Free Essays

Work-life balance policies can lower absence and help to tackle low morale and high degrees of stress that can lead to retention problems as employees’ tire of juggling work and life responsibilities.


In a society filled with conflicting responsibilities and commitments, work-life balance has become a predominant issue in the workplace. Three major factors contribute to the interest in, and the importance of, serious consideration of work-life balance: global competition; renewed interest in personal lives/family values; and an aging workforce. Work-life balance (WLB) is an important area of human resource management that is receiving increasing attention from government, researchers and management and professionals seeking innovative ways to enhance their organisation’s competitive advantage in the marketplace may find that WLB challenges offer a win-win solution.

Defining WLB has become a social issue all over the world. Blunsdon et al (2006, p. 1-16) defines Work-life balance as people who control or manage the see-saw of both life and career with achievement and satisfaction. It has also been defined that work and non-work activities (e.g. private holiday, seeing friends, sports) are compatible and in accordance with the promotion of an individual’s life quality (Kalliath and Brough 2008, p. 323). Alan Felstad (2002 p. 56) defined work-life balance as: “The relationship between the institutional and cultural times and spaces of work and non-work societies where income is predominantly generated and distributed through labour markets”.

The meaning of WLB has different things to different groups, and the meaning often depends on the context of the conversation and the talker’s viewpoint. The following are working definitions of terms used regarding work-life balance; some definitions overlap and some are continuing to develop. Work-family: a term more frequently used in the past than today. The current trend is to use titles that include the phrase work-life, giving a broader work-life connotation or labelling referring to specific areas of support (e.g., quality of life, flexible work options, life balance, etc.) Work-family conflict: the push and pull between work and family responsibilities.

The role of work has changed throughout the world due to economic conditions and social demands. With the frequent changes in the labour market, companies seek not only the differential to be become more competitive, but also adaptations address the needs of the organisational environment. It is also recognised that work-life balance can lead indirectly to productivity gains through increased retention and helps organisations to respond to customer needs more effectively.

To balance work and leisure is an important issue for all employees and employers. The three main influencers on work-life balance is the government, unions and businesses. The linkage between work and family has been studied as far back as the 1960s (Gregory 2009). These initial studies mainly focused on women and work-family stress. Later other concepts emerged. It was not until the 1970s the concept of “work-life balance” occurred (McIntosh 2003).

The issue of WLB has developed out of demographic and social changes that have resulted in a more diverse, declining workforce, different family and work models. Supporting WLB is seen as a way of attracting and retaining the labour force needed to support economic well-being. In organisations and on the home front, the challenge of work-life balance is rising to the top of many employers’ and employees’ consciousness. In today’s fast-paced society, human resource professionals seek options to positively impact the bottom line of their companies, improve employee morale, retain employees with valuable company knowledge, and keep pace with workplace trends. However, experience has shown that policy on flexible work practices needs to be supported by strategies to achieve effective implementation.

Personal lives and family values to the forefront:

The British work ethic remains intact, yet in recent years personal and family lives have become critical values that British are less willing to put on hold, put aside, or ignore, for the sake of work. The need for work-life balance has been clearly shown by the results of employee surveys, conducted by bodies such as The Work Foundation, which revealed that UK men now strive to be different from their fathers in their approach to home and family (over 60 per cent stating that they are more likely to feel guilty about neglecting domestic duties than their fathers did).

WLB from the employee viewpoint: the dilemma of managing work obligations and personal/family responsibilities. WLB from the employer viewpoint: the challenge of creating a supportive company culture where employees can focus on their jobs while at work. Family-friendly benefits: benefits that offer employees the latitude to address their personal and family commitments, while at the same time not compromising their work responsibilities. Work-life programs: programs (often financial or time-related) established by an employer that offer employees options to address work and personal responsibilities. Work-life initiatives: policies and procedures established by an organisation with the goal to enable employees to get their jobs done and at the same time provide flexibility to handle personal/family concerns. Work-family culture: the extent to which an organisation’s culture acknowledges and respects the family responsibilities and obligations of its employees and encourages management and employees to work together to meet their personal and work needs (Lockwood, 2003).

Stress and the Consequences for Employer and Employee:

We live in stressful times, and each of us deals with stress every day.

It is widely acknowledged that work-related stress can lead to increased sickness absence, higher labour turnover and early retirement. Indeed, between 2007 and 2008, an estimated 13.5 million working days were lost to stress- related absence (HSE research). Scientists agree that in moderate amounts stress can be benign, even beneficial, and most people are equipped to deal with it. However, increasing levels of stress can rapidly lead to low employee morale, poor productivity, and decreasing job satisfaction (Stranks, 2005). Some of the specific symptoms that relate directly to productivity in the work environment are abuse of sick time, cheating, chronic absenteeism, distrust, organisational sabotage, tardiness, task avoidance, and violence in the workplace. Other serious repercussions are depression, alcohol and drug abuse, marital and financial problems, compulsive eating disorders, and employee burnout.

The policies available for the problem associated with WLB are important social issues. Governments and organisations designated various policies for workers as to the work-life balance. Family friendly policies are the most discussed issues regarding balancing work and life i.e. to fulfil both work and life obligations simultaneously (Strachan and Burgess 1998, p.250-265). Gray and Tudball (2003 p. 269-291) proposed four types of family friendly policies: the first one is flexitime arrangements, such as permanent part-time works, and as the most discussed issue for workers in organisations, it allow workers to arrange the working day at different times, and it may also help employees to accomplish their work because they know they can be compensated as day offs (Brough et al 2008, p. 261) “It has gotten positive feedback from employees by implementing flexible work arrangements, including reduced and seasonal schedules as well as telecommuting options”( Deery 2008, p.792). The second one is paid/unpaid leave arrangements, such as paid leave, and unpaid leave for sickness or cultural aspects; the third one is dependent care services, such as the assistance with child-care or age-care; and the last one is the access to information, resources or services such as workplace facilities and stress management (cited in Brough et al 2008, p. 261), and this have been identified as effective methods and it also appears that family-friendly policies help organisations from preventing retention and could help organisations make profits (Melberg 2006, p. 337). Such family friendly policies have been implemented by many countries, for instance UK government has focused on those with children primarily by implementing Labour policies such as long time leave; childcare investigation; flexible working patterns (Lewis & Campbell 2007, p. 4-30).

Work-life balance is also a hot topic in the European Union. This has contributed to work-life balance policies for employees. In addition, the EU has promoted gender equality (through the introduction of ‘gender mainstreaming’). This has to varying degrees, led to national legislation and collective agreements. Trade union is involved in the implementation of work-life balance policies. Trade unions have been considered to have an important role in improving the work-life balance for employees. For example, the UK’s Women and Work Commission promoted the benefits of flexible working options (Women and Work Commission 2006). But concerning voices have stated that unions only are weakly committed because many of the issues raised are seen as “women issues”, and unions are dominated by men (Dickens 1998). WLB measures is often about flexible working hours, which pose a challenge, since unions see this as a removal of collective and protective rights. Measures like this is usually employer led (Ackers 2002). Fleetwood (2007) argues that work-life balance agenda is employer-friendly measures disguised as employee-friendly measures.

Wood’s institutional theory suggests that organisations adopt WLB policies depending on the extent to which they have to maintain a sense of social legitimacy. This will vary according to industry, size, sector and ultimately their visibility as an individual organisation. The benefit they derive from such policies is to protect their reputation amongst suppliers, workers and customers. (Wood, S. 1999). An example of an organisation tackling this issue is Marks & Spencer (2003) developed a long-running strategy / Evolving a family-friendly strategy for a large and diverse workforce. The company has been committed to work-life practices for many years, valuing a balance between employee and customer needs. The company believes in continuously updating its policies and in creating innovative solutions for both customers and staff. In order to remain an employer of choice it needs to keep developing imaginative working practices. They also listed increased staff loyalty and commitment and reduced staff turnover thus reduced retraining costs which highlights another benefit for the company. Generally speaking it is safe to assume happy staffs, both in work and out, is much more likely to be well motivated hard working individuals which will lead to higher productivity.

The consequences of not adopting family friendly policies can be examined by looking at what is likely to come about if you don’t. Staff can struggle with all kinds of issues also including a lack of psychological availability at work (Cooper and Williams, 1994), lower life satisfaction and detrimental effects to a parent’s mood, parent-child interaction and children’s behaviour (Judge, T.A. Boudreau, J.W. and Bretz, R.D. 1994). In terms of the future Sparrow and Cooper points out that it will be necessary to find a broader way to operationalize costs which will include wider social influences that will impact on organisations which will include family breakdown and various other stressors. A good balance holds many benefits for both employers and employees and whilst there are barriers to be overcome there are many examples of organisations breaking through them. ‘The challenge for organisations is to develop approaches to work-life balance that not only fit into the new world of legislation, but also both allow expression to the ethos of individualisation while fitting this into the new models of family that are emerging’, (Sparrow and Cooper, 2003).


Work-life programs have the potential to significantly improve employee morale, reduce absenteeism, and retain organizational knowledge, particularly during difficult economic times. In today’s global marketplace, as companies aim to reduce costs, it falls to the human resource professional to understand the critical issues of work-life balance. By implementing proactive programs and initiatives that support employees, organisations can strengthen employee commitment and loyalty, resulting in higher productivity, improved customer satisfaction and healthier bottom lines. At the same time, management should not only consider how much to pay their employees and how long should they work for because of the law, they should really get involved and help the employees to balance their work life, the management should understand the employees needs and try to adjust the right work life balance for them. The best way to build up a balance is not just considering a balance between employees’ needs and their work, it is also the best if the employees have a good relationship with the employer, and to create a better environment for the work force.

References and Bibliography

Ackers, P., 2002. ‘Reframing Employee Relations: The Case for Neo-Pluralism’, Industrial Relations Journal, 33, (1) pp. 2–19.

Arthur, M.M. and COOK. A., 2003. The relationship between work-family human resource practices and firm profitability: Amulti-theorical perspective. Research in Personnel and Human resources Management, 22, pp. 219-252.

Baroness, M.P., 2006. Women and Work Commission: Shaping a Fairer Future. [online]. London: HMSO. Available from: [Accessed 5 April 2011].

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Blunsdon B. et al., 2006. Work-life Integration: International Perspectives on the Balancing of Multiple Roles. London: Palgrave, Macmillan. pp.1-16.

BROUGH, P. et al., 2008. The ability of work – life balance policies to influence key social/organisational issues. Asia Pacific Journal of Human Resources, 46, pp.261.

Clutterbuck, D., 2003. Managing work-life balance: a guide for HR in achieving organization and individual change. [online]. London: CIPD. Available from: [Accessed 4April 2011].

Cooper, C., Dewe, P., O’Driscoll, M., 2001. Organizational Stress. London: Sage.

Cooper, C.L. and Williams, S., 1994. Creating healthy work organisations. Chichester: Wiley.

DEERY. M., 2008. Talent management, work-life balance and retention strategies. International Journal of Contemporary Hospitality Management, 20, (7), pp.792.

Dickens, L., 1998. What HRM means for gender equality. Human Resource Management Journal, 8 (1), pp. 23–40.

Gifford, J., 2007. Work-life balance. [online]. Brighton: IES. Available from: . [Accessed 4April 2011].

FELSTAD. A. et al., 2002. Opportunities to work at home in the context of work-life balance. Human resource management journal, 12 (1), pp. 54-76.

FLEETWOOD, S., 2007. Why work-life balance now?. International Journal of Human Resource Management, 18 (3), pp. 387–400.

GRAY, M. and Tudball, J., 2003. Family-friendly work practices: Differences within and between workplaces. Journal of Industrial Relations, 45, pp.269-291.

GREGORY, A and MILNER, S., 2009. Trade Unions and Work-life Balance: Changing Times in France and the UK?. British Journal of Industrial Relations, 47, pp. 122.

HYMAN. J. and Summers. J., 2004. Lacking balance?: Work-life employment practices in the modern economy. Personnel Review, 33, (4), pp.418- 429.

JUDGE, T.A., BOUDREAU, J.W. and BRETZ, R.D., 1994. Job and life attitudes of male executives. Journal of Applied Psychology. 79, (5), pp. 767-782.

Kalliath, T. and Brough, P., 2008. Work-life balance: A review of the meaning of the balance construct. Journal of Management and Organization, 14, pp.323.

KERR.R., McHUGH. M. and McCRORY. M., 2009. HSE Management Standards and stress-related work outcomes. [online]. UK: Occupational Medicine, 59, pp. 574-579. Available from: [Accessed 3April 2011].

LEWIS, J. and CAMPBELL, M., 2007. UK Work/Family Balance Policies and Gender Equality, 1997–2005’. Social Politics, 14, pp.4-30.

Lockwood. N.R., 2003. Work/life balance: challenges and solutions. [online]. UK: HR Magazine Find Available from: [Accessed 4April 2011].

McIntosh, S., 2003. Work-Life Balance: How Life Coaching Can Help. Business Information Review, 20, pp. 181.

MELBERG, K., 2006. Family Well-Being between Work, Care and Welfare Politics the Case of Norway. Marriage & Family Review, 39, pp.337.

Pedler, M. and Burgoyne, J.G., 2007. A Managers Guide to Self Development, 5th ed. Maidenhead: McGraw-Hill.

SPARROW, P.R. and COOPER, C.L., 2003. The employment relationship: key challenges for HR. Oxford: Butterworth Heinemann.

STRANKS, J., 2005. Stress at work: Management and prevention. Oxford: Elsevier.

Roberts, K., 2007. Work-life balance- the sources of the contemporary problem and the probable outcomes. A review and interpretation of the evidence, Employee Relations, 29(4), pp. 334-351.

STRACHAN, G. and BURGESS, J., 1998.The family friendly workplace: Origins, meaning and application at Australian workplaces. International Journal of Manpower, 19(4), pp. 250-265.

The work foundation, 2011. Employers and work-life balance. [online]. London, UK: The work foundation. Available from: [Accessed 5April 2011].

The work foundation, 2003. M&S Case study. [online]. London, UK: The work foundation. Available from: [Accessed 5April 2011].

TORRINGTON, D., HALL, L. and TAYLOR, S., 2008. Human Resources Management. 7th ed. Harlow: Pearson Education.

VISSER, F. and Williams. L., 2006. Work-life balance: Rhetoric versus reality?. [online]. UK: And independent report commissioned by UNISON. Available from: [Accessed 3April 2011].

WIKINSON. H., 2009. The recessionary cloud’s silver lining Enforced flexible working could reduce employees’ stress levels and give them more control over their work-life balance. [online]. UK: Guardian News. Available from: [Accessed 3April 2011].

WOOD. S., 1999. Family Friendly management: testing the various perspectives. National Institute for Economic Research, 168, (2), pp. 99-116.

Free Essays

Occupational Health Psychology (OHP) is concerned with the application of psychology in other to improve the quality of working life to protecting and promoting the safety , health and well being of workers(NIOSH).


OccupationalHealth Psychology (OHP) is concerned with the application of psychology inother toimprove thequality ofworking life to protecting and promoting thesafety , health and well beingofworkers(NIOSH). Protection and promotion are geared towards interventionsto reducehazards at work and to equip individual workers with knowledge and resources toimprove theirhealth(CDC, 2010).

Theterm OHP wasfirst mentionedby FriedrichEngels in1845 and in1987 ashe wroteon “theconditions of workingclass in England”. Karl Marx (1867 & 1999) also usedit inwriting “the horrificways whichcapitalismtookadvantageofworkers in Das Kapital”. Karaserk (1979) castigatedTaylors approach on how jobmustbe done havealso made contributionstoOHP.

OHPrequires aninterdisciplinaryapproach(Maclean, Plotnikoff & Moyer, 2002). Examples arepublic health, preventative medicine, industrialengineering, etc. The primary focus of OHP is the prevention ofillness andinjurybycreating safe andhealthyworking environment (Quick et al.,1979, Saiter, Hurrel, Fox, Tetrick and Barling , 1999). Themajorchallenge in promoting occupationalhealthischangingnature of work and workforce (Quick & Tetrick, 2002). Peoples exposure to workenvironment may bevery dynamic making it verydifficultfrom anepidemiological perspective to identify the sources ofill health (Berkman & Kowachi, 2000).


Amyriadofbenefits toboth employersandemployees can be realised from OHP. The Health and Safety atworkAct (1974) says,“it shall be theduty of every employer to ensure the health at work ofall employees. Employers have to uphold a duty of care and to ensureas far asisreasonable andpracticable, the health, safety and welfare of all their employees. Theemployermustnot act or conducthimself in a waythat will causeinjury to theemployee”.(HSE, 1995).

TheHealthand Safety Executive (HSE) in the United Kingdom hasbrought to bear ManagementStandards in OHP to helpbring downthelevel ofworkrelated stressbythe introduction ofthecompetency framework (CIPD, 2007). Stress is defined as a particular relationship between the person and environmentthatisappraisedby the person astaxingor exceedinghis or herresources and endangeringhisor her well being (Lazarus and Folkman, 1984). Management Standards is defined as characteristics or culture of an organisation where the risk from work related stress are being effectively managed and controlled (Kerr et al.,2009). In theManagement Standards, six potential variables(demand, control, support, relationships, role and change) ifnotorganisedappropriately could lead to poor health and well being, decreased productivity andincreased sickness and absence (Cousins et al., 2004 & Mackay et al., 2004) . Theyalsohave the potential of impacting on workersdisregarding the type and size of the organisation (Mackay et al., 2004).

OHP, emphasise on the importance ofemployee control and participation. The SwedishWork Environment Act(1978) has made psychosocial and psychological stands. The Swedish Act ofCo-Determination(1977) give workers a mouth piece on job design, methods of production, working environment and organisational decision making (Gardell & Johansson, 1981).

