables
Design
Analysis & comparison
FSAE chassis Rules and Requirements.
Structural requirements.
Minimum material requirements.
Baseline Steel Material.
Alternative Tubing and Material
Minimum wall thickness for steel tubing requirements
Minimum wall thickness for steel tubing requirements
Aluminium tubing requirements
Roll Hoops
Main Hoop
Front Hoop
Main Hoop General Requirements
Front Impact Structure
Bulk Head
Side Impact Structure
Tube Frames
Literature review
Analysis and interpretation of results
Project Risk Assessment, Healthy and Safety
Ethical Issues
References

Introduction

The purpose of the project is to increase the stiffness and reduce the weight of the existing car chassis, without disturbing the shape provided for engine mountings and driver's space and other constraints provided by the existing chassis model.

Why is it so important to increase the stiffness and reduce the weight of the chassis?

In general to define chassis in this way, first a clear meaning of structure should be known. In general perspective a structure can be defined as a specific arrangement of material to resist loads. This structure should also enable to the location of the components such as engine mountings, transmission, fuel tank, suspension system etc. So it must resist loads without breaking, and without more deflection. If the chassis cannot resist loads it leads to a serious handling problems, and will not support the engine and transmission system, also the chassis should be light enough to maintain weight to power ratio and better handling in corners.

Background to project

The principle loads that includes on the chassis are, by the engine, the aerodynamics, brakes, road irregularities, the inertia loads due to masses under accelerations and vibrations. Also the chassis must with stand impact loads, having absorbed part of crash energy by deformation which includes the bending, torsion, combined bending and torsion, also lateral and longitudinal loads. So the chassis structure should be strong in stiffness in design case rather than strength. The chassis and body developments should also reduce weight because it improves the vehicle ride, handling, improves the performance of car by reducing the drag because of high weight to power ratio, and also will reduce the need for power there by increases the fuel efficiency. Because of this now even mass produced passengers cars lightened up by the most detailed weight-watcher engineering techniques due to corporate Average Fuel Economy (CAFE) regulations of the federal government. Lighter vehicle requires less power, hence less fuel, for equal performance.

History

The demand for the chassis with high torsion stiffness and low weight had increased from the World War 2. This demand had led to the innovation of many kinds such as Space frame, stressed skin etc. These types had become universal among the European road race cars following its appearance in the Lotus MK and the Mercedes-Benz 300SL in 1952. These are the cars which used strictly space frame chassis and the attention they received had popularized the idea. Major automobile industries in present era are purchasing the competitive vehicles and disassembled them carefully to study the weight and stiffness of car for comparison with the equivalent part of their own vehicle. So this lead to a competitive reasons than for increase fuel economy. Today have been included to expand the following three reasons:

A means for recognising opportunities for overall weight reduction for better fuel economy.

The means for determining centre of gravity (CG) location and polar moment of inertia.

Detail weight estimates provides target figure of cost estimates of all parts.

To resist inertial loads under accelerations, accidents etc.

Structural efficiency

A designer can achieve enough stiffness for a chassis from any form of construction, if enough material is used. This is not the criteria of a designer, to assess the efficiency of structure its stiffness must be considered in relation to the weight. The below shows the absolute increase in stiffness achieved in recent years is the increase in stiffness to weight ratio.

Vehicle	year	Torsional stiffness(lb-ft/degree)	Structure weight (lb)	Stiffness/weight ratio
Lotus 21 F1	1961	700	82.0	8.5
Lotus 24 F1	1962	1,000	72	13.9
Mc Laren F1	1966	11,000	Na	Na
Lotus 79F1	1979	3,000	95	31.6
Lotus 79 F1	Late 1979	5,000	85	58.8
Lotus F1	1980	10,000	75	133.33
Lola F1	1993	30,000	80	375

Table1: Demand for increase in structural efficiency.

Literature Review

Introduction:

The loads that are experienced on a chassis are light commercial loads due to normal running conditions are considered. That is caused as the vehicle transverses uneven ground as the driver performs various manoeuvres. Basically there are five load cases to consider. Bending case. Torsion case. Combined bending and torsion case. Lateral loading. Fore and aft loading.

Bending case

This type of loading is caused due to the weight of components distributed along the frame of the vehicle in the vertical plane which causes the bending about y-axis. The bending case depends mainly on the weight of the major components in the car and the payload. First the static condition is considered by determining the load distribution along the vehicle. The axle reaction loads are obtained by resolving the forces and by taking the moments form the weights and positions of the components.

Torsion case

The vehicle body is subjected to the moments applied at the axels centrelines by applying both upward and downward loads are at the each axle in this case. Because of this it results in a twisting action or torsion moment about x-axis of the vehicle. The condition of pure torsion does not exist on its own because of the vertical loads always exist due to gravity. However for the calculation purpose the pure torsion is assumed. The maximum torsion moments are based on loads at the lighter loaded axle, its value can be calculated by the wheel load on the lighter loaded axle multiplied by the wheel track. The loads at the wheels are shown in the above figure. So the torsion moment is given as: RF tf = RR tr 2 2 Where tf and tr are front and rear track respectively and R f and Rr are front and rear loads. These loads are based on the static reaction loads but dynamic factors in this case are typically 1.3 for road vehicles (Pawlowski, 1964).

Combined bending and torsion

In practice the torsion will not exist without bending as gravitational forces are always present. So the two cases must be considered when representing a real situation. Fig3: combined bending and torsion.

Lateral loading

This type of loading is experienced by the vehicle at the corner or when it slides against a Kerb, i.e. loads along the y-axis. The lateral loads are generated while cornering at the tyre to ground contact patches which are balanced by the centrifugal force MV2 / R, M stands for vehicle mass, V vehicle velocity , R is the radius of the corner. The disaster occurs when the wheel reactions on the inside of the turn drop to zero, that means that the vehicle ready to turn over. In this case vehicle will be subjected to bending in x-y plane. The condition that applies to the roll over is shown in the below figure and it also depends up on the height of the vehicle centre of gravity and the track. At this particular condition the resultant of the centrifugal force and the weight that passes along the outside wheels contact patch. And hence lateral acceleration is V2/R=gt/2h Lateral force at the centre of gravity MV2/R = Mgt/2h. Front tyre side forces YF = Mgt b/2h(a+b). At the rear tyres YR = Mgt a/ 2h(a+b). From the lateral acceleration it is clear that it is t/2h times that of the gravitational acceleration. Kerb bumping will cause high loads and will roll over in exceptional circumstances. And also this high loads will cause in the bending in the x-y plane are not critical as the width of the vehicle will provide the sufficient bending strength and stiffness.

Fore and aft loading

At the time of acceleration and breaking longitudinal forces will come into picture along the x-axis. Traction and braking forces at the tyre to ground contact points are reacted by mass time's acceleration inertia forces as shown in below figure. The important cases such as bending, torsion, bending and torsion will come into play as these determine the satisfactory structure (Pawlowski, 1964).