OHP opens thegatewayfor employers todevelop stresspolicies which aregeared towards protecting health, safety and welfare ofemployees. In the UK, the HSE Act of1974 allowsorganisations to take note of all stressors andconduct risk assessment toquash stress and controlrisksfrom stress, consultations withtrade unions’safetyrepresentatives on all proposed actionsrelating to the prevention of workplace stress, managers and supervisorsaretrained on goodmanagement practice, providing confidential counsellingfor staffs if need be and lastly, provisionof resources to implement agreed stress managementstrategies. For example, The Barking, Havering and Redbridge University Hospitals have a stress management policy in place which aim todesign andimplement services, policies and measures that meet the diverse need of their services, people and workforce ensuringthatno one is disadvantaged (BHRUT, 2009). They also aim to improving working lives (IWL), providing staffs with occupationalhealth services andprovidingconfidentialcounselling services (MSWRS, 2007).

Occupational Healthhelps in the setting ofperformancestandards bytheidentification ofhazards, assessment of risk basedon probability andseverity(major, serious and slight), risk control andthe need to monitor andmaintain it ( Cox et al., 2000). In Controlling workplace hazards, potentialhazards are eliminated, employees are restricted to hazards and aretrainedon how todo away with hazards (Smith et al., 1978). Employeesgetadequate information about thename of the hazard, its health effects and the types of exposure (OSHIA, 1970). Safety andhealth is effective in reducing employee risk at work (Cohen & Collagen, 1998).

Employers canuse global objectives (where a percentage of hazard reduction is set) to measure the incidence of workplaceinjury ( Quick & Tetrick, 2002). By this, they could see the viability of a health and safety training programs. Studies show that increasing hourly ratesof employerscan bebeneficial to safety behaviours and reduction in hazardexposure (Hopkins, Conrad & Smith 1986; Smith, Anger, Hopkins & Conrad 1983).

OHP giveemployers the opportunity to know the causes ofstress at work soasto put measures in placetostifle employees fromcapitalising onemployers’negligenceonhealth and safety at work since, as long asemployees havejustified evidence that the employerhas been negligent or breached theirstatutory duty, they will be due forcompensation which affects employersfinanciallybut will enrichemployees. Three examples ofsome compensation cases arethatofpoliceman Martin Long whoearned?330,000 from the Hillsborough disaster in 1989 andthat ofsocial worker ThelmaConwaywho alsoreceived ?140,000 in compensation after she developed stressrelated illness throughwork. Recently, Joyce Walters, a teacher who had a painful nodule on her vocal cord after handling a noisy classroom was paid ?150,000 (Haywood, 2010).


There is more toensuringsafety performance than a written health and safety policy (Smith et al., 1978). Itmust be emphasised thatholding safety programs for organisations are good however, there is the need to encourage communication throughout the various departments inorganisations. Informal communication provides motivation and meaningful information forhazard control ( Quick & Tetrick, 2002).

Curbinginjuries and illness atwork really requires a multifaceted approach that can definehazard, evaluate risk, establish means to control risk and incorporate managementsupervision and employees activelyin theprocess. Topmanagement should have a responsibility to be committed to health and safety programs (Cohen, 1977).The HSE stress indicator tool (HSE, 2007) must alsobe used concurrently to measure stress atwork in order to have a healthy and safer place to work.

Berkman, L. F. & Kawachi, I.(Eds) (2000) Social Epidemiology, New York: Oxford University Press.
BHRUHT(2009) Stress Management Policy 51(3)
CIPD(2007) What Happening With Well being at Work
Cohen, A. & Colligan, M. J.(1998) Assessing occupational safety and health training: A literature review. Cincinnati, OH: NIOSH.
Cohen, A.(1977) Factors in successful occupation safety programme. Journal of Safety Research, 9, pp. 168-178.
Cousins, R., MacKay, C., Clarke, S.D., Kelly. C, Kelly, P.J, McCaig R.H.(2004)Management standards and work-related stress in the UK: practical development. Work Stress;18. Pp. 113–136
Cox, T, Griffiths, A. & Rial- Gonzalez, E.( 2000). Research on Work Related Stress. Luxemburg.
Engels, F.(1987) Conditions of Working ClassinEngland. London: Penguin Books.
Gardell, B. & Johansson, G.(1981) Working Life: A Social science contribution to work reform. Chichester, UK: Wiley & Sons.
Haywood, L.(2010) SPEECHLESS: Outrage as teacher gets ?150,000 for losing her voice in ‘noisy’ classroom. The Sun, 10 November, p. 4.
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Karasek, R. A., Baker, D., Marxer, F., Ahlbom & Theorell, T.(1981) Job decision latitude, job demands and cardiovascular disease: A prospective study of Swedish men. American Journalof Public Health, 77, pp. 694-705.
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Lazarus, R.S. & Folkman, S.(1984) Stress Appraisal and Coping. New York: Springer.
Lewin, L.(1951) Field theory in social science. New York: Haper.
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Occupational Safety and Health Act of 1970 (1970), 91- 596.
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Sauter, S.L., Murphy, L.R. & Hurrell, J.J.(1999) Prevention of workrelated psychological; disorders. A national strategy proposed by NIOSH. American Psychologist, 45, pp. 1146-1158.
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Free Essays

Palliative care is an approach that improves the quality of life


1.1 Definition of Palliative care

According to the WHO, Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual.

Palliative care provides relief from pain and other distressing symptoms, affirms life and regards dying as a normal process, and intends neither to hasten nor to prolong death.2 Palliative care integrates the psychological and spiritual aspects of patients care, and offers a support system to help patients live as actively as possible until death. It also offers a support system to help the family cope during the patient’s illness and in their own bereavements. In many countries, the terms hospice and palliative care are used interchangeably to refer to the support provided to people with little or no prospect of cure.3

In the United States, a distinction is made between general palliative care and hospice care, which delivers palliative care to those at the end of life; the two aspects of care share a similar philosophy but differ in their payment systems and location of services. Whereas in the United Kingdom, this distinction is not operative; in addition to specialized hospices, non hospice-based palliative care teams provide care to those with life-limiting illness at any stage of the disease.

According to the Scottish Partnership for palliative care, palliative care is the term used to describe the care that is given when cure is not possible. The word comes from the Latin “palliatus”(covered or hidden with a cloak) and is used to mean “relieving without curing”.4 Although palliative care is historically associated with later stages of cancer, it is now established that palliative care should be a routine part of care for those living with and dying from a wide variety of non-malignant conditions, such as dementia, heart failure, Huntington’s disease, motor neurone disease, multiple sclerosis, muscular dystrophy, Parkinson’s disease, renal failure and respiratory failure among others.

General palliative care is an integral part of the routine care delivered by all health and social care professionals to those living with a progressive and incurable disease, whether at home, in a care home, or in hospital.4 Specialist palliative care is based on the same principles of palliative care, but can help people with more complex palliative care needs. Specialist palliative care is provided by specially trained multi-professional specialist palliative care teams and can be accessed in any care setting.

1.2 Public health context of palliative care

Public health approaches to palliative care have a valuable contribution to make in understanding and developing community capacity related to , dying, loss and care acknowledging that carers of the dying and bereaved are an important group who have their own significant needs in end -of-life care.5 Primary care has a vital role in delivering palliative care. 6,7 In most developed countries more people die in hospital than at home 8,although substantially more people would prefer to die at home.9 Primary care professionals play a central role in optimising available care, but they often lack the processes and resources to do this effectively.6,10 The Gold Standards Framework (GSF) for community palliative care 11 is a primary care led programme in the United Kingdom that is attracting international interest.7 The framework enables general practitioners and community nurses to optimise practice by providing guidance through workshops and locally based facilitation on how to implement processes needed for good primary palliative care. It is supported by a plethora of practical tools, guidance documents, and examples of good practice.12 It is regarded by many as “the bedrock of generalist palliative care”. GSF is recommended as best practice by the Department of health End of life care strategy, NICE, Royal College of General Practitioners, Royal College of Nurses and other major policy groups.

1.3 Care pathways in palliative care

A care pathway is a plan of how someone should be cared for when they have a particular medical condition or set of symptoms. There is increasing evidence that using an integrated care pathway to manage care at the end of life is good way to implement and monitor best practice, and to standardise care in a variety of care settings. The use of pathways to manage the care of dying patients has gained considerable support from the clinical teams who have used them, as there is evidence that use of such pathways improves the quality of care in the last days and hours of life. A number of end of life care pathways have been developed but the first and most well known is the Liverpool Care Pathway for the Dying Patients (known as the LCP).13

A number of other pathways are available in relation to supporting the care of dying patients:

– Pathway for Improving the Care of the Dying (PICD) (Australia)

– Palliative Care for Advanced Disease (PCAD) pathway (USA)

– Department of Veteran’s Affairs (DVA) Palliative Care Clinical Pathway (Australia)

– Gold Standards Framework (GSF) for community Palliative Care (UK)

– Preferred Priorities for Care Plan (PPC) (UK)

The Liverpool Care Pathway (LCP) is aimed at improving care and communication in the dying phase. In the UK, the LCP was developed to improve care for dying patients.14 The LCP was developed to take the best of hospice care into hospitals and other settings. It is used to care for patients in the last days or hours of life once it has been confirmed that they are dying. The LCP is designed to enable all healthcare workers to provide optimal care to dying patients, whether they are specialists in palliative care or not, by guiding clinical decision making. The LCP is a legal document which replaces the usual medical record at the end of life, and is structured to facilitate audit and outcome measurement.15 It promotes clear communication around the dying and death of the patient, and it supports psychosocial and spiritual care to the patients and their relatives, for example, by promoting adequate communication and support and giving relatives a brochure for bereavement after the death of the patient.15 The UK and 13 other countries are registered with the LCP Continuous Quality Programme. 16 In Scotland the LCP is applied by 12 of the 13 voluntary hospices; but only a quarter of district nurses reported in 2008 that they are currently using the LCP.17 In NHS Greater Glasgow and Clyde 37% of the GP practices, 33% of the nursing homes and 47% of the wards in the acute operating division are in the process of implementing the LCP.18

1.4 Pharmaceutical care context of palliative care

It is estimated that one in three people in the UK will develop cancer and one in four will die from it.19The survival rate for cancer is increasing with more patients being treated as day-case patients. The length of stay for in patients is also decreasing, therefore it is essential to ensure appropriate care continues in the community setting.20 Hepler and Strand defined pharmaceutical care as improves a patient’s quality of life.21 For pharmaceutical care to be successful, a quality system should be implemented to ensure appropriate patient outcomes. It is important that all pharmacy members of the healthcare team in different settings are included in the delivery of pharmaceutical care.22To ensure continuity of care, pharmaceutical care plans require to be updated when the patient’s needs change. Seamless care helps patients to move across healthcare boundaries without experiencing a gap in the standard of healthcare delivery, but this requires effective communication between primary and secondary care.23 In providing pharmaceutical care, pharmacists co-operate with doctors, patients and/or carers in designing, implementing and monitoring a “pharmaceutical care plan”. The pharmaceutical care provided aims to optimize drug treatment and achieve specified therapeutic outcomes. This has the potential to reduce drug-related problems and improve patient’s quality of life

To support the local delivery of chemotherapy, models of care need to be developed and remote models of care need to be developed and remote patient monitoring performed which is linked to an electronic health record.24 The use of an electronic record would undoubtedly improve seamless care. It is therefore essential that improvements are made in the transfer of pharmaceutical care. Over the past decade, there has been a large increase in the number of patients receiving cancer treatments and symptom relief treatments at day-case chemotherapy clinics25. With the increase in the prescribing of oral chemotherapy and the use of ambulatory intravenous pumps which allow patients to receive continuous chemotherapy at home, there is increasing need for hospital pharmacists to liaise more closely with general practitioners (GPs) and community pharmacists to explain unusual indications for a drug or unconventional dosage regimens. This liaison is needed to avoid incidents reported through the in-house reporting system such as inadvertent continuation of intended short courses of medication, for example, dexamethasone prescribed for three days as an anti-emetic after chemotherapy. There is a need for the required clinical monitoring to be undertaken in primary care to minimise risks associated with these medicines. It is essential that detailed information on monitoring requirements is conveyed from the day-case clinic to the patient’s GP and community pharmacist, so that both are aware of the therapeutic plan for the patient and management of potential toxicities and possible drug interactions.

Methods of transferring care require exploration and hence Julie Fisher et al,in their study examined and designed a documentation system to monitor pharmaceutical care between cycles of chemotherapy for patients who attended an oncology care unit.24 Their study confirmed a recognised need for continuity of pharmaceutical care between hospital and community pharmacists.

The Gold Standards Framework Scotland (GSFS) was introduced in 2003 and is an adapted version of the GSF for implementation within NHS Scotland. The Gold Standards Framework Scotland provides a means of improving the quality of care provided by primary care teams in the final year of a patient’s life. The main differences to the core GSF are : addressing the needs of patients from diagnosis onwards; maintaining a GSF palliative care register, and ; advanced care planning, defined as a process of discussion between an individual and their care providers about individual’s concerns, their preferences for types of care and their understanding of their illness and prognosis.26

Across Scotland, 75% of GP practices are registered as using the GSFS.17 As of 2009, 80%of GP practices in NHS Greater Glasgow and Clyde are signed up for the GSFS.18 The most recent development in 2009 has been the electronic Palliative Care Summary (ePCS). The ePCS allows, with patient or carer consent, the access to daily updated summary information from GP records for Out of Hours services and NHS 24. This facilitates structured and accurate information to be available in hours and out of hours to support palliative care patients and their families. The ePCS includes: prescribed medication, medication diagnosis, patients’ and carers understanding of prognosis, patient wishes about place of care and resuscitation.26, 18.

The UK department of Health has proposed that Primary Care Trusts across England should invest in pharmaceutical care services giving patients access to more help from pharmacists in using their medicines.27 Evaluation of pharmacists’ interventions has shown that they can make a valuable contribution in secondary care settings such as hospices and hospitals.28 Lucas et al found that more than 60% of pharmacists’ interventions in an inpatient palliative care unit could significantly improve patient care.29 The pharmacist advised on the appropriateness of medication regimens, side effects and contraindication of medication and provided drug and prescribing information to patients and staff. Despite being perhaps the most accessible healthcare professional, there is limited research into the possible contribution of community pharmacists to community-based palliative care in the UK. A recent review showed that the delivery of palliative care to patients in the community is far from ideal.30 Inadequacies in knowledge and training of professional currently providing palliative care to patients at home may prevent the patient receiving optimum pain and symptom control.31, 32 Fragmentation and poor organisation of current palliative care services may result in a loss of continuity of care for such patients or hinder the timely availability of appropriate medication.33,34 Poor communication within existing teams and across organizational boundaries also limits the provision of effective palliative care to patients in the community.35,36 If community pharmacists were included in the local network of healthcare professionals, this would benefit all parties, especially patients and carers, and it would help to share the over-increasing work load in palliative care, due in part to an aging population. Needman et al, 37 assessed the effectiveness of community pharmacists’ clinical intervention in supporting palliative care patients in primary care using an independent multi-professional panel review. In their study, they suggested that when trained community pharmacists are included as integral members of the multi-professional team, they can intervene effectively to improve pharmaceutical care for palliative care patients in the community, providing additional support for them to remain at home; because majority of palliative care patients spend most of their last year at home under the care of their GP and the primary care team.38 It is only when the community pharmacist knows and have the details of the patient’s medical condition and prognosis , that she is able to suggest new therapies or to titrate existing ones. Unfortunately in the present UK community pharmaceutical services system, the community pharmacists are unlikely to know the medical diagnosis of the patients or other essential clinical details.39, 40 As a result, community pharmacists in general are unable to make full use of their knowledge and expertise or to anticipate problems and advice on them. The recent NHS pharmacy plan advocates that personal medicine management services should be provided by community pharmacists in the future.27

The study of Needman et al showed that the personal palliative pharmaceutical care services are feasible in everyday practise when community pharmacist is included in the multidisciplinary palliative care team.37

In 2002, the Scottish Government through its publication “The Right Medicine: A

strategy for pharmaceutical care in Scotland”, proposed a better use of pharmacists’ professional competence in planning and delivering services, especially in priority areas such as cancer, heart disease and mental health.41This policy document placed emphasis on the continued development of Pharmaceutical Care Model Schemes including palliative care, initiated in 1999 in collaboration with the Royal Pharmaceutical Society in Scotland. This work has developed and now all NHS Boards have developed Community Pharmacy Palliative Care Networks. Access to specific palliative care medicines within and out with working hours via this network is quality standards in all NHS Board areas.42 Within the NHS Greater Glasgow and Clyde area 71 of the current 312 pharmacies are involved in the Community Pharmacy Palliative Care Network. This network was established in 2001 and is funded by NHS Greater Glasgow and Clyde18, 43, 44. The purpose of the project is to increase awareness of the community pharmacist’s role, their capacity to manage patients requiring cancer and palliative care support, reduce risks and effectively manage anticipatory care needs to minimise out of hours issues. The services of the network pharmacies includes: retailing a stock of more specialized medication which may be required for palliative care; a courier service for transport of urgent prescriptions and medicines, and ; provision of advice and support to other pharmacies, GPs and district nurses.

In 2006, a new community pharmacy contract was agreed with the Scottish Government to modernise community pharmacy practice and to support the delivery of pharmaceutical care. The contract is based on four core services, namely the acute medication service, the minor ailment service, the public health service and chronic medication service (CMS) 45 of which palliative care is one. The Chronic Medication Service (CMS) will also require patients to register with a pharmacy. It will enable a pharmacist to manage a patient’s long-term medication for up to 12 months. Under this service, a patient can have his or her medicines provided, monitored, reviewed and, in some cases, adjusted as part of a shared care agreement between the patient, the GP and the community pharmacist. It is in this service that an emphasis on the systematic approach to pharmaceutical care is particularly apparent; it will incorporate the pharmaceutical care model schemes, serial dispensing and supplementary prescribing.

In October 2008, the Scottish Government published “Living and Dying Well in Scotland. ‘Living and Dying Well’ is the first plan for the development of a single, cohesive and nationwide approach to ensure the consistent, appropriate and equitable delivery of high quality and person centred palliative care based on neither diagnosis nor prognosis but on patient and carer needs. The concepts of assessment and review, planning, coordination and delivery of care, of communication and information sharing and of appropriate education and training are addressed in this Action Plan. The Action Plan states that NHS Boards and Community Health Partnerships (CHPs) should take steps to ensure that patient with palliative care needs are included in a palliative care register and are supported by a multidisciplinary team. The Action Plan also emphasises the importance of proactive care planning and anticipatory prescribing to aid the prevention of unnecessary crisis and unscheduled hospital admissions, particularly out of hours. This also includes the planning for stages of illness trajectories that are likely to produce changing patient needs in the future.

Key to the progress of “Living and Dying Well” is its emphasis on a person centred approach to care and care planning and on the importance of communication, collaboration and continuity of care across all sectors and all stages of the patient journey. In order to fully realise the necessary improvements in palliative and end of life care, NHS Boards should review their projects the “Living and Dying Well” actions and the actions set out in Living and Dying Well: Building on Progress – with particular priority on the following areas.

– Early identification of patients who may need palliative care

– Advance / Anticipatory Care Planning (ACP)

– Palliative and end of life care in acute hospitals

– Electronic Palliative Care Summary (ePCS)

– Do not Attempt Cardiopulmonary Resuscitation (DNACPR)

1.5 Transfer of information in Palliative Care

Access to specialist palliative care services must be more consistent across Scotland, according to a report published by Audit Scotland.17 Audit Scotland investigated the provision of specialist and general palliative care in all NHS board areas. It found a significant variation in the availability of specialist palliative care services and in the ease with which patients can access services.46 Although community pharmacists’ provision of palliative care medicines was not specifically reviewed by the audit, the report notes: “NHS boards reported that provision was well organised through the national community pharmacy scheme”

Many people, who are terminally ill, do prefer to spend their last days in their own homes. It is therefore, essential that these patients have easy access to care and medicines that can help them if their condition were to change rapidly or deteriorate suddenly at night or during the weekend (as is common in terminal illness). However, the provision of out-of-hours specialist palliative care and the availability of palliative care medicines in the community can present major problems.

Communication between professionals and patients/carers is an important aspect of palliative care in any setting. However, effective communication and co-ordination between professionals, especially across organisational boundaries, systems and structures, can play an even more crucial role in ensuring the quality of care and enhancing patient and carer experience. According to “Living and Dying well” in Scotland the aim of communication and co-ordination is

– to ensure that all patients and carers with palliative and end of life care needs are supported to participate fully in developing care plans and making decisions about their care

– to ensure that their needs are communicated clearly across care settings and systems to all professionals involved

– to ensure that the care of all patients and carers with palliative and end of life care needs is co-ordinated effectively between specialists and across care settings and sectors.

The transfer of appropriate information between care settings, including out of hours services and NHS 24, could be improved, and is known to have particular significance for those with palliative and end of life care needs. The Scottish Government is therefore facilitating development of an electronic Palliative Care Summary (ePCS) which is developed from the Gold Standards Framework Scotland Project 47 and is based on the Emergency Care Summary. The ePCS will, with patient and carer consent, allow automatic daily updates of information from GP records to a central store, from where they will available to out of hours services, NHS 24 and Accident and Emergency service. The ePCS is currently being piloted in NHS Grampian, and subject to successful evaluation, will be rolled out nationally from 2009. NHS Quality Improvement Scotland is currently developing National Key Performance Indicators for palliative care which address out of hours issues. The timely sharing of information between primary and secondary care, especially at times of admission and discharge and including transfer between home, care homes and hospitals remains a challenge to be addressed.46 The ePCS now provides a helpful framework for identifying the type of information from assessments and care pans which should be shared. NHS Boards will be expected to ensure, by whatever means are locally available, the availability over 24 hours of such information to all relevant professionals.

1.6 Electronic Palliative Care Summary

The ePCS builds on the Gold Standards Framework Scotland project and the Emergency Care Summary (ECS). The ePCS will, with patient /carer consent, allow automatic daily updates of information from GP records to a central store, from where they are available to Out Of Hours (OOH) services, NHS 24, Acute Receiving Units, Accident Emergency Departments and shortly to the Scottish Ambulance service. The ePCS is now in use in over 23% of practices across 11 Health Board in Scotland.48 The electronic Palliative Care Summary (ePCS) allows practices to: replace the fax form used to send patient information to out of hours services, clearly see essential information on patient with palliative care needs, view or print lists of patients on the practice Palliative Care Register, set review dates to ensure regular review of patients. The information allows practises to build up Anticipatory Care Plans which may include:

– medical diagnoses as agreed between GP and patient

– patient and carer understanding of diagnosis and prognosis

– patient wishes on preferred place of care and resuscitation (DNAR)

– information on medication and equipment left in the patient’s home “just in case”

– current prescribed medication and allergies, as per the Emergency Care Summary (ECS).

ePCS needs to be developed to meet the needs of palliative care patients. This will require electronic transfer of appropriate information across care settings and to be accessible by recognised healthcare workers supporting patient care. This project will review the development to date of relevant electronic transfer systems.

2. Aim and Objectives


Describe current pharmaceutical care provision and make recommendations for electronic transfer of information through evolving palliative care summaries.


2.1 To conduct an extensive literature review to establish current published work as a baseline for describing information summaries to support pharmaceutical care of palliative care patients.

2.2 To describe relevant information summaries in current practice.

2.3 To describe current information transfer across care settings.

2.4 To identify developments in electronic transfer of care summaries and make recommendations on data fields to support information transfer based on evidence.

2.5 To make recommendations to support an electronic palliative care summary (ePCS) for use by pharmacists in different settings providing pharmaceutical care to palliative care patients.


3.1 Description of literature searching

A literature search was conducted in order to identify relevant previous work and experiences in the transfer of information in palliative care to support pharmaceutical care of such patients. The findings are presented in the introduction.

For the outline literature review the biomedical database MEDLINE was accessed and browsed via University of Strathclyde library services. The search was carried out using both MeSH (Medical Subject Headings) vocabulary and plain search terms, either individually or in different combinations. The inclusion criteria comprised articles published between 2010 and around 2000 and publications in English Language.

The following search terms were mainly considered.

Palliative careEnd of life careCancerChronic disease management

Pharmaceutical care provisions


United Kingdom

Qualitative research

Out-of-hoursPharmaceutical carePharmaceutical serviceCommunity pharmacyPharmacist

Patient care

Electronic palliative care summaries

In addition, the Google search engine, PubMed, the Google scholar database indexing full texts of scientific literature and the search engine Bing from Microsoft were used and the web pager of several journals like the Pharmaceutical Journal, Palliative Care Journals, Palliative Medicine Journal, British Journal of General Practise, and the British Medical Journal were reviewed applying the same key words. In addition, the websites of a number of professional organisations such as NHS Scotland, NHS 24, and NHS Boards across Scotland, Scottish Government, Community Health and Care Partnerships, Audit Scotland, the Scottish Partnership for Palliative Care and the World Health Organisation were searched for government policy documents relating to palliative care.

3.2 Identification of current practice

Face to face interviews and group meetings and telephone discussions were also deployed in this research work. Group meetings were held with the University team of the Macmillan Pharmacist Facilitator Project, head of pharmacy of NHS 24, a district nurse as well as a palliative care link nurse. The meetings helped as appropriate tools of information due to the fact that they enabled the participants to describe and talk freely about their experiences while retaining a focus on the subjects of interest. A method that facilitates the expression of criticism and the suggestion of different types of solutions is invaluable when the aim is to improve services.49

3.3 Current information transfer to support practice

The head of pharmacy of NHS 24 advised making contact with district nurses or palliative care nurses and the need for them to participate in face to face interviews. The actual recruitment of one district nurse was co-ordinated by a Macmillan Pharmacist Facilitator and the palliative care link nurse agreed to a telephone conversation to capture clinical care issues arising as part of their daily practice.


The services provided to patients out-of- hours (OOH) are an essential part of palliative and end of life care, and the issues relating to OOH service provision were of paramount relevance in this research work. The recent changes to the General Medical Services (GMS) contract shifted the responsibility for OOH service provision from GP practices to NHS Boards. This has changed the way in which patients access care outside normal working hours. The establishment of NHS 24 has introduced a new model where 24-hour telephone advice is the single point of access to all OOH services. Patients are now unlikely to receive OOH care from a doctor who knows them and the importance of continuity to palliative care patients means that they are likely to be particularly affected by these changes.50More recently, the establishment of centralized services (NHS Direct in England and Wales, NHS 24 in Scotland) present a new model 24-hour telephone advice that will be the single point of access to all OOH services, even in rural areas. The intention is to benefit patients and carers by offering simple and convenient access to advice and effective triage, so that appropriate care can be delivered quickly and efficiently.51 Responsibility for healthcare is been transferred from GPS to local primary care organisations, which are currently setting up new unscheduled care services. There has been a progressive shift in the locus of care from the home and local general practices to more distant emergency clinics or telephone advice.52 An understanding of the needs and experiences of palliative care patients and their carers is essential to ensure that OOH care is effect as well as efficient.

Alison Worth et al, in their qualitative study of OOH palliative care, explored the experiences and perceptions of OOH care of patients with advanced cancer, and with their informal and professional carers.50 this study made explicit the barriers experienced by palliative care patients and their carers when accessing care. The importance of good anticipatory care particularly provision of information to patients and carers along with regularly updated handover forms sent to OOH services, was identified as key by both patients and professionals. Professionals described the barriers to achieving individualised patient care and the problem posed by competing priorities, but saw potential for improvements through an expansion of OOH resources, particularly nursing and supportive care. Worth et al, compared their study to previous studies which suggested that good anticipatory care, particularly provision of information to patients and carers about sources of help OOH, and what to expect from services, helps maintain care at home and manage patients’ and carers’ expectations of services.53,54According to Worth et al, GPs and district nurses wanted 24-hour access to specialist palliative care advice on symptom management and medication use.55Access to palliative care drugs and advice via a community palliative care pharmacy network is a quality standard in Scotland.42

Many people who are terminally ill want to spend their last days in their homes. For this reason therefore, these patients should have easy access to care and medicines that can help them if their condition change rapidly or deteriorate suddenly at night or during the weekend. However, the provision of out-of-hours specialist palliative care and the availability of palliative care medicines in the community can present major problems. Palliative care medicines are only readily available during normal working hours, Monday to Friday. Feelings of uncertainty and anxiety can be heightened in patients and carers, particularly OOH, if there is no easy access to familiar sources of professional help and advice or to the medicines needed to control symptoms that commonly occur in the terminal phase of a disease.11

The “just-in-case” six-month pilot study which was set up in three areas of the Mount Vernon Cancer Network was aimed to avoid distress caused by inadequate access to medicines OOH by anticipating pharmaceutical needs stemming from new or worsening symptoms; and prescribing medicines to be used on a “just-in-case” basis. The initiative was intended to support the “Gold Standards Framework”, a programme that aims top develop a practice-based system to improve the organisation and quality of care for patients in their last 12 months of life.56 the “just-in-case” box (blue plastic hobby box-27x20x10cm) where medicines were stored at the patient’s home. The prescriptions reflected the individual needs of each parient and were written up in the patient’s notes and on an administration sheet used only for anticipatory or when required medicines. An approved list of medicines for symptom control in patients in the terminal phase of an illness was made available through the Liverpool Care Pathway for the dying patient15, 57 and this was adopted for the pilot. As a result, the medicines usually supplied on a “just-in-case” basis were diamorphine (for pain), midazolam (for agitation), cyclizine, haloperidol or levomepromazine (for nausea or vomiting), glycopyrronium or hyoscine hydrobromide (for respiratory secretions).

Information transfer in palliative care is currently underdeveloped because most of the information is within the decision of the GP. Presently NHS 24 does not have access to patients’ medical records. Anytime a call is made to NHS 24, a record is made, a previous contact is seen and all reports are documented as well as the resources and advices used in the past. However, from May 2007, all NHS 24 centres are now able to access a patient’s Emergency Care Summary (ECS) provided patient’s consent is first obtained.

The Emergency Care Summary (ECS) is a relatively new system which allows information on a patient’s medication and allergies to be automatically extracted from their GPs records. The security around accessing ECS is very strict and any time an access is made, it is logged so as to know who has been seeing it and this is especially doctors. The NHS 24 has access to ePCS but there is nothing on the ePCS that mentions medicines and that element of pharmaceutical care is missing in the ePCS.

Legislation was introduced throughout the UK in 2000, which provided the framework for the supply and administration of medicines without the need for an individual prescription.

This framework was Patient Group Directions (PGDs).

According to NHS Education for Scotland (NES), a Patient Group Direction (PGD) is a written instruction for the sale, supply and /or administration of named medicines in an identified clinical situation.58 It applies to groups of patients who may not be individually identified before presenting for treatment.

Before now, out-of-hours GP care in England, Denmark and the Netherlands has been reorganised and the Netherlands has been reorganised and is now provided by large scale GP co-operatives. Adequate transfer of information is necessary in order to assure continuity of care, which is of major importance in palliative care. Schweitzer et al, conducted a study to assess and investigate the availability, content and effect of information transferred to the GP co-operatives.59 According to their study, GPs in the UK were satisfied with the palliative care provided by their out-of-hours co-operatives, but satisfaction was less for inner city GPs who had concerns about the continuity of care.60 District nurses reported less satisfaction, especially with the quality of the advice, the reluctance to visit, and difficulties in obtaining medication.61 In their study , the total number of palliative care phone calls was 0.75% of all calls to the GP co-operative. Information was transferred and the content consisted mainly of clinical data. It was also found that half of the calls regarding palliative care resulted in a home visit by the locum, and that medication was prescribed in 57%of all palliative care calls. According to this study, a report from the UK stated that a lack of information can lead to problems in symptom control and an increase in unnecessary hospital admissions.62 This study recommended that GP co-operatives needed to develop and implement an effective system of patient information management. The potentials for improvement in the end-of-life care that is provided by the GP co-operatives was a factor of information transfer especially if an electronic patient file is accessible during the out-of-hours period, and this should contain information that is of relevance to locums.

The two nurses who took part in the interviews suggested that the service provided for palliative care patients has improved a great deal over the past few years especially with the introduction of the Gold Standards Framework Scotland. An integral part of this improvement was said to be the anticipation of patients’ possible future needs [by the development of Anticipatory Care Plan (ACP)], so that the essential equipment and drugs are either already in place when they become necessary or else can be obtained without delay. This act was identified as reducing the need to call the local out-of-hours GP services over the weekend or in the evenings. The district nurse explained that patients and their carers/family were given details of how to contact the evening or night nursing service who was on call and when one action/plan was carried out the next nurse who is giving care to the patient is able to see what the previous nurse had done. This was done with the use of a “mobile computer”. The palliative care link nurse explained that the ePCS was not accessible by nurses yet but this is being looked into by GPs but nurses who needed access were allowed by their GPs.

During out-of-hours, GP practices cannot provide essential services and general management to patients who are terminally ill. Following an independent review of GP out-of-hours services, Primary Care Trusts (PCTs) are also responsible for developing a more integrated out-of-hours system. (Carson Review). The Carson review envisaged that the needs of palliative care patients will be identified in advance noted on the NHS Direct database and passed directly without triage to the service they needed.63This followed from recommendations that transfer of information between GPs and their out-of-hours provider is essential to ensure continuity of care 62, thus forming one of the current GP co-operative accreditation standards.64 Burt J et al, conducted an audit across four co-operatives to assess progress of continuity of care within primary palliative care in England.61Across these four co-operatives, there were 279 palliative care-related calls (2.1% of all calls), form 185 patients during the audit month. The co-operatives held handover information for between 1 (12%) and 13 (32.5%) of these patients. Co-operative doctors had information about previous co-operative contacts for 7.5-58.1% of repeat calls. Three co-operatives faxed details of every palliative care contact to the patient’s GP the following morning, one did so for only 50% of calls. This system of alerting the co-operatives to the needs of palliative care patients was under-utilized. Even within the most frequently used systems, the diagnosis, prognosis and care preferences of two thirds of patients with palliative care were not made known to the co-operatives.

5. Discussion

Information that encourages appropriate use of out-of-hours services needs to be made accessible for all patients and carers. Primary care professionals and community palliative care specialists share responsibility for advising patients and carers on how to seek help out-of-hours. Practices and primary care organisations need to develop and audit effective systems of patient information management and transfer. These could be included in quality standards. Reviewing the way calls are handled by NHS 24, in addition to their factual content, offers opportunities for communication difficulties to be highlighted and included in staff development. Effective out-of-hours community palliative care requires an integrated, multidisciplinary service that is able to respond to planned and acute needs. Continuity of care may be personal, informational or managerial, the latter implying a consistent and coherent approach responsive to the patient’s changing needs.63 In the context of current primary care provision, personal continuity of care is increasingly unlikely to be provided out-of-hours, but informational and management continuity, supplemented by good communication, may suffice.