Longitudinal loading

At the time of vehicle accelerates or decelerates, the inertia forces are generated. The loads generated can be transferred from one axle to another by the inertia forces as the centre of gravity of the vehicle is above the road surface. While accelerating the weight is transferred from front axle to the rear axle and vice versa at the time breaking and decelerating condition. To have a clear picture of forces acting on the body a height of the centres of gravity of all structures are required. And it's not so easy to determine. A simplified model considering one inertia force generated at the vehicle centre of gravity can provide useful information about the local loading at the axle positions due to breaking and traction forces. Front wheel drive, the reaction on the driving wheel is: RF = Mg(L-a) - Mh(dV/dt) L Rear wheel drive, the reaction on the driving wheel is: RR = Mga + Mh(dV/dt) L In braking case the reactions on the axles are: RF = Mg(L-a) + Mh(dV/dt) L

Allowable stresses

From the above discussed loads it is clear that it will induce stresses in all over the structure. So it is important that under the worst load conditions that the stresses induced into the structure are kept to acceptable limits. In consideration of the static loads of a limited amount should give a stress level certainly below the yield stress. If analysed the bending case for a road gong car is considered the maximum allowable stress should be limited as follows: Stress due to static load A—Dynamic factor yield stress. The above equation says that under any worst load condition the stress should not exceed 67% of the yield stress. Alternatively the safety factor against yield is 1.5 for the worst possible load condition.

Bending stiffness

It is equally important to consider the bending stiffness weather to say the structure is sufficiently strong or not. So an equal and important assessment is given to the structural stiffness. Therefore many designers consider the stiffness is most important than strength. It is possible to design a structure which is sufficiently strong but yet unsatisfactory because of insufficient stiffness. Designing for acceptable stiffness is therefore often more critical than designing for sufficient strength. For vehicles the bending stress is determined by the limits of deflection of the side frame door apertures. In case of excessive deflection the doors will not shut properly. Local stiffness of floor is also important because it minimises the safety of the passenger.

Torsion stiffness

If the stiffness is low the driver may feel that the vehicle in front will be shaking with the front wing structures moving up and down. The practical problems of doors failing to close properly will also be seen. A similar thing will be seen in the jacking points that are positioned at the corners of the vehicle. For fast moving cars the torsion stiffness is very important because it may cause serious handling problems. Therefore care should be taken in maintaining sufficient torsion stiffness. So from the all above dimensions of forces and handling of a vehicle chassis should be stiff enough and also should be less in weight.

Chassis types

Chassis are classified into several types they are: Ladder frames. Cruciform frames. Torque tube back bone frame. Space frame. Monocoque. In the present era of automotive industry designers are using the space frame and monocoque for the justification of design problems and to sufficient structural stiffness.

Space frame

A space frame chassis is a development of four tube chassis, both of them look quite similar. But the space frame differs in several key areas and offers very good advantages when compared to the predecessor. A space frame is an arrangement of many straight tubes in which the loads acting are either in tension or compression. The figure below shows the clear idea of a space frame. But from the above figure it is clear that the diagonal member is pulled in tension when a load is acted on it. This above illustration is the simple idea of the space frame chassis. This experiencing of loads in either tension or compression is a major advantage. So none of the tubes will be subjected to the load will tend to bend in the middle. Since the space frames are very good in torsion stiffness. The three dimensional space frame chassis are used for specialist cars such as sports racing cars. This type of vehicle design is used for low volume and mass production as well. In this type of structure it is imperative to ensure that all planes fully triangulated by doing so the beam elements are essentially loaded in tension and compression. In the space frame welded joints are done it retains bending and torsion at the joints, but to rely on this restrains will render the structure less stiff. The stiffness is provided by the diagonal member subject to direct tension or compression.

Space frame principles

A space frame is three dimensional arrangements of tubes loaded in pure tension and compression. The joints between them can be replaced by the ball joints without affecting the stiffness. Other important feature is all loads enter and leave the structure at the points of intersection of three or more tubes. The structural elements do not have to be tubes and the joints do not have to be welded. In terms of torsional stiffness the space frame attempts to connect the four spring anchorages so that is impossible to twist the pair without stretching and compressing the tube.

AIMS

The first thing to undertake this research is to set some basic aims that need to be achieved. As the aim of the project is stated to reduce the weight and increase the stiffness of existing vehicle chassis. So the main aims are in terms of weight, stiffness, and size.

Weight

Weight was a main consideration in the research it is very crucial to reduce it to that of original weight. It helps in improving the weight to power ratio, better fuel efficiency and performance.

Stiffness

It is also another key factor to be considered in the research. The stiffness must be improved to that of existing one in case of torsion, bending.

Size

Last but not the least, the above reduction in weight and increase in stiffness must be achieved without effecting the size and shape of the chassis. This is important because it should not affect the driver to get in the car, and appearance of the car. And also the constraints set for the positioning of the engine etc should not be changed.

Requirements

Certain requirements beyond my research boundary and aims are needed to be specified, to make up and achieving success in my research they are:

The elements in the space frame which should not disturb must be specified.

The dimensions of the chassis, and the materials used must be specified.

The specification of the loads on the chassis.

The original weight of the chassis which is going to be modified.

The stiffness that chassis must be in terms of torsion, bending.

Project Objectives

The objectives of the project are:

To analyse the original chassis, its structure, weight, stiffness, torsion, and materials used.

Research the characteristics of space frame chassis and discover the effects with respect to vehicle handling and performance in case of bending and torsion loads.

The benefits and performance of materials when replaced by the original one in terms of weight and stiffness.

The research should be done with resources available.

From testing and changing the elements, dimensions other than the constraints in lab, modifying the improvements in chassis.

Analysing the results to that of the original chassis and comparing.

Research Questions

What are the materials used for the chassis construction?

What are positions in the chassis which should not be disturbed?

What is maximum allowable weight, stiffness and loads that being subjected by the chassis?

What will be effect on stiffness and weight if certain elements of the chassis were replaced by the other materials?

If the diameter and size of the elements were changed what will be the effect on weight and stiffness?

If the positions of the elements other than the elements which should not be disturbed, i.e. by mix and matching, replacing the positions. What will be the effect on stiffness and weight?

If the circular tube cross-sectional elements of the chassis in some areas are replaced by square tube cross-sectional elements, what will be the effect on stiffness and weight?

Research Approach and Design

The problem being researched is quantitative rather than qualitative. It deals in numerical values and variables, predetermined categories, focuses on specific knowledge and control of variables. The approach of this research is different to that of qualitative research which would involve human subjects, questionnaires and interviews. The approach will be analytical which will include experimental analysis, analysing the data, interpreting the results, comparisons etc.

Approach and design

The research is about how to increase the stiffness and reduce the weight of existing vehicle chassis. The research is based on a lot of literature, experimental design and analysis. It should be well designed, planned and managed to ensure that the results can be analysed, interpreted and presented. Throughout the period of the research a process was followed to produce a successful report on the analysis done with that of the original chassis they are:

Setting some benchmarks in regarding to the design of chassis.

Analyse the previous chassis, and getting an idea in terms of stiffness, weight, shape.

Developing the modelling, and analysing techniques that allows the process to be simple and can be modified easily.

Gaining the information regarding the dimensions of the chassis from the designers and the areas in the chassis which should not be disturbed in terms of design.

Looking for the possibility of the new considerations that were not previously included in the design.

Considering the feedback of the supervisor as the process of the research goes on.

Experiment design

It includes a statement of problem to be solved. Before going to do the research on the experimental design it is important to consider all points of view of what the experiment is intended to do.

Response variable

The problem must include reference to at least on characteristic of a unit on which information is to be obtained. Those characteristics are called response or dependent variables. In this research the response variables are weight and stiffness, which are dependent on material, design, etc. In addition to reference of the response variable, some questions should be asked. They are measurements methods, what tools are required to measure the variable? Can variable can be measured accurately or not?

Independent variables

The variables which control the response variables are called Independent variables. In this piece of work the independent variables are:

Load on the space frame chassis.

Material used for the chassis.

Design of the chassis.

Size and shape.

The independent variables will be chosen randomly one at a time or by considering more than one independent variable. The response on the dependent are analysed and compared to that of original chassis.

Design

Before the data is collected and results are drawn, it is important to know how to solve the problem with a limited amount of time and available resources. It is important to note how many observations should be taken, what is the maximum amount of deviation in terms of stiffness and weight in comparable to original one. Also attention is required in handling the independent variables.

Analysis & comparison

The final step in the experiment is to compare the results of the optimised chassis to that of the results on the original one, and approach the problem by checking and comparing the results. This will be done by the preparation of the graphical displays of the values in terms of weight and stiffness. It's important to make sure that the results are within the prescribed limits. If it's not, follow the investigation again by controlling the independent variables.

FSAE chassis Rules and Requirements.

There are some rules that must be followed throughout the design and construction of chassis. If these rules are not followed strictly the FSAE car will be eliminated from the competition. The rules that have to be followed are.

Structural requirements.

Minimum material requirements.

Alternative tubing and material.

Steel tubing requirements.

Aluminium tubing requirements.

Composite material requirements.

Roll hoops requirements.

Tube frames.

Structural requirements.

The structure of the vehicle must include two roll hoops, front bulk head with support system and impact Attenuator, and side impact structures.

Minimum material requirements.

Baseline Steel Material.

The structure of the car must be constructed with: Round, mild or alloy, steel tubing (minimum 0.1% carbon) of the minimum dimensions according to the following table.

Item or Application	Outside diameter A— Wall thickness
Main and Front hoops, Shoulder harness mounting bar.	inch (25.4 mm) x 0.095 inch (2.4 mm) 25.0 mm x 2.50 mm metric
Side Impact Structure, Front Bulkhead Roll Hoop Bracing, Driver's Restraint Harness attachment.	inch (25.4mm) A— 0.0065 inch (1.65mm) or 25.0mm A— 1.75mm metric or 25.4mm A—1.60mm metric.
Front bulk head support.	1.0 inch (25.4mm) A— 0.049 inch (1.25 mm) Or 25.0 mm A—1.5 mm metric or 26.0mm A— 1.2 mm metric.

Table 6.4.2: Minimum material requirements. (Source: FAE rules 2008)

Alternative Tubing and Material

The chassis can be constructed with alternative tubing and material but not for the Main Roll Hoop and Main Roll Hoop Bracing. These must be constructed only with the Steel, to say in other words the use of Composites and other materials such as Aluminium or alloys are strictly prohibited. If the chassis was to constructed with alternate tubing rather than material, the tubing must not be thinner than as shown below.

Minimum wall thickness for steel tubing requirements

Material and Application:	Minimum wall thickness:
Steel tubing for front and Main Roll Hoops	2.0 mm (0.079 inch)
Steel tubing for Roll hoop Bracing, Front bulk head & driver's harness attachment.	1.6 mm (0.063 inch)
Steel tubing for side impact structure & front bulk head support.	1.2 mm (0.047 inch)

Minimum wall thickness for steel tubing requirements

Source: FSAE 2008 rules.

Aluminium tubing requirements

Minimum wall thickness:

Material & Application :	Minimum wall thickness:
Aluminium tubing	3.0 mm (0.118 inch)

Table 6.4.2.3: Aluminium tubing requirements. (Source: FSAE 2008 rules).

Roll Hoops

The Roll hoop design criteria must justify the following:

Main Hoop

The drivers head and hands must not contact the ground in any rollover attitude.

The frame must include both Main Hoop and Front Hoops

The Main Hoop must be constructed of single uncut tubing made of steel as per the minimum tubing requirements.

The use alternate material is prohibited for construction of main hoop.

The main hoop must extend from the lowest member on one side of the frame, to the down towards the lowest Frame member on the other side of the frame.

In the side of the car the portion of the attachment of the Main Roll Hoop which lies above the attachment point of the main structure of the frame must be within 10 degrees to the vertical.

The vertical members of the Main Hoop must be at least 380mm apart at the location where the Main Hoop is attached to the Major Structure of the Frame. In the Front view of the vehicle.
Front Hoop

The Front Hoop must be constructed of closed structure of steel as minimum tubing requirements. The use composite materials are prohibited. The Front Hoop Frame member must extend from one side of the Frame, to the down over and towards the lowest Frame member on the other side of the Frame. The top most surface of the Front Hoop should not be below the top of the steering wheel in any angular position. The front Hoop should be no more than 250 mm forward of the steering wheel when measured horizontally through the vehicle centre line. No part of the Front Hoop should be inclined at not more than 20 degrees in the side view.

Main Hoop General Requirements

A straight line drawn from the top of the main hoop to the top of the front hoop must be clear by 50.8 mm of the helmet of the team's drivers and the helmet of a 95th percentile male. When seated normally and restrained by the Drivers Restraint system. 95th Percentile Male Template Dimensions A two dimensional template used to represent the 95th percentile male is made to the following dimensions: A circle of diameter 200 mm (7.87 inch) will represent the hips and buttocks. A circle of diameter 200 mm (7.87 inch) will represent the shoulder/cervical region. A circle of diameter 300 mm (11.81 inch) will represent the head (with helmet). A straight line measuring 490 mm (19.29 inch) will connect the centres of the two 200 mm circles. A straight line measuring 280 mm (11.02 inch) will connect the centres of the upper 200 mm circle and the 300 mm head circle. The 95th percentile male template will be positioned as follows: the seat will be Source: FSAE rules 2008.

Front Impact Structure

The driver's feet are always with in the Major structure of the Frame. No part of the driver's feet should be above or outside the Frame in the side and front views, while touching the pedals. Forward of the Front bulk head must be energy- absorbing Attenuator.

Bulk Head

The requirements of the Bulk head in a Front impact structure are: It should be constructed of closed section tubing. It should be located in front of all non-crushable objects. It should be positioned in such way that the soles of the driver when they touch the pedals must be rearward of the bulkhead plane. Monocoque construction must approve a Structural Equivalency Form.

Side Impact Structure

The Side Impact structure must satisfy the following:

Tube Frames

The Side impact structure must be contained with at least three tubular members located on the each side of the driver when seated in the normal driving position. The required three tubular members must be within the material specification. The location for the three required tubular members are: The top structural member of the side impact must connect the Main Hoop and the Front Hoop at the height in between 300 mm and 350 mm above the ground including the 77kg driver seated in the normal driving position. The impact structural member on the lower side must connect to the bottom of the Main Hoop and the bottom of the Front Hoop. The diagonal side impact structural member must connect the upper and lower sides of the impact structural members forward of the main Hoop and rearward of the Front Hoop. Planning the time scales of project. Organising, and fixing the time schedules. Setting aims and objectives. Research questions.