There is a relative lack of communication and joint working between all health care professionals involved in the care of patients with palliative care needs and this is a major issue affecting the effective delivery of services. Since the district nurses are the professional seeing the patients more regularly, they are an important resource and a vital link person and pharmacists could consult them for information about a patient’s clinical condition or for clarification of problems caused by incorrect or incomplete prescriptions. As at January 2011, the ePCS is now in use in over 32% of practices across 11 Health Boards in Scotland. All three GP IT systems have software for recording ePCS information which is updated automatically to ECS when any changes are made. ePCS is the available to all out-of-hours-and unscheduled care users who already have access to ECS. The information in the ePCS is recorded in the GP system to form an Anticipatory Care Plan which will be available out-of-hours and includes medical diagnoses (as agreed between the GP and patient), patients and carers’ understanding of diagnosis and prognosis, patient wishes {preferred place of care and resuscitation (DNACPR)}, information on medication/equipment left in patients’ home “Just in Case and prescribed medication (this includes all repeat and last 30 days acute and allergies as per ECS. Though the patients’ medicines are not described in detail, that element of pharmaceutical care is not present on this current ePCS. (Appendix 1). The reason for this may be because of a skills gap for instance, independent prescribers might be few in this clinical area. The way pharmacists can adjust medicines as part of an agreement in the delivery of care to palliative care patients should be included in the ePCS.

Boards across Scotland are aligning the rollout of ePCS with their plans for moving GP IT systems from GPASS to either InPs Vision o EMIS and local champions in Greater Glasgow and Clyde and Dumfries and Galloway have encouraged uptake of ePCS. Work is at early stages in Ayrshire & Aran, Fife, Orkney and Western Isles. Shetland is planning to start the rollout shortly. Grampian has completed connection for all EMIS and Vision practices and further rollouts will start shortly. Lothian has been using ePCS for a year, and is now planning how to maintain usage and encourage the remaining practices. Lanarkshire have a good uptake in Gpass practices and are awaiting the completion of the Gpass to InPs Vision migrations before wider rollout is commenced. Scottish Ambulance Services (SAS) is now piloting the use of ECS and ePCS in Lothian.48

According to Burt et al, co-operative doctors were required to provide care in a range of complex and time-consuming cases, including during the last days and hours of a patient’s life, with little or no information. Continuity of care within co-operatives was frequently threatened by a lack of information about previous contacts to the service by a patient.61 Within the present and new integrated out-of-hours systems, the effective transfer of patient information between all providers will be critical if palliative care patients and other vulnerable groups are to receive the care they need, especially where GPs opt out of providing out-of-hours care. Electronic patient records may provide a solution, although concise, up-to-date information will be needed and as services move to a more integrated approach (ePCS), a careful scrutiny of information transfer systems and encouragement of providers such as GPs and district nurses to update information, may help to ensure better continuity of care.

The current ePCS (see Appendix I) describes the patient’s medical conditions (current drugs and doses, and additional drugs available at home); the current care arrangements (syringe driver at home); the extent to which patients and carers understands the present condition of the patient and the advice for out-of-hours care. According to “Living and Dying Well 46, there is a need for communication and co-ordination between all professional who are involved in providing care to palliative care patients. This will help ensure that all patients and carers with palliative and end of life care needs are supported to participate fully in developing care plans and making decisions about their care. To ensure that their needs are communicated clearly across care settings and systems to all professional involved. To also ensure that the care of all patients and carers with palliative and end of life care needs is co-ordinated effectively between specialities and across care settings and sectors. The introduction of more joint out-patient clinics for example the joint respiratory/palliative care out-patient clinic at Victoria Infirmary in Glasgow should be encouraged.

6. Conclusion

Although the electronic Palliative Care summary (ePCS) is being rolled out in almost all Health Boards across Scotland, there are still some areas of care delivery that needs to be improved in palliative care especially during out-of-hours. A model needs to be fashioned out to enhance what the next step in the delivery of palliative care should be. If anything is done by one member of the palliative care team, other members need to know within the shortest time possible. The pharmacist who is an important member of the team, at the moment do not have access to the ePCS, this area needs to addressed. There is also need to use the new and emerging technology in the delivery of unscheduled healthcare, for instance strategic frontline application, which means upgrading the current IT and telephoning capability as well the potential for video conferencing in pharmacies. In current practice special notes (a flag facility that can be attached to a patient’s CHI number by GPs) used by GPs can be replaced by special texts in palliative care practice.

Calls to out-of-hours through NHS 24 can also be by video calls and texts as this enhances telephone assessments especially in palliative care. Development of specialized care plans should also be encouraged. There should be equitable access to a range of health care professionals and support staff across the UK and this may well demand additional resources, particularly for district nurses. Partnership working with non-statutory palliative care providers should also be enhanced. Specialist palliative care telephone advice to unscheduled care services, including access to a consultant in palliative medicine, may need to be delivered through extended rotas in areas where there is a shortage of specialists. The ePCS should be able to provide more pharmaceutical care provision to patients.

Free Essays

Techniques, methods and tools used in the project life cycle


A Project is the combination of organizational resources pulled together to create something that did not previously exist and that will provide a performance capability in the design and execution of organizational strategies (Cleland and Ireland, 2006). Projects have a distinct life cycle, starting with an idea and progressing through design, engineering and manufacturing or construction through use by a project owner. For a project to be successful there are main things which are to be considered always, like the cost of the whole project, time that it’s going to take for it to be complete, the technical performance capability that it’s going to provide and be able to match the results with the design and execution of organizational strategies. This whole process in the other name it’s called Project Management.

Project management is an important management tool to implement strategy and achieve an organization’s strategic goals. Organizations are using projects to adapt to changes in the competitive environment including increasing cost pressures, scarce available resources, global competition, new technologies and a race to get products to customers first (Hyvari, 2006). Projects deliver the most benefit when they are directly linked to corporate strategy (Crawford, 2006, Srivannaboon, 2006).

Also, Project Management is a continuing process of controlling the development of a project from initial planning, to monitoring progress and finally to seeing the successful completion of the project. Every program, project, or product has certain phases of development known as life cycle phases. A clear understanding of these phases permits managers and executives to better control resources to achieve organizational goals (Kerzner, 2003). As a result, the project manager must learn to deal with a wide range of problems and opportunities, each in a different stage of evolution and each having different relationships with the evolving project (Cleland and Ireland, 2002).

In this assignment, I’m going to discuss all the activities that are required and analyse some of the techniques, methods and tools used on the project life cycle. Also, I will discuss the skills and competences that project managers’ needs to possess. At the end, I will talk about the roles played by the stakeholders and the contribution of the computer packages towards the successful running of a major project.


The Project Life Cycle refers to a logical sequence of activities to accomplish the project’s goals or objectives. Regardless of scope or complexity, any project goes through a series of stages during its life. There is first an Initiation or Birth phase, in which the outputs and critical success factors are defined, followed by a Planning phase, characterized by breaking down the project into smaller parts/tasks, an Execution phase, in which the project plan is executed, and lastly a Closure or Exit phase, that marks the completion of the project. Project activities must be grouped into phases because by doing so, the project manager and the core team can efficiently plan and organize resources for each activity, and also objectively measure achievement of goals and justify their decisions to move ahead, correct, or terminate. It is of great importance to organize project phases into industry-specific project cycles. WhyNot only because each industry sector involves specific requirements, tasks, and procedures when it comes to projects, but also because different industry sectors have different needs for life cycle management methodology. And paying close attention to such details is the difference between doing things well and excelling as project managers.

Diverse project management tools and methodologies prevail in the different project cycle phases. Let’s take a closer look at what’s important in each one of these stages:

1) Initiation

In this first stage, the scope of the project is defined along with the approach to be taken to deliver the desired outputs. The project manager is appointed and in turn, he selects the team members based on their skills and experience. The most common tools or methodologies used in the initiation stage are Project Charter, Business Plan, Project Framework (or Overview), Business Case Justification, and Milestones Reviews.

2) Planning

The second phase should include a detailed identification and assignment of each task until the end of the project. It should also include a risk analysis and a definition of a criteria for the successful completion of each deliverable. The governance process is defined, stake holders identified and reporting frequency and channels agreed. The most common tools or methodologies used in the planning stage are Business Plan and Milestones Reviews.

3) Execution and controlling

The most important issue in this phase is to ensure project activities are properly executed and controlled. During the execution phase, the planned solution is implemented to solve the problem specified in the project’s requirements. In product and system development, a design resulting in a specific set of product requirements is created. This convergence is measured by prototypes, testing, and reviews. As the execution phase progresses, groups across the organization become more deeply involved in planning for the final testing, production, and support. The most common tools or methodologies used in the execution phase are an update of Risk Analysis and Score Cards, in addition to Business Plan and Milestones Reviews.

4) Closure

In this last stage, the project manager must ensure that the project is brought to its proper completion. The closure phase is characterized by a written formal project review report containing the following components: a formal acceptance of the final product by the client, Weighted Critical Measurements (matching the initial requirements specified by the client with the final delivered product), rewarding the team, a list of lessons learned, releasing project resources, and a formal project closure notification to higher management. No special tool or methodology is needed during the closure phase.

Reference List

Kerzner, H. (2003). Project management: a systems approach to planning, scheduling, and controlling (8th ed.). New Jersey: John wiley & Sons Inc.

Cleland, D.I, Ireland, L.R. (2006). Project Management: Strategic Design and Implementation (5th ed.). New York: McGraw-Hill, pp. 26

Cleland, D.I, Ireland, L.R. (2002). Project Management: Strategic Design and Implementation (4th ed.). New York: McGraw-Hill, pp. 32

Crawford, L., Hobbs, B. & Turner, J.R. (2006), Aligning capability with strategy: Categorizing projects to do the right projects and to do them right, Project Management Journal; Jun. 37, 2; ABI/INFORM Global, pp.38-50

Hyvari, I. (2006), Project management effectiveness in project oriented business organisations, International Journal of Project Management, 24 pp. 216-225

Srivannaboon, S. (2006), Linking project management with business strategy, Project Management Journal, Dec; 37, 5; ABI/Inform Global, pp.88-96

Free Essays

Vector-borne bacterial and parasitic diseases have developed or re-developed in a lot of geographical regions inducing economic problems and global health which include livestock, companion animals, wild life and humans.


Recently, vector-borne bacterial and parasitic diseases have developed or re-developed in a lot of geographical regions inducing economic problems and global health which include livestock, companion animals, wild life and humans. Globally diseases that their transmission occurs via arthropod vectors are the main significance to the health of animals and humans. Furthermore these diseases and their epidemiology associated with a range of hosts, infectious agents and vectors. As result of an oversupply of factors, is the over time change of disease patterns that also vary from one geographic zone to another.

Infectious agents included in developing pathogens have been showed in other regions and were introduced into already unknown areas. However, agents that were continually showed on a low level or in a different host in the affected area and owning to some modification have appeared more broadly spread in the population. On the other hand those were not previously recognized and the organisms that have been classified and correlated with a new disease with an unknown etiology. Conversely, for disease such as piroplasmosis naive wildlife or domestic animals transmitted into an endemic region has resulted many times in epidemic outbreaks. Unexpected induction of disease vectors like mosquitoes or tick species originating at one area to another eventually could be reliable for the spread of infection to new regions. Over the last two decades, the progress in molecular biology has also led to a new vector-borne pathogenic organism’s discovery. These bacteria transmitted by arthropod and have been correlated with disease syndromes such as peliosis hepatis, bacillary angiomatosis, endocarditis and cat scratch disease. The most prevalent vector-borne disease that became known just over 20 years ago in North America as a new disease with a spirocheatal causative agent is the Lyme disease which has been exposing as a main pathogen of dogs and humans represented by molecular detection of historical specimens.

Clearly, climatic and demographic changes affect the global distribution of vector-borne protozoan pathogens. At first, epidemiology and ecology of vector-borne diseases are affected by three main factors constituting the host, the environment and the pathogen. Main factors that are reliable for the spread and evolution of vector-borne parasites contain modifications in irrigation habits and water storage, climate and atmospheric changes, habitat changes, public health and evolvement of drug resistance and insecticide pollution. Global or governmental or war and civil unrest management failure are also the main factors that are associated with the spread of infectious diseases. In the last two decades, the progress in epidemic understanding and planning even with the evolution of recently diagnostic molecular techniques have permitted researchers to better diagnose and trace pathogens, helped to establish intervention programs, their source and routes of infection and defensive public health. An important responsibility of veterinarians, physicians, biosecurity officers and health care workers is the future vector-borne disease prevention. A corresponding global approximation for the vector-borne disease’s prevention should be achieved by governmental agencies and international organizations in association with research institutions.

Moreover, an important factor which affects the global distribution of vector-borne protozoan pathogens is habitat change which is a result of widespread land use, agricultural development, deforestation and modifications in irrigation habits and water storage which supply new niches for vectors. Transformation and deforestation of forests to human settlements or open areas, grazing land and agricultural areas, which are result of important changes in the environment and in the structure of vectors, and thus, the induction of new pathogens. Other widespread changes, like deforestation and agricultural practices, increase the transmission risk for vector-borne disease. In the past 50 years, several irrigation systems and dams have been developed except regard to their effect on vector-borne diseases. Furthermore, agricultural practices like rice production has increased and also tropical forests are being cleared at an enhancing rate. Ideal breeding sites for domesticated mosquitoes are formed by consumer products. Products that tend to be disposed in the environment where they collect rainwater are those packaged in cellophanes, nonbiodegradable plastics and tin. An excellent mosquito breeding places are the several disposed automobile tires in the domestic environment. The global used tire industry and container shipping have conduced to the raised geographic distribution of selected mosquito species that lay their eggs in used tires. In the Thar Desert in north-western India where occurred the Plasmodium falciparum malaria evolution and Anopheles culicifacies spread and establishment which followed the development of irrigation canals. The world is encountering the development and substantial urbanization of human population. Moreover in Senegal the construction of the dam at Diama was intended to intercept the invasion of seawater into the river and as a result the salinity reduction and increased water pH thus increasing the development and fecundity of freshwater snails and the exposure of humans in the lower and middle valleys of the Senegal River Basin to Schistosoma mansoni. Development of new contacts changes in the new massively inhabited environment caused by the movement of people from rural areas to urban centers. Generally more susceptible to the endemic diseases are the newcomers to which they may not be immune. Furthermore in the new environment have the induction of new vectors and pathogens. Below these circumstances, the opportunities of parasites and vectors are increase for transmission and exchange. In past 50 years the global societal and demographic alterations have directly contributed to the vector-borne and other infectious diseases regeneration. Generally uncontrolled and unplanned urbanization in evolving countries causes the worsening of public health infrastructure, management systems of water, sewage and waste. New roads construction supplies means of vector and host transportation. As result of these changes is the formation of optimal situations for the vector-borne disease’s transmission to large populations. Finally, the jet airplane has had a profound influence on rapid global transportation. Airplane travel provides an easy means for transporting pathogens between population centers. The result is a constant movement of viruses, bacteria, and parasites among cities, countries, regions, and continents.

Also another factor that induces global distribution of vector-borne protozoan pathogens is public health. Decisions of policy for public health have greatly reduced the surveillance resources, that principally because control programs had decreased the menace of public health from vector-borne diseases as a result reduced the prevention and control of those diseases. However, the drug resistance and technical problems of insecticide which are also public health decisions, have an important function for the regeneration of diseases like malaria and dengue. The result of the cessation or merger of many programs usually are the reduced resources for infectious diseases and eventually to the worsening of the public health infrastructure needed to deal with these diseases. Moreover, after 1970 in vector-borne diseases the good training programs decreased dramatically. The lack of preventive medicine training in most medical schools is another important problem for vector-borne diseases. The medicinal emphasis and approximation on high-tech solutions to disease control have led health officials, most physicians and the public that is based on “magic bullets” to control an epidemic or cure an illness.

In addition, another factor is the alterations in temperatures and climate that affect the pathogen transmission effectiveness by vectors and the vectors distribution. As a result of human activities the atmospheric composition alters constantly, especially burning of fossil fuels. In addition is the plant water loss decrease and the increase of atmospheric carbon dioxide concentrations via evapotranspiration. Accordingly, plants are enhancing the density of plant foliage for elongated periods in the year, derive more foliage with the same amount of water and supplying more favourable microclimates for insect vectors. The greenhouse effect and stratospheric ozone layer increase destruction by the release of carbon monoxide, methane, halogenated compounds and volatile organic compounds together with upsurge in atmospheric carbon dioxide concentrations. In response to the raised global temperature the hydrological cycle has changed, as warm air can hold more moisture, and so did the waterborne disease vectors. Ticks and mosquitoes are excessively sensitive to climate and temperature alterations. Their reproduction, mortality rates and feeding activity are generally exactly associated with the environmental temperature. Finally was recommended that the spread of habitats of tropical insects into more southern and northern latitudes along with higher increases is induced by global warming.

Furthermore, pollution is another factor that affects global distribution of vector-borne protozoan pathogens. The Tropical Rainfall Measuring Mission satellite provide measurements, detected that both ice precipitation evolvement and cloud droplet coalescence were interrupted in polluted clouds. Also indicated by satellite data that industrial and urban air pollution inhibits precipitation. The precipitation onset delayed from 1.5 km above cloud base in pristine clouds to more than 7 km in pyro-clouds and more than 5 km in polluted clouds and reduced cloud droplet size by heavy smoke from the Amazon forest fires, that indicated by latter study. Pollution associated changes in rainfall first of all change vector environments and therefore, the distribution of correlated pathogens.

Eventually the last factor that induces global distribution of vector-borne protozoan pathogens is the insecticide and drug-resistance. The most important factors are first of all the extensive and inappropriate drug use and also improvement of genetic mutations. In the improvement of drug-resistant pathogens and vectors include vector movement and population between other factors.

For the re-development and sudden increase of diseases the potent drivers are the insecticide and drug resistance of parasites and vectors. Examples for the function of resistance Malaria spread are including in the following reports. Was latterly related from Saudi Arabia that chloroquine-resistant P. falciparum cerebral malaria inducing a high mortality rate, where previously malaria was contemplated chloroquine-susceptible. The increase in chloroquine resistance induces a significant rise in specific mortality of malaria in Senegal, Malawi and Zaire. During the previous decade when an outbreak of malaria has occurred in Chindwara in central India, the DDT-resistant A. culicifacies was found as the main mosquito species.