Literature review

Need for reducing the weight and increase the stiffness of chassis. Loads that act on chassis in various cases. Looking at Space frame chassis clearly, and understanding it. Looking at any previous work done similar to this. Any bench marks regarding the weight and stiffness i.e. minimum weight and rigidity that a chassis should be. Also the positions of elements in regarding to the drivers safety, suspension, steering, engine mountings etc. Materials that were used to build the chassis. Diameter of tubes and permissible wall thickness in a chassis should be. Can the outer diameter of the tube be increased and wall thickness be decreased or vice versa. Any option given for change the material of tubes, for example can a mild steel element be replaced with Aluminium or Composites? If the materials were changed does it meet the requirements in weight, stiffness and cost, manufacturability?

Analysis and interpretation of results

Importing the image files of CAD drawings of the original chassis into the FEA software. Analysing the original chassis in weight, stiffness, materials used, outer diameter, wall thickness. Designing the experiments. Changing the wall thickness, outer diameter, positioning of elements by using the FEA software tool. Looking for any areas were design can be changed. Looking at areas where maximum elements can be replaced with minimum elements. Getting the results after running the solver and then comparing it with results to that of original chassis. If the results were satisfied in terms of weight and stiffness, problem was solved. If not the experiment was repeated again and analysed.

Project Risk Assessment, Healthy and Safety

In this Project the use of resources are: LRC, and journal data bases for literature searching. FEA laboratory for interpretation of results and analysis. The benchmarks are provided by the makers of original chassis. Also the chassis provided is just the CAD drawing but not structure is given in physical way. So analysis will be took place in the LAB which includes change in material, diameters, wall thickness, position of elements etc all will done by use of FEA software tool. But not done manually with machining, welding etc while changing the parameters of elements. So the project risk assessment, health safety are very minimum. And the project will not include for health safety and risk assessment.

Ethical Issues

The Research which is being done is Quantitative rather than Qualitative. It concentrates on measuring the variables and interpretation results and analysing, and comparing. So it is clear that it does not contain involvement of investigating subjective data and also the perceptions of involvement of people.

References

Race car chassis : design and construction / Forbes Aird. Publisher: Motorbooks International, 1997. Practical research: planning and design. Edition: 8th ed., International ed. / Paul D. Leedy, Jeanne Ellis Ormrod. Publisher: Merrill Prentice Hall, c2005. Design and analysis of experiments / Douglas C. Montgomery. Edition: 2nd ed. Publisher: Wiley, c1984. An introduction to modern vehicle design / edited by Julian Happian-Smith.
Publisher: Butterworth-Heinemann, 2001 The modern Formula 1 race car: from drawing board to racetrack / Nigel Macknight. Publisher: Motorbooks International, 1993. Formula 1 technology / Peter Wright; illustrations by Tony Matthews Publisher: Society of Automotive Engineers, c2001. The science of Formula 1 design: expert analysis of the anatomy of the modern Grand Prix car / David Tremayne. Haynes, 2004.

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Hakkasan Restaurant Review

Contents

Hakkasan Restaurant Review
- Critical Appraisal of a Lifestyle Offering
- Bibliography

Hakkasan Restaurant Review

Christian Liaigre’s magnificent designs and Tong Chee Hwee’s magical food makes the experience at Hakkasan truly memorable and out of the world, quite befitting to their glowing Michelin star …well except that it also creates a massive black hole in your money-bag. It is not easy to find the restaurant in Hanway Place. The lack of visible sign-boards make the journey to the restaurant like a game of treasure hunt (Juliane 145, 2015). There is a fair amount of mystery surrounding its location and you soon realize that the feeling does not end there. As you open the doors of the restaurant you enter into a dark mysterious orient dream. The blue lighting, the play with the colours, the dark wooden screens and latticing, the black and gold panels all add to the mysterious aura of the place. It is creative and contagious in a ‘secret-society’ kind of way (Vera B, 2015). I am seated on my table which is daringly close to the next one where two men in suits are having a quiet conversation. I am tempted to lean and listen and that makes me instantly uncomfortable. The tables are too close to each other and around me are all groups of well-dressed and elegant people. As a blogger from London said ‘The interiors are dimly lit enough for wisp thin socialites of the evening crowd to avoid interacting with the food without attracting too much attention to the fact. There’s a lot of black leather, dark wood and deep pockets’. (Kazim, 2013). Bits of conversation about the sublime and delicate dim sum floated into my ears and I ordered exactly that to start with. There is a strange sense of mystery and secrecy about the place. Imagine if ‘Men in Black’ was shot in some of the sets from ‘Kill Bill’. I was almost expecting an action scene from a Chinese movie or even a James Bond film to start unexpectedly in the middle of my meal and some writers who visited the restaurant before me seem to agree. ‘It looks like it could be some sort of high class opium den in the heart of Hong Kong’, one of them said. (Waters, 2011). However, as soon as the food arrives you forget about everything else. The smell, colours taste and feel of the food take you on a journey to the far corners of China. Now the dream is no more dark but beautifully tasteful. The food not only tastes fascinating but it appeals to each one of your senses. The dim sum platter was truly sublime and delicate and they are definitely the best dim sums that I have ever encountered. A gentle cloud of smoke comes out as soon as I open the steaming basket, then the aura fills my lungs and when I eat it, my taste buds start to tingle. My journey continued and rendered me more speechless with every course. However due to the lack of great service the wait between each of my courses seemed endless. As I waited impatiently, I witnessed impersonal waiters shuttling between tables and guests walking down the corridor which had turned itself into a ‘makeshift runway’ (Kazim, 2013). However, that is not a surprise considering that it is one of the few restaurants in London that imposes a dress-code. On the bottom of the website these words glare back at you, ‘Our dress code is smart casual. No sportswear. Jeans are permitted as long as they are worn smartly with shoes and a collared shirt. Please do not wear hats inside Hakkasan’ (Hakkasan Hanway Place, N.D.). I ordered the stir-fry rib-eye beef and asparagus with lemon-grass for main course. It was flawlessly presented and the taste was exquisite. Each component complemented the other and the meat was so precisely cooked that it melted like butter on my tongue. I ended my meal with the chocolate and kalamansi ganache. The perfect amount of citrus infused in the rich chocolate created an impeccable end to my star studded culinary experience. Undeniably Hakkasan is special and sensual in its own mysterious ways. Even though the sight of the bill will momentarily burst your bubble, it is an experience that will entice your taste buds and leave you begging for more.