As a conclusion, the complicated correlation among disease drivers like global travel or weather, their financial and health impacts and modifications in pollution, are progressively being defined by research. In the last few decades, epidemiologic techniques and tools for the research of infectious diseases have refined importantly. The development of epidemic prediction, epidemic knowledge and the planning of policy analysis and efficient control provide tools for the use of geographic information systems (GIS), risk analyses, climate models and remote-sensing technologies in research. Furthermore, in the vector-borne pathogens the evolvement of complex diagnostic procedures and particularly the establishment of molecular techniques, mostly the evolution of the nucleotide sequencing and PCR, have permitted rapid, specific and sensitive diagnoses, which in turn accommodate timely prevention and exact treatment efforts. The evolution of new vaccines, chemotherapeutics, repellants, biological products and insecticides contrary to the main vector-borne diseases is critical for accomplishing control or elimination. Rotational therapy or multi-drug therapies should be employed contrary to parasites and vectors in case of the prevention of the evolvement of drug-resistance. Another preventative approximation such as biological pest control, in the protection of ticks and other vectors which are the essential need for the repellants and insecticides for example the use of nematodes, wasps, birds and entomopathogenic fungi that are safe for the environment. Programs for multi-national control and elimination have proven powerful in the battle against various vector-borne diseases comprising River blindness in western Africa and Chagas disease in Latin America. The association of global organizations, has a significant function in the funding and allocation of programs, such as the Untied Nations’ agencies constituting the WHO and World Bank. The significant allocations of the above associations have also made by public organizations such as philanthropic trusts and societies and private pharmaceutical companies. Also have been published risk evaluations and sustainability studies for future outbreak’s anticipation and then evolve the consequence of global alterations upon the transmission of diseases and the environment. Studies have been applicable by making suggestions for intervention and policies achievements. Nevertheless there is further requirement for bigger complication of international non-governmental evolvement and aid organizations. More global resources in the future, to the evolvement of prevention and prediction programs, should be appropriated to minimize or eliminate vector-borne diseases in evolving countries. It is essential that an allocated global rather than a single governmental approximation should be acted in vector-borne disease prevention.


Free Essays

Explore how the human body functions as one unit in harmony in order to maintain life


The different parts of the human body function as one unit in harmony to maintain life. In this crucial goal, the body’s mechanisms are all functioning toward achieving homeostasis or simply put, balance. Homeostasis can be best defined by explaining its two root words: homeo, which means sameness; and stasis, which means stability (Clark 2005). Using these keywords, homeostasis is described as a stable state of balance, which the human body maintains to achieve despite influences that threaten to disrupt the balanced state (Clancy, Baird, and McVicar 2002; Clark, 2005).

The nervous system and the endocrine system are the two main regulatory mechanisms in the body that maintain homeostatic balance (Clark 2005; Sherwood 2006). In order to maintain homeostasis, the body uses feedback mechanisms to respond to influencing factors that may disrupt homeostasis. These so called feedback mechanisms are categorised into either positive or negative feedback processes (Coad, Dunstall, and McCandlish 2005). This classification does not entail one as being good or bad but rather delineates the direction of change to stabilise or balance reactions.

A positive feedback mechanism acts by synergising a change inside the body causing a bigger response than the initial one (Sherwood 2006). On the other hand, a negative feedback mechanism acts in the direction opposite of the change in such a way that the initial response becomes diminished (Sherwood 2006). These feedback mechanisms are in a loop in which these mechanisms that cause the initial changes to become either greater or lesser stop when the body achieves balance.

An example of the positive feedback mechanism is when a tissue in the body becomes injured; this stimulus will signal the production of platelets for blood clotting (Coad, Dunstall, and McCandlish 2005). In this case, there is a need to increase platelet production thus the initial response will trigger more platelets to be produced to avoid further blood loss. On the other hand, a negative feedback mechanism is seen when the body experiences extreme cold – a state in which the body loses heat. In this case, the body will act in the opposite direction by producing heat through shivering, which is a state of muscle contraction that produces energy and heat for the body (Coad, Dunstall, and McCandlish 2005). Note that the direction of the feedback mechanism is dependent on the direction at which balance could be attained.

In this paper, the concepts on anatomy and physiology will be applied to discuss and explain the body’s responses. A patient will be followed during the perioperative phase. Different body responses to both internal and external influences of the patient will be discussed in terms of physiological changes and body’s attempts to maintain balance.

Patient Case

The patient at focus in this paper is a 65 year old, healthy male who was scheduled for endarterectomy of common femoral artery under general anaesthesia. Endarterectomy is a surgery that is performed on individuals who manifest signs and symptoms of limb ischemia due to thickened or clogged arteries (Eskandari et al. 2010; Hands 2007). The surgical procedure is done to remove the fatty deposits or plaque in the arterial lining that occludes the normal blood flow in that area (Hands 2007). In the case of the patient, endarterectomy of common femoral artery will be done – indicating that the occluded artery is that of the common femoral artery.

The pathology of this disease lies in its occlusive nature that disrupts the normal blood flow and oxygen delivery to other parts of the body (Smeltzer et al. 2009). The pathophysiology of the patient’s condition can be likened to a water pipeline. A normal artery looks like a new pipe that allows water to flow freely through it and deliver its contents sufficiently and timely. On the other hand, when dirt and other materials stick to its walls, a blockage is formed similar to that formed by an atheromatous plaque. This impedes smooth water flow thus delivering less water and in time, it may fully block the pipe. When the blockage is removed, the water may flow normally again.

In this case, the patient needs to have the surgical procedure done to remove the cause of the occlusion in the common femoral artery; otherwise, blood flow as well as oxygen delivery will be compromised leading to vascular complications (Smeltzer et al. 2009). A dangerous complication is amputation of the limb because when there is poor blood and oxygen supply to parts especially those below the femoral artery, then the tissues will die in that limb. In the patient’s case, once the atheromatous plaque is removed, the femoral artery will be reopened thus restoring the normal blood flow in that area as well as other parts of the body (Smeltzer et al. 2009).

The benefits of common femoral artery endarterectomy for this patient will save the patient from disability and death. There will be reduced risk for stroke and heart attack because these diseases are usually caused by ischemia or lack of oxygen, which usually results from poor blood circulation from any part of the body (World Health Organization 2003: 47). Also, it provides relief of symptoms and increase rates of saving the limbs from amputation (Hoch, Turnipseed, and Acher 1999).

Preliminary Assessment Stage

The patient is generally healthy. Vital signs as well as routine physical assessment and observations were performed and documented; assessment findings were normal. The client’s blood pressure is a very important measure in this pre-operative stage. Blood pressure is the measurement of the force acted upon on the arteries – which is the blood vessel that carries blood away from the heart – as the heart pumps out the blood into the different parts and systems of the body (Singh 2008).

Blood pressure readings are expressed in two numbers in which the numerator is the systolic blood pressure and the denominator is the diastolic blood pressure (Dugdale 2010). The systolic blood pressure is the pressure that the blood in the heart exerts during contraction or when the blood is moved forward (Porth and Matfin 2010). This is the highest pressure exerted when the heart beats. On the other hand, diastolic blood pressure is the pressure exerted on the heart during its resting or relaxed state (Porth and Matfin 2010). Conversely, this is the lowest or minimum pressure exerted.

The measure of the blood pressure is an indicator of the sufficiency of blood pumped out by the heart. If the blood pressure is too high, then the heart may be having hard time pushing out the blood into the system (Carter and Lewsen 2004). On the other hand, a very low blood pressure indicates insufficient output thus resulting to inadequate blood and oxygen circulation to other body parts (Carter and Lewsen 2004). These abnormalities can be attributed to different causes or factors that may affect blood pressure.

Factors affecting Blood Pressure

The three main factors that influence blood pressure are cardiac output, blood volume, and peripheral resistance (Carter and Lewsen 2004; Timby 2008). An important concept in understanding these factors is the Frank-Starling law of the heart. Starling’s law states that the amount of blood that fills and stretches the muscle fibres of the heart determines the force of heart contraction (Timby 2008). This means that a greater stretch in the heart’s muscle fibres will yield a more forceful contraction of the heart and vice versa.

Cardiac Output.

Cardiac output is the amount of blood that the heart ejects from the left ventricle to the aorta per minute (Timby 2008). The higher the cardiac output, the higher the blood pressure. Conversely, a lower cardiac output leads to lower blood pressure. An important concept in understanding cardiac output is stroke volume.

Cardiac output is the product of heart rate multiplied by the stroke volume. Stroke volume is the actual amount of blood ejected by the heart every time it beats (Porth and Matfin 2010). Thus, the stroke volume is the amount of blood that is ejected during the systole or when the heart contracts. To measure the stroke volume, the end diastolic volume or the blood in the ventricle during the resting phase is subtracted with the end systolic volume or the blood that remained in the ventricle after the heart contracted (Timby 2008). If the heart contracts more forcefully, then there is a higher stroke volume because there will be more blood ejected per contraction. It also follows that when the heart is beating so fast, there is lower stroke volume because the heart is not given enough time for blood to fill and stretch its muscle fibres before it contracts again – thus less forceful contraction. Nevertheless, if either stroke volume or heart rate is increased, then the cardiac output increases.

Blood Volume.

The second factor that affects blood pressure is blood volume. This factor’s concept is also based on Starling’s law of the heart which states that the force of heart contraction is determined by the preload (Timby 2008). Preload is the volume of blood that enters the heart’s chamber and stretches its walls during its relaxed state (Timby 2008). The amount of existing blood that enters the heart determines the stretch, which consequently affects the blood pressure.

When there is little amount of blood in the vessels to begin with, then there is also little amount of blood that enters the heart thus the heart’s muscle fibres will not be stretched enough – resulting to low blood pressure. This is seen in patients who have recently lost a lot of blood such as in haemorrhage (Carter and Lewsen 2004). On the other hand, when the blood volume is increased, the blood pressure is also increased because there is a greater amount of blood that fills and stretches the heart’s muscle fibres leading to a more forceful ejection of blood into the system (Carter and Lewsen 2004).

Peripheral Resistance.

Another factor affecting blood pressure is peripheral resistance. Peripheral resistance is the force that the heart needs to overcome in order for it to push blood into the system (Timby 2008). When there is greater peripheral resistance, the heart works harder to push the blood leading to a higher blood pressure. This occurs in conditions when the artery is either too narrow or obstructed (Timby 2008). On the other hand, a diminished peripheral resistance leads to a lower blood pressure because the heart needs to overcome very little resistance to eject blood into the system (Carter and Lewsen 2004; Timby 2008). This occurs when the blood vessel is dilated.

Intraoperative Assessment Stage

When the patient was transferred to the anaesthetic room, he was very nervous and his blood pressure, respiratory rate, and heart rate increased above normal limits. These manifestations are responses of his body to the perceived stress, which is the upcoming surgery. The stress response is the general adaptation responses produced by the body as it perceives stress (Martini 2005).

Stress is any stimulus, both positive and negative, that may disrupt the body’s homeostasis (Martini 2005). It may be psychological such as joy of seeing one’s loved one, or physical such as exhaustion from a strenuous exercise. Stress serves as an information or signal to stimulate the hypothalamus, which in turn responds by activating the autonomic nervous system’s sympathetic division.

The activation of the sympathetic division causes the adrenal gland to produce adrenaline and noradrenaline – also known as epinephrine and norepinephrine, respectively –as it works with the sympathetic nervous system (Martini 2005). When these hormones are released into the bloodstream, the sympathetic response is increased and prolonged. These hormones cause the blood pressure, pulse rate, and breathing to increase (Timby 2008). This reaction is the fight or flight response that occurs every time the body is faced with stress, which counteracts the parasympathetic division’s maintenance of the resting state (Martini 2005).

Other effects of these hormones in the body include dilatation of the pupil and inhibition of the salivary glands (Porth and Matfin 2010). Glucose secretion from the liver is also stimulated as well as epinephrine and norepinephrine release from the kidneys – which has been discussed to intensify the sympathetic response (Porth and Matfin 2010). Vasoconstriction occurs in the blood vessels and stimulation of the sweat glands cause perspiration (Porth and Matfin 2010). This peripheral vasoconstriction draws the blood away from the digestive tract thus decreasing or inhibiting digestion (Porth and Matfin 2010).

Effects of Pharmacologic Agents

In the anaesthetic room, the patient was given different medications. The following are the medications given to the patient and their respective effects on the patient’s body.


The patient was given 50 mg of Fentanyl. This drug belongs to a class of opioid analgesics or opioid anaesthetics (Deglin and Vallerand 2008). It is given to the client to supplement the anaesthetic agent that will be administered to decrease pain (Deglin and Vallerand 2008). As a premedication before inducing anaesthesia, fentanyl is usually given intramuscularly at a dosage of 50 to 100 mcg (Deglin and Vallerand 2008). Its mechanism of action is binding to opiate receptors in the central nervous system wherein they increase the action of eukephalins and endorphins by mimicking the effects of these opioid peptides (Deglin and Vallerand 2008). Endorphins are commonly known as the happy hormone because it produces pain relief and feelings of pleasure. Similarly, fentanyl creates a similar effect that results to alteration of feeling and responding to pain (Deglin and Vallerand 2008).

The adverse effects of the drug include bradycardia, depression of the central nervous system, hypotension, and increased intracranial pressure (Deglin and Vallerand 2008). Fatal effects include respiratory depression, laryngospasm, and bronchoconstriction (Deglin and Vallerand 2008). These adverse and fatal effects are related to its main effect on the body, which is depression of the central nervous system. Because of its possible life-threatening effects, special precautions are taken when administering the drug to patients with respiratory diseases and problems with the central nervous system.


Propofol was administered in the patient to achieve anaesthetic induction. Propofol is a short-acting sedative and hypnotic (Deglin and Vallerand 2008). In combination with the effects of fentanyl, this drug allows induction and maintenance of a balanced anaesthesia thus producing an analgesic effect with amnesia. On its own, propofol does not produce any analgesia and requires the supplementation of a narcotic for pain relief (Deglin and Vallerand 2008). Similar with fentanyl, propofol depresses the central nervous system. It decreases the blood pressure as well as intracranial pressure (Finkel et al. 2008).

When the patient is on propofol, one of the most important adverse reactions to watch out for among many others is apnea (Deglin and Vallerand 2008). The occurrence of apnea upon anaesthetic induction by propofol is fatal. This drug can cause significant depression of the respiratory system leading to a period of breathing cessation that can last for several minutes (Finkel et al. 2008). This is life-threatening as it can significantly diminish the oxygen supply of the patient that can lead to hypoxia if no oxygen support is given.

Vecuronium (Muscle Relaxant).

Vecuronium is a muscle relaxant indicated to facilitate endotracheal intubation and to relax the skeletal muscles during surgical operations (De Jong and Karch 2000). It belongs to the drug class non-depolarising neuromuscular blocking agent (De Jong and Karch 2000). Muscle relaxants are usually given after the general anaesthetic agent has been administered. Aside from aiding in anaesthesia, this drug was administered in the client to facilitate his intubation in preparation for surgery and to control ventilation.

This drug acts by blocking the neuromuscular transmission thereby paralysing the body and inhibiting muscle contractions produced by acetylcholine (De Jong and Karch 2000). Once muscle relaxation is achieved, the jaw and the larynx become relaxed that makes it easier to insert the endotracheal tube with the least resistance because the gag reflex has already been suppressed (De Jong and Karch 2000). Aside from this, the total muscle relaxation would allow undisturbed tissue handling during the surgical operation.

Nitrous Oxide and Isoflurane.

Blood pressure was monitored by means of an arterial line inserted into the patient’s radial artery. This provides constant and accurate measurements of his systolic, diastolic and mean arterial pressure. Anaesthesia was maintained using a combination of oxygen nitrous oxide and isoflurane.

Isoflurane is an inhalational anaesthetic agent that is used for maintenance of a balanced anaesthesia (Aschenbrenner and Venable 2008). This drug is commonly administered with nitrous oxide and has a rapid onset of action within 7 to 10 minutes (Aschenbrenner and Venable 2008). Because of its bad odour, administration of the inhalant anaesthetic is slow to prevent coughing and holding of breath.

Isoflurane depresses the respiratory system thus respiratory depression is one of its adverse and fatal effects. Increase in dosage administration of this drug causes the tidal volume and respiratory rate to decrease (Finkel et al. 2008). Moreover, isoflurane relaxes the muscles and produces peripheral vasodilation, which causes increased blood flow to the coronary vessels (Finkel et al. 2008).

Nitrous oxide is an inhalation anaesthetic as well. However, it differs from isoflurane in such a way that it does not produce muscle relaxation thus providing incomplete anaesthesia (Finkel et al. 2008). Nevertheless, it is a good analgesic and has a similarly rapid onset of action and recovery. Nitrous oxide decreases the required concentration of isoflurane that need to be inhaled to produce a preferred level of anaesthesia (Finkel et al. 2008). The combination of these two gases aids in the maintenance of a balanced anaesthesia in the patient’s surgery.

Hemodynamic Changes

During the procedure, the observations remained stable with some exceptions; when the femoral artery was clamped, the cardiac output, blood pressure, and heart rate increased. In addition, there were some changes in the tissues below the clamp due to lack of blood supply and oxygen. These changes can be attributed to the altered blood flow and oxygen delivery.

First, the hemodynamic status of the client changed because blood flow was impeded at the level of the femoral artery and below. When the artery is blocked, the peripheral resistance increases because there is a greater load systemically. As previously discussed in the earlier sections on factors affecting blood pressure, a stronger peripheral resistance will lead to an increased blood pressure because there is a greater resistance that the heart needs to overcome to pump out the blood systemically (Timby 2008).