Critical Appraisal of a Lifestyle Offering

In 2014, 38 million adults (76%) in UK accessed the Internet every day. Access to the Internet using a mobile phone more than doubled between 2010 and 2014. It rose from 24% in 2010 to 58% in 2014. 74% of all adults bought goods or services online which went up from 53% in 2008 (Office for National Statistics, 2014). Internet has consumed a huge portion of our lives and the above facts prove that a large section of people do most of their reading and shopping online. Howtospendit.com was launched in 2009 and in September 2011 they launched their free ipad app which has been downloaded 260,000 times. With extensive numbers of people using the internet, it makes it an intelligent choice for advertisers to use online platforms like blogs and websites to promote their products. Thus for the past few years sponsored posts have become exceedingly popular with advertisers and sponsors. A sponsored post is when an editor receives payment to publish an article provided by the sponsor or written by the editor/ writer, but includes at least one contextual link. These articles are also known as a guest posts. (Castellani, 2011). This article on Howtospendit.com is an example of a sponsored post by Raid Senso. However, it is not one that is generic and uninformative. There are several factors that need to be considered while writing a good sponsored post. The first and the most important thing to remember is the target audience. The writer/editor must put themselves in the shoes of the readers to see if the content is either answering their questions or providing them with relevant and useful information. Howtospendit.com is a luxury lifestyle magazine and this article fits in with the target audience base that the online magazine caters to. The article is about Rais –Senso, a boutique inn in Rabat, Morocco, and it caters to the fairy upmarket, luxury holiday seekers. There are three people who need to be pleased when writing a sponsored post. Firstly, the writer/editor must be proud of the content they create. Second are the readers, because without the readers the publication will cease to exist. Finally there are the sponsors. The writers must make sure that all the requirements of the sponsors are met without compromising the integrity of the blog (Linsey, 2013). The relationship between the reader, editor and sponsor can be quite complicated and difficult. However, it is the responsibility of the editors to mediate between the readers the sponsors. The sponsors want to promote their brands and the readers are looking for engaging and informative pieces of content. So the editor needs to find this middle ground which will give both sides what they are looking for but also at the same time stay true to themselves. A sponsored post usually works by creating engaging pieces of content related to the advertiser and then a link is added in the article with the intention of promoting the brand. This is done not only to promote products and services but also the addition of the link helps to drive traffic to the advertiser’s websites resulting in ranking higher on Google by the creation of backlinks (Google, 2015). However, there has been several controversies related to the backlinks and Google has laid down strict policies regarding that. Google Webmaster tools clearly states that buying or selling links that pass PageRank can negatively impact a site’s ranking. ‘This includes exchanging money for links, or posts that contain links; exchanging goods or services for links; or sending someone a “free” product in exchange for them writing about it and including a link’ (Google Webmater Tools, 2015). A large number of editors think of ways of making money from their online publications. However, that is often done by creating irrelevant generic content which do not provide the user with any relevant information resulting in no engagement. This can be harmful for the advertisers as well. The link on the article results in the addition of a backlink but that does not convert into actual sales. However, with the fear of getting penalized by Google, many editors have taken Google policies into consideration and have started creating content solely keeping the reader in mind. This article on Howtospendit.com is a great piece of content. It tells us a story. It takes the reader on a journey. This is a journey that a lot of readers are looking for and can identify with instantly. It is personal and informative at the same time. The vivid descriptions give the readers a sense of the mystique, colours and culture of Morocco. Even though Howtospendit.com caters to a luxury upmarket audience base, this article can also be categorised as edgy because it combines culture and intellect and puts it together in the shell of a romantic get-away. Such places cater to people who are looking for an experience that different and unique. The compelling back story of Migrants du Monde adds to the personal touch. It is also an informative piece of content. It gives the readers information on sightseeing, food, costs and souvenirs. If the readers are looking for such an experience, from the information that has been provided in the article, they can easily recreate the exact same experience. This article not only creates a perfect environment for the sponsors to promote themselves by painting a picture of the brand but it also tells the readers the story behind it. In keeping with the edgy upmarket theme, the design, the use of the colours black and gold and the layout give the article a simple, sophisticated but luxurious feel. This helps in creating the perfect backdrop for this article. However, a few more pictures would have enhanced the article further and helped the readers to visualize their stay in the beautiful Riad Senso.

Bibliography

Castellani, J. (2011, September 9). What is a Sponsored Post? Retrieved February 25, 2014, from https://blogadvertisingrates.com/2011/09/09/what-is-a-sponsored-post/ Google. (2015). What are backlinks and how do I use them? Retrieved February 26, 2015, from Blogger: https://support.google.com/blogger/answer/42533?hl=en Google Webmater Tools. (2015). Link schemes. Retrieved February 26, 2015, from https://support.google.com/webmasters/answer/66356?hl=en Hakkasan Hanway Place. (N.D.). Hakkasan Hanway Place: Overview. Retrieved February 25, 2015, from https://hakkasan.com/locations/hakkasan-hanway-place/ Juliane 145. (2015, February 21). Honoured by a star. Retrieved February 25, 2015, from Trip Advisor: https://www.tripadvisor.co.uk/ShowUserReviews-g186338-d699656-r255595602-Hakkasan_Hanway_Place_Restaurant-London_England.html#REVIEWS Kazim, L. (2013, October 6). hakkasan hanway, dim sum sundays - review. Retrieved February 24, 2015, from The Cutlery Chronicles: https://www.thecutlerychronicles.com/2013/10/hakkasan-hanway-dim-sum-sundays-review.html Linsey, C. (2013, June 14). How to write a sonsored post. Retrieved Februray 26, 2015, from https://thebloggingbunch.com/how-to-write-a-sponsored-post/ Office for National Statistics. (2014). Internet Access – Households and Individuals 2014 . Retrieved February 25, 2015, from https://www.ons.gov.uk/ons/rel/rdit2/internet-access---households-and-individuals/2014/stb-ia-2014.html Vera B. (2015, February 22). Memorable Dim Sum lunch! Retrieved February 25, 2015, from Trip Advisor: https://www.tripadvisor.co.uk/ShowUserReviews-g186338-d699656-r255856983-Hakkasan_Hanway_Place_Restaurant-London_England.html#REVIEWS Waters, C. (2011, August 11). gourmet chick. Retrieved February 25, 2015, from Hakkasan: https://www.gourmet-chick.com/2008/02/about-gourmet-chick.html

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Turbocharger Petrol Engine

Contents

1.0 Introduction
1.1 Background
1.2 Aim
1.3 Objectives:
2.0 Initial Critical Review of Literature
Supercharging
Turbocharging
Turbocharger Theory
Turbocharging Diesel (CI) or Petrol (SI) engines
Energy Available In the Exhaust Gas:
Constant Pressure Turbocharging
Pulse turbocharging
Pulse converters in turbocharging
8.0 References
9.0 Bibliography

The quest for higher efficiency of the internal combustion engine will always be pursued. Increasingly stringent emission regulations are forcing the manufacturers to downsize on engine displacement and increase the specific power. By adding the turbocharger, the air flows through the engine and hence specific power can be increased. The advantage of a small turbocharged engine over a naturally aspirated (NA) engine of a similar power is that it is lighter, having better part load efficiency when operating at the same load, while producing less emission. The objective in this study is to investigate a turbocharger in a naturally aspirated engine and testing the engine before the installation of the turbocharger. Boost refers to the increase in the manifold pressure that is generated by the turbocharger in the intake path or specifically that exceeds the normal atmospheric pressure. This study also aims to develop a strategy for the control of boost for the engine.

1.0 Introduction

1.1 Background

Turbocharged spark ignition engines have been around since the 1970s, but their popularity outside the motorsport sector has been small until the recent advances in engine control. The lack of popularity could partly be due to the drivability issues associated with early turbocharged engines. The engine's response to a sudden increase in driver's demand was delayed due to a turbocharger lag. The lag was then usually followed by a rapid increase of power which resulted in loss of traction and possible loss of control over the car. The developments made in the electronic control and management of internal combustion engine made it possible to overcome most of these drivability limitations. Passenger vehicles with turbocharged SI engines are now becoming more common. A number of companies such as Audi and Volvo now offer different passenger vehicle models with turbocharged SI engine whereas Mercedes offers supercharged and turbocharged engines. The operating principle of the turbocharger is to use the energy recovered from the exhaust gases to force more air into the combustion chamber. This increases the amount of oxygen in the combustion chamber and hence more fuel can be burned and more power can be produced. Therefore a turbocharged engine can produce more power than a similar sized naturally aspirated engine. It is claimed that the displacement of the turbocharged engine can be reduced by up to 40% relative to NA engine, without compromising power output. Thus the turbocharged engine could be smaller, lighter and more fuel efficient as well as produce less emissions.