Also, the presence of a clamped femoral artery will trigger the activation of the sympathetic nervous system as it is under stress. When the sympathetic division is activated, the heart beats faster leading to an increased heart rate (Porth and Matfin 2010), which is seen in the patient. Similarly, cardiac output increases because it is directly related to the measure of heart rate. Since cardiac output is the product of heart rate and stroke volume, when either of the two factors increase, cardiac output also increases.

Second, tissue changes were noted below the clamp because of the poor oxygen supply to this area. When the femoral artery was clamped, the flow of blood below that area also stops because arteries are the blood vessels that carry oxygen-filled blood away from the heart into other parts of the body (Porth and Matfin 2010). Since there is no blood supply below the clamp, there will also be no oxygen supply because blood transports oxygen. When there is no oxygen, the tissue will die and the earliest signs of compromised oxygenation that could lead to tissue death include discoloration of the area (Porth and Matfin 2010).

Blood Loss

About 1000 mL of blood was lost by the patient during the surgery that required blood transfusion. Blood transfusions are performed to people who had massive blood loss similar to the case of the patient. Also, blood transfusions are indicated for patients who undergo major operations because they would really lose a lot of blood because their skin and tissues will be injured during the operation (Ashalata 2006). During blood transfusion, lost blood is re-infused to the patient thus providing an active means to support and maintain homeostatic fluid balance in the patient’s body. Normally, the total blood volume of an adult person is 5600 mL (Ashalatha 2006). In the patient’s case, he lost approximately 18% of his blood. To restore the blood volume to the normal level, blood transfusion is done because the body on its own cannot cope with this big loss.


The concepts of anatomy and physiology are very important in understanding the changes in the body and its attempts to maintain homeostasis. When there is a change in the body that threatens to disrupt the balance, the body responds in a way to bring back the body to its normal state. In the case of the patient, disruption of homeostasis started with an atheromatous plaque in the artery that occludes normal blood flow. Since the body can no longer restore the artery to its normal state, endarterectomy of the common femoral artery was done to resolve this. Before, during, and after the operation, the body experienced many changes both from internal and external influences. In these changes, the body was in an active state of action toward maintaining homeostasis.

List of References

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Ashalatha, P. R. (2006) Textbook of Anatomy and Physiology for Nurses. New Delhi: Jaypee Brothers Medical Publishers

Carter, P. J. and Lewsen, S. (2004) Lippincott’s Textbook for Nursing Assistants: A Humanistic Approach to Caregiving. PA: Lippincott Williams & Wilkins

Clancy, J., Baird, N., and McVicar, A. (2002) Perioperative Practice: Fundamentals of Homeostasis. London: Routledge

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World Health Organization (2003) Prevention of Recurrent Heart Attacks and Strokes in Low- and Middle-income Populations: Evidence-based Recommendations for Policy Makers and Health Professionals. Switzerland: World Health Organization

Free Essays

Key to the food chain: explore how plants are the basis of all life on earth


Plants are essential for humans and all living organisms. They are the producers in ecosystem which can turn sunlight into usable energy and provide consumers with energy, food and oxygen. Chemical reactions are running on earth all the time. Photosynthesis is probably the most important chemical reaction on earth involving sunlight, the air we breathe, water and green pigment chlorophyll. All biochemical reactions are occurring in a cells, while water and air is combined sugars are stored, than this energy is released by respiration.

Plants are the basis of all life on earth and a starting point in ecosystem. They provide the main energy source received by sunlight, and convert inorganic compounds into organic ones, whereas heterotrophs are absolutely dependent on plants – autotrophs. Most of the autotrophs are photosynthetic organisms which use sun light for synthesizing sugars and other organic compounds and afterwards use it for cellular respiration, fuel and growth. The primary producers on earth are algae, plants and photosynthetic prokaryotes. In the next food chain level are heterotrophs, organisms that directly or indirectly depend on primary producers. Herbivores which consume plants and other primary producers are called primary consumers. Carnivores consuming herbivores are secondary consumers and carnivores that consume carnivores are tertiary consumers. The last group is decomposers. These consumers get their energy from detritus as these matters are organic material such as dead organisms, fallen leaves and wood. They have a secrete enzyme that digest these breakdown products into inorganic compounds where primary producers can use these compounds for their sustenance. Here is an end of ecosystem’s chemical cycling, which shows that we need all of these life organisms in order to function properly and keeping energy flow in ecosystem.

The food chain requires a lot of photosynthesis. This is a process of plants capturing the sunlight and making carbohydrates and releasing by-product oxygen from carbon dioxide and water. Carbohydrates are perfect source of energy for the body, they are breaking down into sugars as glucose which is more readily to use for our bodies. Overall process is summarized in this word equation: carbon dioxide + water light energy glucose + oxygen. The environment which is essential for photosynthesis to take place is sunlight energy, carbon dioxide which we get from atmosphere and water from the soil. The place where photosynthesis process takes place is in plant leaves organelles, called chloroplasts. It contains important pigment, light sensitive chlorophyll which is responsible for the production of food. It absorbs blue and red light and reflects green light, so that’s why so much of the earth looks green. There are two stages of photosynthesis: light reactions and Calvin cycle. In chloroplast there are stacks of membrane vesicles- thylakoids which contains pigment chlorophyll. Thylakoids are the first place where light energy is converted into chemical energy. When light energy is captured by pigment chlorophyll, then this energy is used to break water molecules into oxygen and hydrogen. The oxygen gasses are diffused to atmosphere threw microscopic pores stomata, where these gasses are used for oxygen- dependent organisms. The hydrogen molecules are further breaking down into electrons and protons and then NADPH is formulated from proteins which are delivered by electrons through thylacoid membrane to NDP molecule. NADP is a vitamin made part of niacin and function as an energy carrying molecule. Forming ion gradient hydrogen ions are building into interior space of thylakoids and this is way of storing energy. This energy is used for synthesis the energy- rich molecule ATP, which is used for all its biological activities.

The second photosynthesis stage is Calvin cycle. The cycle starts by assimilating carbon from atmosphere into organic molecules. This transformation of organic compounds is called carbon fixation. Additional electrons are added to the fixed carbon which is formed then to glucose. This reduction power is provided by NADPH molecule, which was formed in a light reaction. Conversion of carbon dioxide to glucose is required chemical energy, where ATP was formed. Therefore the process making sugars occurs in Calvin cycle, but with a help of ATP and NADPH produced in a light reactions. Glucose is an instant source of energy, and can be converted into other carbohydrates such as sucrose, starch or fructose for long-term energy storage. The majority of food that we eat comes from plants, for example the most storage of starch is found in potatoes and cereal grains. Seeds like corn, nuts use oils as a storage product.

Energy is needed for all living organisms, to maintain reproduction, growth and other cells activities. We get energy from foods we consume and glucose is an instant energy, which is first used by cell. The next essential process is respiration. It is a chemical process which takes place in a cell and must not be confused with breathing. Aerobic respiration which needs oxygen and is combined with food is called oxidation. Food molecules consist of hydrogen, oxygen and carbon atoms. The oxidation process converts carbon to carbon dioxide and hydrogen to water and release the energy whereas cell can use it for other cellular reactions. Aerobic respiration word equation: glucose + oxygenenzymescarbon dioxide + water + energy. Oxidation takes in a series of small steps, because energy is not released all at once, it needs its own enzyme and at every stage a little energy is released. Moreover energy used for this process is always ends as a heat and radiates back into space.

Photosynthesis and respiration is a circulation of chemical reactions in biosphere, without these processes life wouldn’t exist.


1. James E. Bidlack, Shelley H. Jansky,(2011), Stern’s Introductory Plant Biology, Edition twelve, New York, McGraw-Hill.

2. D.G.Mackean, (2002), GCSE Biology, Third edition, London, John Murray (Publisher) Ltd.

3. Campbell Reece, Urry Cain Wasserman, Minorsky Jackson, (2008), Biology, Eight edition, San Francisco, Pearson Benjamin Cummings.

4. Eli C. Minkoff, Pamela J. Baker, (1996), Biology today: An issues approach, United States of America,The McGraw-Hill Companies.

Free Essays

One Life for the lives of many: How Maragaret Edson’s “Wit” depicts the beginnings of technological and medicinal feat


In the play Wit written by Margaret Edson, the main character, Vivian Bearing, decides to donate her body to medicine to help better understand the ruthless disease of cancer and death itself. While many seem to believe that the theme of the play deals with the relationship between the doctor and patient, I felt the sole purpose of Wit was purely educational and depicted the beginnings of technological and medicinal feat. Dr. Bearing undergoes full dosage of painstaking treatments in chemotherapy against her stage-four metastatic ovarian cancer and is ultimately used as a specimen for the greater good of humanity. When Dr. Bearing had been notified that her cancer had become in an advanced stage, this event in itself, justifies that a person’s life can change drastically in a matter of seconds. Dr. Bearing’s infatuation with John Donne also supported the theme of Wit in which both had a deep urge to comprehend death and cancer to a whole greater level. According to, “The Amazing Grace of Margaret Edson’s Wit” by John Heilpern, while Vivian Bearing was enraptured with John Donne’s poems, Donne’s infatuation dealt with “the fatal mystery of replicating cancer cells.” In which John Donne explains, “immortality in culture.” The desire of wanting to know more about the development of cancer is evident in both characters. The reputation and facade Dr. Bearing had gotten was an arrogant and uptight professor who had nothing to give, but in reality her agreement to undergo the treatments and staying “tough” throughout the entire process gave science and medicine a huge leeway.

Katherine Margaret Rossiter, the author of “Undoing Wit: A Critical Exploration of Performance and Medical Education in the Knowledge Economy” states that Margaret Edson’s play has been widely used in medical education. (Paragraph 3) The advancements made in the medical field are still fairly new and young and are still currently continuing to advance at a very rapid rate. Dr. Bearing is held accountable to be a heroic character in Wit because she had led a life in which she wanted to and then undoubtedly is sacrificing her deteriorating body to science. According to the article, there has been a movement in the applied health research where the medical field is starting to use performance and stories as a tool for knowledge translation. Rossiter goes on to say, “researchers have struggled to find new and engaging ways to communicate complex research findings regarding the human condition.” (Paragraph 1) Essentially, the act of performing out these medical related problems helps viewers to understand and comprehend the realistically portrayal of everyday hospital life. Pamela Renner, the author of “Science and Sensibility” also states, “Wit sticks closer to realism, and closer to home. The performance is a landmine: explosive, unsentimental and wise to the core.” (Paragraph 4) The reaction retrieved from viewers depicts how a real life performance done by actors has a greater effect on people’s emotions and thought process.

After agreeing to Dr. Kelekian’s offer of undergoing full dosage of chemotherapy Vivian Bearing admits that there is going to be a “test.” (Edson, 13). The “test” refers to a gamble with life and death, in which Dr. Bearing is now in limbo of either surviving the tiring effects chemotherapy has on a human body or falling into the cold hands of death. Dr. Bearing goes on to state John Donne, the poet in which she deeply holds a passion for in analyzing his work, and how Donne explored the mortality in greater depth than any other works in the English language. The poem that is analyzed thoroughly in this play is “Death Be Not Proud” by John Donne. The line, “And death shall be no more, Death thou shalt die.,” becomes notable once Vivian Bearing realizes that, “death is no longer something to act out on a stage, with exclamation points. It’s a comma, a pause.” (14). The idea of death and that the only thing separating every living creature a step away from death is the fact that, it is merely nothing but a breath, this in turn heightens the sentimental atmosphere.

The realization of how fragile the human body can be is the main foundation and reason that drives scientists to get a better understanding about the diseases that can harm us. The studies and research scientists have and are still accomplishing are results from experiments and observations made on test subjects. Elizabeth Klaver, the writer of the article, “A Mind-Body-Flesh Problem: The Case of Margaret Edson’s Wit” claims, “For medical science, that object is, not surprisingly, the human body, which offers itself as the field of research, the specimen under observation, the flesh subjected to ‘wit.’” (559) The role of Vivian Bearing was ultimately a role in which it helped the medical field a great step towards improvement and greater research. It is seen throughout the entire play that humanity is still by her side every minute of the way. Dr. Bearing’s nurse, Susie, is the face of humanity whereas Jason, Vivian’s Oncologist, and Dr. Kelekian are the faces of medical science and the greater future. There are breakthroughs every day in science and in the medical field. Although Margaret Edson based her play from her own personal experiences, such as working as an inpatient floor captain in the AIDS and cancer wards at the National Institute of Health’s research hospital located in Washington, D.C., the happenings in a hospital room is something one can always find themselves relating to it.

According to the article, “Trends in United States Ovarian Cancer Mortality, 1979-1995” by Kathleen A. Oriel, Ellen M. Hartenbach, and Patrick L. Remington, studies show that, “Better understanding of how modifiable risk factors and treatment methods affect ovarian cancer mortality trends is needed.” (Paragraph 3) Essentially, research on the treatment towards ovarian cancer and the understanding of the cancer were still being tested and needed to be experimented upon even more. The playwright Wit was publicly published around the year 1995, and the article displays the trends that were obtained during the periods of 1980-1995 and the impact on the deaths caused by ovarian cancer. The article also claims, “Ovarian cancer is the fourth leading cause of cancer death among women, with one in 70 women developing this disease during her lifetime.” (Paragraph 4) Ovarian cancer, like AIDS, was a new strain of disease that was discovered and a range of experiments on how to cure or decrease the cancer cells had to be performed. As technology and studies on ovarian cancer increased, the survival rate had also improved greatly over time. The treatments dealt with more aggressive surgical management and effective chemotherapy. This technique of treatment is seen in the play itself and is performed on Dr. Bearing.

Many people feel sympathetic for Dr. Bearing due to the fact that the audience intakes the feeling that Dr. Bearing’s doctors are indifferent and apathetic towards her as she starts to show the side effects of chemotherapy, but I tend to disagree. Once Dr. Bearing had been diagnosed with ovarian cancer, she inevitably fell into the category of research and science. The play in fact depicts a nice balance between humanity and medicine, and the beginnings of human research on cancer and other harmful diseases. As Elizabeth Klever states, “The play demonstrates a contradictory moment in the history of Western culture: two humanist fields dedicated to a tradition of social and individual improvement – medicine and literature.” Jason and Dr. Kelekian are set examples of medicine and science. They are driven to know more about the human body and how it functions. It is evident that once Jason Posner and Dr. Bearing meet, he is overall fascinated about Dr. Bearing’s situation and status. “(He feels the mass and does a double take.) Jesus! (Tense silence. He is amazed and fascinated.)” (Edson, 27) Once he is aware of how large Vivian Bearing’s cancer has gotten to, he is shocked and taken aback. These are the exact situations that scientists and doctors thrive on about the human form and wanting to discover the cures against the harmful diseases that result in a frail and weak body. Klever also claims, “Still today, the collective brainpower of researchers like Dr. Kelekian and Jason focuses all its resources on vanquishing the mysteries of a completely separable and empirical “specimen,” the body – all for a cure” (667). If it had not been for Vivian Bearing to be experimented on, it may have been the next person who developed ovarian cancer to be tested on.

Sayantani DasGupta, the writer of “Reading Bodies, Writing Bodies: Self-Reflection and Cultural Criticism in a Narrative Medicine Curriculum” states, “As reading women’s illness narratives allowed students to hear the voices of patients, writing and sharing their personal illness narratives allowed them to hear their own voices.” (Paragraph 26) This technique is seen in the play Wit, for the narrator, Vivian Bearing, expresses her thoughts and opinions through text and literature, as well as acting. The play is told in the perspective of a dying patient, rather than the doctor or nurse; this puts a more dramatic effect on the audience, displaying how strong Dr. Bearing is mentally.


Rossiter, Katherine Margaret. Undoing Wit: A Critical Exploration of Performance and Medical

Education in the Knowledge Economy.PsycINFO. Web. 26 Apr. 2011.

DasGupta, Sayantani. Reading Bodies, Writing Bodies: Self-Reflection and Cultural Criticism in

a Narrative Medicine Curriculum. 22 Vol. Johns Hopkins University Press, 2003.

ProQuest Central. Web. 27 Apr. 2011.

Edson, Margaret. Wit. Harper & Row, Inc. 1942. Playwright. 20 Apr. 2011. Text.

Jones, Therese, and Delese Wear. THE MEDICAL HUMANITIES: Introduction. 50 Vol. Johns

Hopkins University Press, 2007. ProQuest Central. Web. 27 Apr. 2011.

Klaver, Elizabeth. “A Mind-Body-Flesh Problem: The Case of Margaret Edson’s Wit.”

Contemporary Literature. University of Wisconsin Press. (559-683). ENWR-106-04. Blackboard. 21

Apr 2011. PDF File.

Oriel, Kathleen A., Ellen M. Hartenbach, and Patrick L. Remington. “Trends in United States

Ovarian Cancer Mortality, 1979-1995 : Obstetrics & Gynecology.” Obstetrics &

Gynecology. © 1999 The American College of Obstetricians and Gynecologists, Jan.

1999. Web. 27 Apr. 2011.

Renner, Pamela. Science and Sensibility. 16 Vol. Theatre Communications Group, Inc, 1999.

ProQuest Central. Web. 26 Apr. 2011.

Heilpern, John. “The Amazing Grace of Margaret Edson’s Wit.” – New York

Politics, Media News, Real Estate, Fashion, Gossip, Movies, Books, Theater, and the Arts

The New York Observer. 31 Jan. 1999. ENWR-106-04. Blackboard. 26 Apr. 2011.

Microsoft Word File.

Free Essays

Is midlife the prime of life or time of crisis? Asses these claims with reference to theory and research.


This essay will explore the following aims; it will determine what is meant by midlife; identify some of the issues associated with the concept of midlife, evaluating evidence for and against some of the claims associated with this concept and finally it aims to identify some of the common difficulties of midlife.

Midlife is seen to be one of complexity with the ‘juxtaposition of peaks and valleys across the social, psychological and physical domains’ (Lachman, 2004). With the transition in to midlife come physical ailments, such as high blood pressure, high cholesterol and although these can be treated with medications, they do trigger distress as they signal ageing which is neither desirable nor valued in our culture. This can be seen to contribute to the concept of the ‘Midlife Crisis’. However, the psychological and social changes experienced in midlife are usually associated with positive changes. These may include increased wisdom and practical intelligence (Baltes et al., 1999), better emotional regulation (Magai & Halpern, 2001) or a strong sense of mastery (Lachman & Bertrand, 2001). This adds to the debate of whether midlife is the prime of life or the time of crisis?

One of the most common expectations of midlife is that there is a crisis. Rosenberg et al. (1999) identified the characteristics of a midlife crisis. These include the following; midlife only applies to males, it involves dramatic personality changes and life review, an increased introspection, a realisation of time passing and finally the mourning of lost opportunities. Similarly, recent research shows that major life events such as divorce or illnesses are the most common sources of crises, although these are not necessarily associated only with the midlife period (Lachman et al. 1994, Wethington et al. 2004). It has also been found that one third of the time a midlife crisis is described by events such as job loss, financial problems, or illness (Lachman & Bertrand 2001, Wethington et al. 2004), which supports Rosenberg’s characteristic of the mourning of lost opportunities. However, although events such as job loss, divorce and illnesses can occur at any time in adulthood, these events seem to be more prominent during the midlife period as maybe the midlife crisis is driven by a fear of impending death according to Jacques (1965). On the other hand, another explanation for adults experiencing a midlife crisis may be down to personality, which has been identified as a key factor predisposing some to experience crises at transition points throughout the life course. It has been found that individuals who are more neurotic are more likely to have a midlife crisis (Costa & McCrae 1980, Lachman & Bertrand 2001, Whitbourne & Connolly 1999).

Furthermore, turning points have been found to contribute or trigger a midlife crisis. Turning points are significant changes in the trajectory of life or an experience or realization that causes someone to reinterpret the past, similar to a midlife crisis (Clausen 1998, Rosenberg et al. 1999). Wethington et al. (2004) examined in what areas of life turning points occurred and whether they clustered in midlife. The most common turning points involved the work domain, usually a change in job or career. They were most likely to occur at midlife for men but earlier for women (Clausen 1990, Moen & Wethington 1999). Wethington et al (2004) claimed that entering the thirties may be more disruptive than turning 40. This seems to be consistent with the idea that a “quarter-life crisis,” can occur for those in their mid-twenties and early thirties as they struggle to find satisfaction in work and meaningful relationships (Robbins & Wilner 2001). Furthermore, the conceptual frameworks of midlife are based on Jung’s theory (Lachman & James, 1997). According to Jung (1971), the individuation process is a major goal of midlife. Individuation is the balancing of all aspects of the inner self. Jung (1971) stated that midlife must be approached with a different set of goals than earlier adulthood and the failure to deal with the psychological and physical changes in middle age could lead to difficulties and then to a midlife crisis.

Furthermore, it has been claimed that from a lifespan perspective, the dynamic nature of changes in the middle years can be represented as both gains and losses (Baltes 1987, Eichorn et al. 1981). The midlife experience is determined both biological factors, such as menopause for women or chronic illnesses for both males and females and it is also determined by cultural influences. Although midlife does not exist as a concept in all cultures (Shweder 1998). When life events such as divorce or chronic illnesses are experienced, the middle life adults are faced with finding ways to cope or compensate for the losses. The middle-aged adult may be frequently forced to balance the negative and positive aspects of relationships and other aspects of life. Although this may lead to increased stress, it may also serve as a training ground for emotion regulation in later life (Magai & Halpern 2001). This can be seen as a turning point in middle life and not a midlife crisis.

Furthermore, Neugarten & Datan (1974) found evidence that supports the notion that midlife is the prime of life. They found that midlife was a time of peak functioning in psychosocial competence. Other evidence suggesting that midlife is the prime of life come from key longitudinal studies on cognitive functioning, which have found that cognitive functioning are maintained or even improved in midlife (Eichorn et al. 1981, Hultsch et al. 1998, Schaie 1996). These include the pragmatic aspects of functioning, such as tacit knowledge (Baltes et al. 1999, Sternberg et al. 2001), that depend on experience. Although some aspects of cognitive functioning may show declines, the middle-aged adult typically has the resources and experiences to compensate for them (Miller & Lachman 2000). Furthermore, personality is prominent in deciding whether midlife is the prime of life. It has been found that the self plays a vital role in midlife as it serves as a resource for negotiating the physical changes and social stresses that may arise. According to Lachman & Firth (2004) no one is immune to the complexities of midlife, yet those who feel a sense of mastery and control are better able to meet the challenges head on and find effective strategies for reducing or dealing with stress.

Moreover, social relationships have been found to influence whether midlife is the prime of life or a time of crisis. Markus et al. (2004) states that positive relations with others, such as parents, spouse and offspring is the one major component of well-being at midlife. Social relations bring a major source of satisfaction and contribute to wellbeing and health in midlife, but also can be a source of stress (Rook 2003, Walen & Lachman 2000). Furthermore, the role of work is seen to be central during the middle years (Sterns & Huyck, 2001). An individual is seen to be defined by their work so a large part of their identity lies in their career. It has been found that cognitive capacity and intellectual flexibility can be affected by an individual’s work (Kohn & Schooler, 1978). The progression of career trajectories during midlife is diverse (Barnett 1997). Therefore, many individuals may have stable careers, whilst others may not and there is a higher chance of midlife adults may find it very difficult to find a job due to many factors such as skill and pay demands. Furthermore, health and physical changes can also influence whether midlife is a crisis or the prime of life. One of the major issues in midlife is that of reproduction, especially menopause for women. The median age of the last menstrual period is typically 50–52 years, although there is wide variation in the menopause experience (Avis 1999, Rossi 2004). Avis (1999) found that there is no evidence for a universal experience of distress associated with menopause. Research shows that the transition in to menopause is somewhat exaggerated as according to Avis (1999) it is possible that the association noted between depression and menopause is based on clinic/patient populations who self-select into treatment.

The claims about whether midlife is the prime of life or a time of crisis are quite unclear. The majority of people tend to free associate the word ‘crisis’ to the word ‘midlife’. This reflects a widespread cultural stereotype about the midlife period but not an accurate portrayal, as only a small percentage seems to experience a midlife crisis (Wethington et al. 2004). However, middle age is also associated with positive descriptors such as competent, responsible, knowledgeable, and powerful (Lachman et al. 1994). Therefore, although midlife is referred to as a crisis, it is also described as an age period with desirable characteristics. There is some empirical support for both of these views, as those in midlife may experience turbulence as well as success (Eichornet al. 1981). Midlife seems to be unique to every individual during the transition from adulthood to midlife.

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Robbins A. & Wilner A. eds. (2001). ‘Quarterlife Crisis: The Unique Challenges of Life in Your Twenties’. New York: Putnam.
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Rosenberg S.D, Rosenberg H.J. & Farrell M.P. (1999). ‘The midlife crisis revisited’. In Willis S.L. & Reid J.D, eds. (1999). ‘Life in the Middle: Psychological and Social Development in Middle Age’. San Diego: Academic. Pp. 47-73.
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Free Essays

Essential Life-hacks for International students

Life can be hard as an international student – with lectures to go to, bills to pay, and parents to speak to – it’s hard to stay on top of your studies. But students are resourceful, and they find ways to get the most out of whatever is around them – here are a few essential life-hacks for any student!

1.If you find reading English hard – leave yourself a sweet incentive.

Mark each paragraph with a sweet to give yourself a reward for finishing another section, and to provide an incentive to finish the whole chapter! This is a great way to force yourself to read, especially if you struggle to read English.

2. If you struggle to understand your lecturers – record

you lectures!

You can use a program like Audacity or VLC media player to do this on your PC, or record them with you iPhone. You can then play the lecture back to yourself at a slower speed. This is a great way to also improve your English. Also, when crunched for time, listen to recorded lectures at double the speed!

3. If you’re dyslexic, there’s a special font called Dyslexie that could help you read more easily.

Sometimes reading and writing English can be tough, especially if you are an ESL student. However this can be even tougher if you are dyslexic. Dyslexie makes things a little easier. Read more about it here.

4. If you are struggling to read the book, watch the film!

If you are an ESL student then reading English books can be hard and time consuming. Luckily for you in the 21st century, there are loads of films and documentaries on all kinds of things. For example, for history and anthropology classes, watch a documentary on the topic, it’ll help you have a deeper understanding of the material. If no documentaries exist, open up YouTube and do a search on the topic.

5. Take notes in English.

It might be tempting to try and write your notes in your own language; but forcing yourself to write your notes in English not only helps to improve your English skills, but it forces you to concentrate and focus. This is a proven way to improve the amount you remember and helps when you go to revision as you will remember more clearly the points that you had to focus to write.

6. Write down words you don’t understand in different colours

This will act as a prompt for you to look up difficult words when you check over your notes. This will help to expand your English vocabulary and will also help you to gain a better understanding of your subject. Using coloured pens will fire up your visual memory. It also looks pretty and makes taking notes more enjoyable.

7. Google “site:edu [subject] exam” to find many different exam notes featuring problems pertaining to that subject.

8. Try an online interactive flash card site

Flashcards are proven way to improve your memory, your English, and to generally help you get higher marks. There are loads of websites around that allow you to create your own flashcards and some where you can use ones that other people studying the same subject have already made. A popular site that we like is Quizlet.

9. When giving a presentation, set up a friend to ask you a question that you already know the answer to.

It’s a great way to a) look like you know what you’re talking about b) boost your confidence. Being able to confidently answer your friend’s question will impress the whole class, and your lecturer!

10. Use our site!!

The best thing you can do to really hack being an international student studying in the UK is to use our site’ Essay and Dissertation writing services. our site has worked with 1000s of international students and has helped them to achieve outstanding marks in any number of subjects. Head over to http://www.our to see how you can get the best possible marks in your degree.

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Social Life Tips for International Students

One of the biggest challenges faced by international students and ESL Students, is the obstacle of creating a social life in an unfamiliar place. For many international students, who have travelled from various countries to come to university to study, the thought of making friends can be daunting. However, reaching out and meeting new people is a key part of the university experience and needn’t be something that is feared!

Today we look at a few key social life tips you can use to make socialising a little less daunting.

1) Always Say Thank You!

You’ll be amazed how far smiling and being positive will go. Show people you are helpful, kind and genuine. If someone does something for you, never forget to say thank you, verbally or with a simple note. Small gestures and manners like these go a long way.

2) Use Technology to Connect

Sites like Facebook, Twitter and LinkedIn make it easier than ever to connect with others and share your interests. Be sure to stay in touch with any friends you make, and be sure to join in lots of communities and groups to stay in the loop.

3) Get Involved!

Sports and hobby clubs are a great way to pursue your own interests with others who share them, allowing you to have fun and meet new people at the same time. Have you considered playing a sportYou can get a workout and form some lifelong bonds with others by seeking out sports teams to play on.

4) Always make time

We know it can be tempting to put off socialising, or going out – especially if you are feeling daunted as an ESL student. However, even when you’ve got a ton to do, making time for fun with friends (even if you just meet for dinner) should always be important. It’ll give your brain a rest and let you come back to your work happier and more refreshed.

5) Combine studying with fun

University work and having fun don’t have to be mutually exclusive. Study with friends and you’ll get to socialize while learning as well. University can be incredibly stressful so make sure to take a moment to step back now and again and take a breath. It can also be a great time to improve your confidence speaking and writing English.

6) Accept a variety of invitations

Take advantage of those moments when people offer you an invitation to do things with them. You could discover a new hobby, meet a great group of people or just have new experiences that open your eyes. It’s easy to get caught up with university, but a big part of the experience is meeting new people, forming friendships and networking with others. Don’t let that fall by the wayside in your academic pursuits.

our site offer a range of services that can make it less daunting to be an international student. Or if you ever need to just chat – we’ve a team of professionals at the other end of the phone line who are happy to assist +44 (0)207 060 1205.

Free Essays

Select an aspect of the “End of life Strategy” and critically evaluate the implications for community health care providers.


The Liverpool Care Pathway (LPC) was created in the late 1990’s as an alliance between the Royal Liverpool Hospital and the Liverpool Marie Curie Hospice. Designed as a template model utilizing numerous resource locations such as hospitals, care homes, hospices and patients own homes its fundamental vision was to ensure the greatest quality of care for the dying patient in their last moments. The Liverpool Care Pathway first emerged as a template from the Department of Health in 2006 and was championed to reflect the best practice model available for a person entering their first stages of death. The Department of Health released the “End of Life Strategy” consisting of a three-part strategy of which the Liverpool Care Pathway formed an integral component in 2008 and 2009 (LPC, 2009). Initially, the LCP initiative was directed towards the care of cancer patients however has increasingly been utilized for patients entering their last days of life, irrespective of diagnosis (Nursing Times 2005).

The fundamental objective of the LCP is to improve the care the dying patient encounters in their last days or hours of life (MLPCIL, 2009). In a comprehensive, structured outline it identifies key areas including initial and ongoing assessments and after death care, pinpoints the main elements of care such as the physical, psychological, social and cultural aspects and finally how the organization of such a task should be governed, the implementation of which encompasses clinical decision making, management and leadership, learning and teaching, research and development and governance and risk (LPC, 2010).

Identifying the stage at which patients are entering the dying phase can be hard; however the MDT approach to diagnoses is key in instigating this transition of care. This united approach, utilizing interpersonal and inter-professional communication avoids conflicting information to the family and enhances patient care. This crucial and sensitive diagnosis of dying is reached when the multi-professional team agree on two of the following; the patient is bedbound, the patient is semi-comatose, the patient is can only take sips of fluids, and if the patient is unable to consume tablets (Nursing Times 2005).

In the early part of the decade The National Institute for Clinical Excellence (NICE) put forth recommendations to create a “suitably trained workforce” with the aim of providing support and palliative care to cancer patients, their families and other informal care givers. The LCP has since been championed within the National Institute for Clinical Excellence (NICE) Guidance for Supportive and Palliative Care (2004) and recently within the White Paper “Our Health, Our choice, Our Say” (2006) as a pathway for guaranteeing the needs of patients, their informal carers are identified and addressed (Gambles and Ellershaw, 2006).

However the LCP guidelines are “only as good as the teams using it”, the robust and sustained education of health care professionals par-taking in this scheme therefore needs regular evaluation; involving continuous reflection, challenge, vital senior decision making and clinical ability in working for the best interest of the patient (MLPCIL, 2009)..

The interpersonal multi-professional team including doctors, nurses and social workers developed the LCP. Naturally such a profession and the nature of the Liverpool Care Pathway mean this health care provider will be a main target of utilization (LPC, 2009)(Department of Health, 2007).

LCP – Patients and relatives.

The LCP’s generic version 2008 has a relative carer information leaflet/information section within the core documentation. This information ensures relatives are given a sense of reassurance, a feeling of being part of the overall process LCP 2009 (12). Main points of emphasis within the information sheet for relatives highlight communication between doctors and nurses, updates of the patient’s state, involvement in important decision making with the health care professionals and the MDT which are in control. The main points of emphasis for relatives within the LCP highlight communication between doctors and nurses ensure they receive updates of the patient’s state, and are involved in important decision making within the interpersonal health care team. The LCP ensures that relatives and friends of the patient are un-interrupted during special time, when the patient wishes to be left alone or with the company of only family and friends during what they themselves feel as sensitive moments, something otherwise not available in busy hospitals or crowded hospice environments LCP 2009 (12).

The LCP creates a dignified environment of choice in all setting be it a hospital, nursing home, hospice or home care. Recent results from an independent evaluation carried out in Lincolnshire showed deaths at home to be 42% compared to 19% and hospital deaths down from 63% to 45% (Department of Health, 2007)(NHS, 2010).

Patients are transferred to a safer, more comforting environment where they will be the focal point and healthcare professionals who are trained to deal with these sensitive and crucial last moments of life can provide the best healthcare. The LCP takes into consideration all factors the physical aspect of care, psychological, social and spiritual to optimize patient and relative encounters (Constantini and Berraco 2009). Recent quasi-experimental studies looking into how the extent LCP has in improving the quality of communication for patients relatives showed that although it was assessed as the same prior to the intervention of the LCP, the level of bereavement was significantly lower for patient relatives after (Simon and Higginson 2009).A similar study also reflected a similar outcome in the quality of communication however reflected an improvement in both the nurse and relative perspective with the written documentation attributed to death which was seen to increase and the symptoms burdens associated decreases after the LCP was introduced (Veerbeek et al 2008).

Liverpool Care Pathway – community health care professionals.

The responsibility is upon individual organizations to select a “multidisciplinary team” (MDT) of which at the least constitutes a doctor and a nurse however this can be expansive including other healthcare professionals/trained personnel such as community health workers, volunteers and hospice workers. The MDT trained professionals work as part of an organization or are self-employed by numerous types of organizations for example, a charity, or a government entity in providing health care (Gambles and Ellershaw, 2006). Research carried out soon after the LPC implemented and found nurses in the acute hospital setting had a positive opinion of its impact.

The general consensus was that the LCP equated to improvements in symptom control, enhanced nursing care and raised patient and relative profiles (Letter to editor)

A study exploring the perspective of doctors and nurses in the hospice environment towards the LPC also found that the LPC had become an invaluable tool and that they would not consider regressing to a pre-LPC state. The major benefit of the LPC in hospices was that it “streamlined and reduced the documentation of care, allowing them to spend quality time with the patients and relatives during a sensitive phase of care provision. Health care providers within the hospice setting further favored this approach to anything previously due to the ability of the LPC, if adhered to promote consistency through continuous education of the staff (both doctors and nurses) (Gambles and Ellershaw, 2006).