1.2 Aim

To design and specify turbocharger in a Vauxhall 2.2 litre engine

1.3 Objectives:

Critical literature review of the project.
To investigate turbo system, develop a system for the Vauxhall 2.2, produce drawings and design.
Testing the engine before installation of turbocharger
To investigate and develop strategy for control of boost for the engine over a wide range of condition.

2.0 Initial Critical Review of Literature

This project is related to the turbocharging of a four stroke petrol engine. In this discussion a turbocharged four stroke diesel engine will also be discussed briefly and the differences will be highlighted. However, it omits to discuss two stroke engines due to their different gas exchange processes.

Supercharging

The term supercharging refers to increasing the air density by increasing its pressure prior to entering the cylinder. This allows a proportional increase in the fuel that can be burned and hence raises the potential power output. Three basics categories are used to accomplish this. The first is mechanical supercharging where a separate pump or compressor, usually driven by power taken from the engine, provides the compressed air. The second method is turbocharging, where a turbocharger, a compressor and turbine on a single shaft is used to boost the inlet air density. The third method is pressure wave supercharging which uses wave action in the intake and exhaust systems to compress the intake mixture. The main advantage of turbocharging as opposed to supercharging is that turbocharging uses the energy in the exhaust gas that would have been lost. Supercharging uses power from the engine's crank shaft and thus less power is available for propulsion

Turbocharging

The author acknowledges that the theory represented in this section is extracted from Watson and Janota (1982). The exhaust driven turbocharger was invented by a Swiss engineer named Alfred Buchi, his patent applied to a diesel engine in 1905. It took a very long time to establishe a turbocharger, but it is now proved that their characteristics are suited to the diesel engine, the reason being that only air is compressed, and no throttling is used. A turbocharger consists basically of a compressor and turbine coupled on a common shaft. The exhaust gases from the engine are directed by the turbine inlet casing on the blades of the turbine and subsequently discharged to atmosphere through a turbine outlet casing. The exhaust gases are utilized in the turbine to drive the compressor, which compresses the air and directs it to the engine induction manifold, to supply the engine cylinder with air of higher density than is available to a naturally aspirated engine. Figure1: Automotive Turbocharger Since diesel engines having no knock limitations, the maximum allowable boost on CI engines depends only on the mechanical strength of the engine. On an SI engine, the boost pressure is limited by knock. Thus if boost pressure is high on SI engines, the compression pressure must be low, high octane number fuel must be used or ignition timing must be retarded.

Turbocharger Theory

The operating characteristics of turbo machines such as turbines and compressors are totally different from the reciprocating internal combustion engine. The most common turbocharging assembly used in the automotive industry is made up of radial compressor coupled to radial turbine. Between the two is a wide supporting plain journal bearing, because an ordinary roller bearing would not survive the high rotational speed of up to 25000 rev/min of which a small turbine is capable. For racing application, ceramic ball bearings are being used more frequently. Axial turbine coupled with a radial compressor is a common configuration. Axial turbines are preferred for their superior efficiency to those of a radial turbine, but according to manufacturer's radial flow turbines are simpler and cheaper to manufacture and also the operating range of radial flow compressors are limited to certain pressure ratios, because a high pressure ratio will cause the supersonic flow and cause shockwaves at the inlet, this will impair the efficiency of compressor.

Turbocharging Diesel (CI) or Petrol (SI) engines

Today turbocharged diesel engines are common but turbocharged petrol engines are rare. There are sound reasons, both technical and economic for this situation. The principal reasons stem from the difference between the combustion systems of petrol and diesel engines. The petrol engine uses a carburettor or fuel injection system to mix air and fuel in the inlet manifold so that a homogeneous mixture is compressed in the cylinder. A spark is used to control the initiation of combustion which then spreads throughout the mixture. This is because the mixture temperature during the compression must be kept below the self-ignition temperature of the fuel. Once the combustion has started it takes time for the flame front to move across the combustion chamber burning the fuel. During this time unburnt 'end gas' is heated by further compression and the radiation from the flame front. If it reaches the self-ignition temperature before the flame front arrives, a large quantity of mixture may burn extremely rapidly producing severe pressure waves in the combustion chamber. This situation is commonly referred to as 'knock' and may result in severe cylinder head and piston damage. This is due to the fact that the compression ratio of the engine must be low enough to prevent knock occurring. In the CI engine cylinder, air alone is compressed. Fuel is sprayed directly into the combustion chamber from an injector only when combustion is required. This fuel self-ignites as in a diesel engine the compression ratio must be high enough for the air temperature on compression to exceed the self-ignition temperature of the fuel. As injection takes time, only some of the fuel is in the combustion chamber when ignition starts, and since much of this fuel is not as damaging as the knocking situation in a petrol engine. The maximum CR of the petrol engine, but not the diesel engine, is therefore limited by the ignition properties of the fuel. The minimum CR is limited by resulting low efficiency. Turbocharging results not only give a higher boost pressure, but a higher temperature. Unless the compression ratio of a petrol engine is reduced the temperature at the end of compression stroke will be too high and the engine will knock. The engine may remain knock free under mild boost - but only because there should be a sufficient safe knock free margin, or a fuel of higher self-ignition temperature/octane number has been used. Thus the potential power output of a turbocharged petrol engine is limited. The diesel engine has no such a limitation and can therefore use a much higher boost pressure. Petrol engines cost substantially less to produce than diesel engines of equivalent power output. The cost of the turbocharger on a diesel engine is more than offset by reduced engine size required for a specified power output (with the exception of very small engines). This situation will rarely occur in the case of petrol engine.

Energy Available In the Exhaust Gas:

Figure 2 shows the ideal limited pressure engine cycle in terms of pressure/volume diagram for the naturally aspirated engine. Superimposed is a line representing isentropic expansion from point 5, at which the exhaust valve opens, down to the ambient pressure (Pa) which could be obtained by further expansion if the piston were allowed to move to point 6. The maximum theoretical energy that could be extracted from the exhaust system is represented by the shaded area 1-5-6. This energy is called as 'blow-down' energy. Figure2: Naturally Aspirated Ideal Pressure Limited Cycle (Watson and Janota,1982) Considering the supercharged engine, the ideal four stroke pressure/volume diagram would appear as shown in figure, where P1 is the supercharging pressure and P7 is the engine back pressure in the exhaust manifold. Process 12-1 is the induction stroke, during which fresh charge at the compressor delivery pressure enters the cylinder. Process 5-1-13-11 represents the exhaust process. When the exhaust valve first opens (point 5) some of the gas in the cylinder escapes to the exhaust manifold expanding along line 5-7 if the expansion is isentropic. Thus the remaining gas in the cylinder is at P7, when the piston moves towards the TDC, displacing the cylinder contents through the exhaust valve into the exhaust pipe against the back pressure. At the end of the exhaust stroke the cylinder retains a volume (Vcl) of residual combustion products, which for simplicity can be assumed to remain there. The maximum possible energy that could be extracted during the expulsion stroke will be represented by area 7-8-10-11, where 7-8 represents isentropic expansion down to the ambient pressure. Figure3: Turbocharged Ideal Pressure Limited cycle (Watson and Janota, 1982) There are two distinct areas in figure 3 representing energy available from the exhaust gas, the blow down energy (area 5-8-9) and the work done by the piston (area 13-9-10-11). The maximum possible energy available to drive a turbocharger turbine will clearly be the sum of these two areas. Although the energy associated with one area is easier to harness than the other, it is difficult to devise a system that will harness all of the energy. To achieve that, the turbine inlet pressure must rise instantaneously to P5 when the exhaust valve opens, followed by isentropic expansion of the exhaust gas through P7 to the ambient pressure (P8=Pa). During the displacement part of the exhaust process, the turbine inlet pressure must be held at P7. Such a series of process is impracticable. Considering the simpler process in which a large chamber is fitted between the engine and the turbine inlet in order to damp down the pulsating exhaust gas flow. By forming a restriction to the flow, the turbine may maintain its inlet pressure at P7 for the whole cycle. The available work at the turbine will then be given by area 7-8-10-11. This is the ideal constant pressure system. Next consider an alternative system, in which a turbine wheel is placed directly downstream of the engine close to the exhaust valve. If there were no losses in the port, the gas would expand directly out through the turbine along line 5-6-7-8, assuming isentropic expansion. If the turbine area were sufficiently large, both cylinders and the turbine inlet pressure would drop to P9 before the piston had moved significantly up the bore. Hence the available energy at the turbine would be given by area 5-8-9. This can be considered the ideal pulse system. The system commonly used and referred to as 'constant pressure' and 'pulse' are based on the above principles but in practice they differ from these ideals.

Constant Pressure Turbocharging

In constant pressure turbocharging exhaust ports from all the cylinders are connected to a single exhaust manifold, whose volume is sufficiently large to dampen down the unsteady flow entering from each cylinder. When the exhaust valve of a cylinder opens, the gas expands down to the (constant) pressure in the exhaust manifold without doing useful work. However, not all of the pulse energy is lost. From the law of conservation of energy, the only energy actually lost between the cylinder and turbine will be due to heat transfer. With a well-insulated manifold, this loss will be very small and can be neglected. Consider what happens to the gas leaving the cylinder, expanding down into the exhaust manifold, and then flowing through the turbine. At the moment of the exhaust valve opening, the cylinder pressure will be much higher than the exhaust manifold pressure. During the early stages of valve opening (when the effective throat area of the valve is very small) the pressure ratio across the valve will be above the choked value. Hence gas flow will accelerate to sonic velocity in the throat followed by the shock wave at the valve throat and sudden expansion to the exhaust manifold pressure. Due to the turbulent mixing and throttling, no pressure recovery occurs. The stagnation enthalpy remains unchanged and hence flow from the valve to turbine is accompanied by an increase in entropy. As the valve continues to open the cylinder pressure will fall and flow through the valve which becomes subsonic. The flow will continue to accelerate to the valve throat and then expand to a pressure in the exhaust manifold. The energy available to useful work in the turbine is given by isentropic enthalpy change across the turbine, whereas the actual energy recovered is given by the enthalpy change across the turbine. Clearly it is a lack of recovery of the kinetic energy leaving the valve throat and throttling gases that lead to poor exhaust gas energy utilization with the constant pressure system. If the exhaust manifold is not sufficiently large, the blow down or the first part of the exhaust pulse from the cylinder will raise the general pressure in the manifold. If the engine has more than three cylinders, it is inevitable that at the moment when the blow down pulse from the cylinder arrives in the manifold, another cylinder is nearing the end of its exhaust process. The pressure in the latter cylinder will be low; hence any increase in exhaust manifold pressure will impede or even reverse its exhaust processes. This will be particularly important where the cylinder has both intake and exhaust valves partially open and is relying on a through-flow of air for scavenging of the burnt combustion products. There are some advantages and disadvantages of using a constant pressure system:

Conditions at the turbine entry are steady with time. Therefore losses in the turbine that result from unsteady flow are absent.
A single entry turbine may be used, eliminating 'end of sector losses'.
Single turbocharger can be used on all multi-cylinder engines, it will be a large turbocharger unit and since it is a large unit it will have low leakage losses and hence have higher efficiency. Turbines designed for constant pressure turbocharging have a high degree of reaction (50%) which, coupled with exhaust diffuser, brings additional gains in efficiency.
From a practical point of view, exhaust manifold is simple to construct although it may be rather bulky, particularly relative to small engines with few cylinders.
Transient response of the system is poor. Due to the large volume of gas in the exhaust manifold, the pressure is slow to rise, resulting in poor engine response and making it unsuitable for applications with frequent load or speed changes.

Pulse turbocharging

Although the constant pressure system is commonly used on certain types of engines, the vast majority of turbocharged engines in Europe use a pulse turbocharging system. In the practical pulse system an attempt is made to utilize the energy represented by both pulse and constant pressure areas of figure 2. The objective is to make the maximum use of high pressure and temperature exist in the cylinder at the moment of exhaust valve opening, even at the expense of the creating highly unsteady flow through the turbine. In most cases the benefit from increasing the available energy will more than offset the loss in the turbine efficiency due to the unsteady flow. Now consider small exhaust manifold as shown in figure. Due to the small volume of exhaust manifold, a pressure build up will occur during the exhaust blow-down period. This results from a flow rate of gases entering the manifold through the valve exceeding that of gas through the turbine. At the moment the exhaust valve starts to open, the pressure in the cylinder will be 6 to 10 times more than the atmospheric pressure, whereas the pressure in the exhaust manifold will be close to atmospheric. Therefore the initial pressure drop across the valve is above the critical value at which choking occurs and the flow will be sonic. Further expansion of the gas to the exhaust manifold pressure occurs by sudden expansion at the exhaust manifold recovery occurs due to turbulent mixing. The stagnation enthalpy remains constant hence the flow from the valve throat is accompanied by an increase in entropy. Finally the gas expands through the turbine to atmospheric pressure, doing useful work. The out-flowing gas from the cylinder loses a very large part of its available energy in throttling and turbulence after passing the minimum section of the exhaust valve. If the ratio of valve throat area to manifold cross section area is very small then throttling losses are very large and pressure drop across the valve is very large, during the initial stages of valve opening. Following further opening of the exhaust valve the cylinder pressure increases, reducing the throttling losses across the valve. The pressure drop across the turbine is now much larger, transferring the available energy to the turbine, which represents a much larger proportion of the available energy in the cylinder. At the end position of the valve opening the flow is sub-sonic and the throttling loss is reduced and is equivalent to the kinetic energy at the entry to the exhaust manifold. During the exhaust stroke, the flow process follows approximately the constant pressure pattern as described in the previous section. At the exhaust valve, the pressure in the exhaust manifold approaches atmospheric value. With pulse operation, a much larger portion of the exhaust energy can be made available to the turbine by considerably reducing throttling losses across the exhaust valve. The speed at which the exhaust valve opens to its full area and the size of the exhaust manifold become important factors as far as energy concerned. If the exhaust valve can be made to open faster, the throttling losses become smaller during the initial exhaust period. Furthermore, if the area of exhaust manifold is smaller than the rise in pressure of exhaust manifold will be faster, contributing to a further reduction in throttling losses in the early stages of the blow-down period. A small exhaust manifold also causes a much more rapid fall in pressure towards the end of the exhaust process improving scavenging and reducing pumping work. This discussion has therefore focused on the single cylinder engine connected to the exhaust manifold. However, in the case of a multi-cylinder engine this problem becomes more complicated. Because the turbocharger may be located at the one end of the engine, narrow pipes are used to connect the cylinders to the turbine to keep the exhaust manifold size as small as possible. By using the narrow pipes the area increase following the valve throat is greatly reduced, keeping throttling losses to a minimum. Scan dig7.2 Consider again a single cylinder engine, connected to a turbine by a long narrow pipe as shown in figure. Since the large quantity of exhaust energy becomes available in the form of a pressure wave, which travels along the pipe to the turbine at sonic velocity, the conditions at the exhaust valve and the turbine are not the same at a given time. Therefore the flow process at the exhaust pipe and at the turbine end, have to be presented separately as shown in figure. For simplicity, pressure wave reflections in the pipe are ignored. During the first part of the exhaust process, in the choked region of flow through the valve, the gas is accelerated to sonic velocity at the throat. Since the contents of the pipe are initially at rest at atmospheric pressure, sudden expansion takes place across the valve throat. However some of the kinetic energy is retained as dependent on the valve throat area to pipe cross-section area. As the valve opens further the pressure at the exhaust pipe entry rises rapidly. This is firstly because a certain amount of time is required for the acceleration of the outgoing gases, and secondly because the gases enter the exhaust pipe from the cylinder at a higher rate than they are leaving the exhaust pipe at the turbine end. The sudden pressure rise at the pipe entry is transmitted along the pipe in the form of a pressure wave and will arrive at the turbine displaced in time. This displacement is a function of length of pipe and properties of gas. The pressure drop across the valve is noticeably reduced due to the rapid drop in cylinder pressure and the rise in the pipe pressure and also because the valve throat area to pipe area ratio has increased. Both effects considerably reduce throttling losses. The velocity at the turbine end of the pipe is greater than velocity after the valve, due to the arrival of high pressure wave at the turbine end. In the subcritical flow region of blow down period, the pressure in the exhaust falls at the same time as that in the cylinder. The velocity at the valve throat is equal to the velocity in the pipe, since the valve is fully open. At the turbine exhaust gas expands to atmospheric pressure, doing useful work in the turbine. It has been established that the pulse turbocharging system results in greater energy availability at the turbine. As the pressure wave travels through the pipe, it carries a large portion of pressure energy and small portion of kinetic energy, which is affected by friction. The gain obtained through the use of a narrow exhaust pipe is achieved partly by reducing throttling losses at the early stages of the blow down period and partly by preserving kinetic energy. Thus the small diameter exhaust pipe is essential because this will preserve high gas velocity from the valve to the turbine. However if pipes are made too narrow, viscous friction at the pipe wall will become excessive. The optimum exhaust manifold pipe diameter will be a compromise, but the cross sectional area should not be significantly greater than the geometric valve area at full lift. The actual flow through a pulse exhaust system is highly unsteady and is affected by pulse reflections from the turbine and closed exhaust valves. It will be evident that effective time of arrival of a reflected pulse changes as per the engine speed. Hence the exhaust pipe length is critical and must be optimized to suit the speed range of the engine. The interference of reflected pressure waves with the scavenging process is the most critical aspect of a pulse turbocharging system, particularly on the engine with a very long valve overlap. Because of this phenomenon it is impossible to connect an engine with more than three cylinders to the same turbine without using a twin-entry turbine or introducing losses on the intake or exhaust processes. The advantage of pulse over the constant pressure turbocharging is that the energy available for conversion to useful work in the turbine is greater. The ideal pulse turbocharging must have following characteristics:

The peak of blow-down pulse must occur just before the bottom dead centre of the cylinder, followed by a rapid pressure drop to below boost pressure.
The boost pressure must be above the exhaust manifold pressure to aid the scavenging process during the valve overlap.
The effectiveness of pulse system is governed by the gas exchange process and overall efficiency of the turbocharger under unsteady flow conditions.

Pulse converters in turbocharging

The pulse turbocharging system has been found to be superior as compared to the constant pressure system on the majority of today's diesel engines. In the previous section it is made clear that the pulse turbocharging is most effective when groups of three cylinders are connected to the turbine entry. When one or two cylinders are connected to a turbine the average turbine efficiency and expansion ratio tend to fall due to the wide spacing of exhaust gases pulses. To overcome some of these advantages 'pulse converter' has been developed. Birmann was the first to use the term 'pulse converter'. His main objective was to design a device that preserved the unsteady flow of gases from the cylinder during the exhaust and valve overlap periods, yet to maintain a steady flow at the turbine, so that it might be possible to achieve good scavenging and high turbine efficiency. For good scavenging he proposed a 'jet pump system', by using high velocity of gas issuing from a central nozzle to decrease the pressure in short pipes at the exhaust valves. The system shown in figure 8.1 has some disadvantages as following:

Each nozzle must be larger than last which results in high manufacturing cost.
The whole installation is bulky and complex.
Because much of exhaust gases will pass through several ejectors and diffusers, the frictional and diffusion losses will be high.
There is insufficient length between exhaust ports to permits efficient pressure recovery in the diffusers.

The majority of pulse converters in use today are based on the concept of minimum energy loss, even if this means not only a loss of all suction effect, but also some pressure wave difference during scavenging. To avoid high mixing losses at the junction, the area reduction in the inlet nozzles is usually small (junction area >50% of pipe area), while the mixing length and plenum and often even the diffuser are omitted completely, as suggested by Petak (as cited in Watson and Janota, 1982). These simple pulse converters have the added advantage of adding little over-all length to the exhaust system. A typical example from a four stroke engine is shown in figure 8.4. The pulse converter is specified by the nozzle and throat area ratios. Clearly such a pulse converter will generate no suction, but the flow losses through it will be very much less than in more complex designs. Tests on a model pulse converters by Watson and Janota (1971) have shown that the area reduction at nozzles has to be severe to reduce pulse propagation substantially. The penalty accompanying large area reductions in the inlet nozzles is higher internal losses and hence reduces the amount of energy available for useful expansion through the turbine. In practice this means that the minimum possible area reduction is used, consistent with reasonable scavenging. It follows that the design of the pulse converter is a compromise between minimum losses and reduction of the pulse interaction between the inlet branches. The compromise adopted may vary from one engine design to another, depending on the amount of pulse interference, etc.

8.0 References

Watson, N and Janota, M, 1982, Turbocharging the Internal Combustion Engine, MacMilan, Great Britain.

Heywood, John, B, 1988,Internal Combustion Engine Fundamentals, McGraw-Hill

Stone, R, 1992, Introduction To Internal Combustion Engine, MacMilan,

Great Britain.

Azzoni, P, Moro, D, Ponti, F & Rizzoni, G, 1998, Engine and load torque estimation with application to electronic throttle control, SAE paper No. 980795, Society of Automotive Engineers.

9.0 Bibliography

Notes posted by Dr Les Mitchell on studynet
'Report Writing guide' posted by Dr. Rodney Day on studynet

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