A report published (2009) “Standard Commission of on Carers” which recognized a closer connection had to be formed between plans for the Carers Strategy and other strategy’s related to carers, such and that of the End-of-life Strategy. Methods of identifying and supporting carers within a range of services, including palliative care have emerged as the DoH has created 25 Carers Demonstrator sites (LCP, 2008).

LCP – implementation in other key diagnostic areas.

The implementation of the LCP entering a new environment encompasses a number of fundamental stages, one of which includes the “training of health and social care professionals”. Four key phases have been outlined which reflect the transferable nature of the LCP into other specific diagnostic areas including pediatrics’ neurological conditions, heart failure, advanced chronic kidney disease, intensive care unit and care homes (MLPCIL, 2009).

Giving two examples, pediatrics and heart failure in which the LCP is thought to be a prospective future goal, namely, pediatrics and heart failure, this paper will briefly highlight its implications. The former consists of a multidisciplinary team (MDT) which includes collaborations of the following; a LCP Team UK, an adult hospital specialist palliative care team, a paediatric palliative care team/oncologist and pediatric medical and nursing personnel (LCP, 2008).

A second proposed diagnostic area for the incorporation of the LCP n is laid out in phase 3 – heart failure. Since the introduction of the National Service Framework (NSF) by the Department of Health (DoH) which addresses critical areas of reform concerning the diagnosis, prevention and treatment of coronary heart disease (CHD), the idea of palliative care has gained immense interest from government, statutory bodies and physicians over the past several years (MLPCIL, 2009).

Experts set out to be key in the delivery and execution of the LCP for heart failure and include the following; LCP Central Team UK, Cardiologists, specialist palliative carers, patients and/carers, and the voluntary sector including the British Heart Foundation (BHF) and the National Council for Palliative Care (LCP, 2008).

Benefits of Intensive Palliative care in the form of the LCP.

Generally, a key aspect, which is detrimental to issues surrounding palliative care, is the initiation of diagnosing death. Professionals are reluctant to diagnose dying due to lack of adequate training; the effect is reflected in the transfer of patients to a side-room which can be viewed as a physical and more importantly emotional withdrawal from the patient and family members – an event which predominantly occurs in the hospital setting (Ellershaw and Ward, 2003).

The hospice model of intensive palliative care at this point should in an ideal scenario come into motion and provide psychological, social and spiritual care for all involved, the patient, relatives involved and the health care providers (Ellershaw and Ward, 2003). The LCP pathway should provide health care professionals with the confidence and training to be able to identity and deal with such difficult situations.

LCP – possible areas of concern and areas of improvement.

Problems with the integration of LCP into Pediatric involve the relative inexperience of health care professionals and their in-exposure to caring for the dying child and their families. This inexperience and lack of knowledge in knowing how to deal with circumstances of near death in children result in feelings of apprehension and discomfort in coping mechanisms faced by community health care professionals working in this intense emotional setting surrounding dying child patients (Sahler et al, 2000).

Possible ways of addressing these issues involve investing in training health care students, both doctors and nurses, to manage the adverse feelings and emotions associated with the death of a child. This training can be achieved through preparing professionals for possible negative outcomes and encouragement in incorporating palliative care into their delivery approach adhering to guidelines set out in the LPC. These measures will enable and ensure health care providers are more competent and empowered to deal with the burdens of death in the emotionally charged pediatric environment (Sahler et al, 2000) (MLPCIL, 2009).

As nurses are essential in the implementation of the LCP, the problem of nurse shortages in the UK is an important concern. An ageing population, advances in technology and the expectations of having to deliver exceptional patient care have caused difficulties in recruitment and pose a burden on those already working within the community health service (Ingleton et al, 2009).

Nurses are faced with a difficult decision as most opt to work with healthy patients, or those who will recover. Palliative nurses requires a different ethical approach, one that tests personal abilities of those involved, and also means they must undergo intensive education. This poses a challenge for nurses working to implement the LCP, as they also have to balance their professional life with family responsibilities, the stress of having to continuous insecurity of finding funding post qualifying professional qualifications for specialist areas of nursing such as that of palliative care. In essence it is the nurses that are present at the bedside delivering the LCP intervention which affect the care aimed at the patients and family (Ingleton et al., 2009)(Nursing Times 2010a).

A key issue concerning the LCP is also the identification of patients nearing end of life by acute sector workers. A strategy in the form of the AMBER (Assessment, Management, Bets practice, Engagement of patients and carers, for patients whose Recovery is uncertain) has been developed by St Thomas’ Hospital and is currently being modeled in four NHS trusts (Glasper 2010).

A recent Dutch study has surfaced weaknesses in the selection criteria and suggests patients such as those suffering from chronic illnesses such as dementia would technically be eligible, and these are individuals most at risk at being put on such pathways without palliative care advice. (Reitjens et al, 2008). This study has certainly highlighted the immense importance surrounding the decision making of the MDT concerning the diagnosis of death and with the area already being one of controversy, i.e. as mentioned earlier the reluctance of health professional to diagnose death, can further be detrimental to the advancement of the LCP into the other diagnostic fields. However it will no doubt ensure a greater degree of communication, education and contemplation will take place in these environments.

Another area of concern comes with the research surrounding palliative care as only a finite number of studies have been carried out to assess the effectiveness of end of life care pathways, on symptom severity and quality of life for those dying and the family members. It is an area which lacks any randomized control trials and therefore it is essential future study designs aim towards assessing and evaluating if and how clinical pathways are effective to the outcome for end of life care (Nursing Times 2010a).


The Liverpool care pathway has had immense implications on the health care profession, in particular those, which deal with patients in a sensitive environment where the last days of life are managed in a more structured, positive way.

Since its advent few experimental studies into the effectiveness of the pathway have found it to be to productive and the overall success or areas of improvement has so related to creating a more peaceful, efficient and positive environment for all those involved in the process (Constantini and Berraco, 2009).

Proposed changes in the divergence of the LCP into other areas will begin to emphasize the need for excellent communication within those who encompass the MDT. It will also require adaptability in an otherwise un-structured area of palliative care giving. It is envisaged this transfer of practice from settings such as that of hospices and hospitals to other more comforting settings such as the patient’s own home for all patients including non-cancer patients will be a major challenge and a prospective area for development (Ellershaw and Ward 2003). Worrying a recent article (Nursing Times 2010 (b))has revealed that only 25% of funds that were given to primary care trusts by the government were spent on direct nursing provision for patient care at homes. This was raised as a major concern by the head of Macmillan Cancer Support, who also said that 8% of money which was directed towards 24 hour services was unsubstantial. The National End of Life Care Network, showed a geographical inconsistency with the proportion of care patients receive around the United Kingdom, describing it as “disease lottery”. This is an obvious flaw and should not be projected onto the future if this pathway is to achieve is optimum effectiveness across the country.

It is difficult therefore to assess such a measure, which is only in its infancy, it shall take a number of years to conclude the impact the LPC has had and is having on the community health care works. The key areas of the LPC have been highlighted, with the emphasis on the main aspects of the LPC, patients, relatives and most importantly those that at the forefront in proving this care being explored. With LPC moving into other areas, including neurology and cardiology the future for community health care professionals shall be very diverse and interesting. It remains to be seen if the LCP continues to be a success and what amendments shall be introduced affecting all encompassed within the framework.

References (part a)

Constantini M., Berraco (2009), Health Services Research on End-of-life Care, Current Opinion in Supportive and Palliative Care, p. 194.

Department of Health (2007), LPC Generic Version

Dept of Health, (2009), New Version LPC, Version 12,

Department of Health, NHS, (2010), End of Life Care Strategy, Second Annual Report.

Ellershaw. J and Ward, C. (2003) Care of the dying patient: the last hours or days of life, BMJ, pp. 30–34

Gambles, M., Stirzaker. S, Jack B. A., Ellershaw. The Liverpool Care Pathway in Hospices: an explanatory Study of Doctor and Nurse Perceptions, International Journal of Palliative Nursing, 2006;No 9, pp. 414-421.

Glasper. A. The Governments eight-point plan for improving end-of-life care. British Journal of Nursing, 2010; Vol. 19, No 18. P 1194-1196.

Ingleton. C, Gott. M., Kirk. S. Editorial: The beginning of the End (of Life Care Strategy), Journal of Clinical Nursing, 2009; Vol. 18, pp. 935-937.

LCP, (2006), The Liverpool care Path in hospices: an explanatory study of doctors and nurses perceptions

LCP, (2010), What is the Liverpool Care Pathway for the Dying patient (LCP), Information for healthcare professionals, Marie Curie Palliative Care Institute: Liverpool

LCP, (2008), End of Life decision making for cancer patients in different clinical settings and the impact of the LCP. Palliative Medicine, 22 (2), pp. 145-51

LCP 2009 (12) – Liverpool care pathway for the dying patient (LCP) supporting care in the last hours or days of life. LCP Generic version 12, December 2009.

Letter to Editor. Liverpool care pathways carers’ survey. Palliative Medicine 2009; 00: 10-2.

MLPCIL, Marie Curie Palliative Care Institute: Liverpool (2009), LCP transferability into specific diagnostic groups. Briefing Paper, Marie Curie Palliative Care Institute: Liverpool.

Nursing times 2005 – “Improving practice with the Liverpool Care Pathway”:

Nursing Times 2010 (a) – “Do end of life care pathways improve symptoms and quality of life for patients and family” –

Nursing Times 2010 (b) – End of life care is compromised as “crucial” services are denied funds.

Rreitjens. J, van Delden. J, Onwuteaka-Philipsen. B, Buiting. H, van der Maas. P, van der Heide. A. Continuous deep sedation for patients nearing death in the Netherlands: descriptive study. British Medical Journal 2008; 336:810-1.

Sahler et al, (2000), Medical Education about the end-of-life care in the paediatric setting. Principles, challenges and opportunities, Paediatric, pp. 575-584

Simon. S and Higginson. IJ. Evaluation of hospital palliative care teams: strengths and weaknesses of the before-after study design and strategies to improve it. Palliative Medicine 2009; 23-28.

Veerbeek. L. Van der Heide. A, de Vogel-Voogt E et al. Using the LCP: bereaved relatives’ assessment of communication and bereavement. Am Journal Hospital Palliative Care 2008; 25: 207-214.

b) Discuss how effective UK policy has been in meeting long-term needs of patients with coronary heart disease.


This essay shall focus on three major points to address this issue, coronary heart disease, cardiac rehabilitation both in the UK and briefly will touch upon progress made in Europe of which the UK is affiliated and UK policy concerning the long term care of patient with Coronary Heart Disease. Coronary heart disease (CHD) accounts for the largest cause of morbidity and mortality in the UK and the majority of nations within Europe (Khunti et al., 2007) (Mera, 1997).

CHD along with stroke is one of the principle causes of cardiovascular disease (CVD), latest figures show CVD cause over an estimated 190,000 deaths within the United Kingdom, of which CHD is accountable for almost 46%. Singularly CHD is the most frequent cause of death, with statistics from 2008 showing 1 in 5 male deaths and 1 in 8 female deaths totaled 88,000 deaths in the UK. Recent data also shows CHD presents as the most common source of premature deaths in the UK, causing over 28,00 deaths. Statistics collated by the British Heart Foundation data also reflect regional, national and socioeconomic variances, a primary concern when attempting to address this fatal disease (British Heart Foundation, 2010). CHD culminates as results of the pathological conditions known as atherosclerosis and thrombosis (Medline, 2010).

Coronary heart disease (CHD)


Atherosclerosis is most often initiated with endothelial damage due to high blood pressure of inflammation, which goes on to affect plasma lipoproteins levels (high and low density lipoproteins (HDP/LDL’s) and their inclination for oxidation. Atherosclerosis causes vasoconstriction of blood vessels, which supply the heart and occur when fibrofatty plaques accumulate in the intimal layer of the arterial wall, known as “atherosclerotic plaques/atheroma” causing them to both thicken and harden, frequently becoming calcified and protrude into the arterial lumen. This fibrofatty plaque build-up adversely affects the luminal radius, by narrowing it this leads to such conditions as angina, dyspnoea, acute myocardial infarction, heart failure and other related cardio-respiratory symptoms (Mera, 1997)(Medline, 2010). The secondary process of thrombosis arises as result of the atherosclerotic plaque, which becomes partially disconnected due to high blood pressure breaking from within the endothelium of the arterial vessel associating itself directly with the blood flow. This thrombus may go onto to further occlude the artery due to its unsmooth surface allowing for nearby blood platelets to adhere resulting in fibrin deposit, which entraps red blood cells forming the “thrombus/clot” or is transported via the bloodstream into the arterial network in the form of an embolus (Mera, 1997)(Hall, 2006).

Risk factors

The risk factors for atherosclerosis of which CHD is the most common manifestation come in various categories consisting of non-modifiable, partially modifiable and modifiable. Non-modifiable risk factors include; age, gender, race, a genetic predisposition in the form of familial hypercholesterolemia, familial mixed hyperlipidaemia, familial type III hyperlipoproteinaemia, familial lipoprotein lipase deficiency and familial apo-CII deficiency. Partially modifiable risk factors encompass the some of the following; secondary hyperlipidaemia, diabetes, hypothyroidism, chronic renal failure, obesity, hypertension and personality type and behavior. The final category of modifiable risk factors amongst which include; cigarette smoking, physical exercise and diet (Mera, 1997).


Numerous tests are available to diagnose CHD, such test include a variety of imaging techniques such as ultrasound (intravascular ultrasonography), magnetic resonance imaging (MRI)-angiography, computerised tomography (CT) angiography. Echocardiography is utilized to hear sound waves reflected as images of the heart, electrocardiography (ECG), Angiography, a common diagnostic tool in which a contrast medium in injected via a catheter, usually into the femoral artery to display continuous images of the beating heart and blood flow by X-ray fluoroscopy. Other tools used are testing for biochemical markers; these are enzymes specific to certain time periods and reflecting certain pathologies such as the release of creatine kinase and lactate dehydrogenase from dying cardiac muscle (Medline, 2010)(Hall, 2006).

Treatment of CHD

The uses of lipid lowering drugs, which aim to reduce LDL cholesterol levels to 100mg/dL or less and possibly lower in some, affected patients in order to slow down the buildup of atheromas (Mera, 1997). Surgical procedures are employed in advanced cases of angina and include bypass surgery, coronary artery angioplasty and coronary stenting (British Heart Foundation, 2010). The first line therapy for angina is the administration of nitrates. Myocardial infarction is treated with the mina objective to restore myocardial perfusion and include some of the following interventions; coronary angioplasty is the immediate choice closely followed by thrombolytic treatment, aspirin therapy and anticoagulation therapy and combinations of other drug therapies are commonly utilized as a long-term aid. Finally diuretics and vasodilators are the chief treatment options for heart failure (Mera, 1997) (Medline, 2010).

An important area of treatment distinguishable from primary intervention is known as “secondary prevention/cardiac rehabilitation (CR)” and will be discussed in great depth in the following sections. (Mera, 1997).

Cardiac Rehabilitation –UK measures.

For this purpose of this paper, the terms “secondary prevention” and “cardiac rehabilitation (CR)” are synonymous terms, the latter (CR) shall be used in the remaining sections. Cardiac rehabilitation refers to a process through which patients suffering from ischemic heart disease are encouraged to develop their maximum physical, emotional, social, vocational an economic condition. This outcome is usually achieved through a multidisciplinary teamwork usually led by a medical director; via a combination the best services available (World Health Organization, 1993). Comprehensive CR is thought to be the most effective method in reducing cardiovascular risk and is the most attractive long-term care of cardiac patients and patients who display numerous coronary risk factors (Giannuzzi et al., 2003). CR is divided into a three-part strategy as laid out by the WHO; (I) the acute phase (II) the reconditioning phase and (III) the maintenance phase. It is the second phase which following the acute heart attack, which sees the integration of the multidisciplinary program that collates knowledge and skills from medical treatment, patient education, exercise training and counselling for CHD patients (Vanhees et al., 2000).

Since the British Cardiac Societies report in 1987, significant amounts of research within the field of cardiovascular research, has identified numerous benefits of lifestyle changes and secondary interventions in the control of coronary risk factors (Aspire, 1996). This was championed by the British Heart Foundation (BHF), which as a result provided financial investments to generate new cardiac rehabilitation programmes. In 1999/2000 64 applications were put forth and of which 11 awards were given to fund new innovative projects, since 1989-1999 approximately 133 awards have been approved at a cost of an estimated ?3.5 million (Fearnside et al., 1999).


To reflect the important nature and incorporate academic findings into clinical practice a workshop took place in the UK with the aim to highlight strategies beyond symptom relief with medical treatment and revascularisation in order to decrease the risk of (re) infarction and enhance survival, this committee was termed “ASPIRE” (Action on Secondary Prevention through Intervention to Reduce Events). Four main aims were the focal point of this committee; a) to measure the number of coronary patients in the UK, eligible for secondary preventative measures, b) determine what major risk factors are recorded in patients medical history notes, such as cigarette smoking, obesity, hyperlipidemia, c) to interview patients within at least months post hospital admission to measure their risk factors and describe risk management and finally d) to determine if other family members, where suitable have been properly advised for coronary risk factor screening The outcome of this survey indentified key areas of improvement and in attempts to reduce further and consequent incidences of morbidity and mortality (Fearnside et al., 1999). .

UK: Department of Health – Frameworks put in place

The National Service Framework (NSF) for Coronary Heart Disease (CHD) was laid out in 2000 by the Department of Health (DoH) and established clear standards for the prevention and treatment of CHD to improve quality and access to care. Cardiac rehabilitation was a key area addressed, emphasizing the need to initiate CR as soon as the patient is admitted to hospital from Phase I through to Phase III and even extend to a long-term maintenance Phase IIII. Three milestones were laid out in the NSF (i) By October 2000, every hospital should have an “effective means for setting hospital-wide clinical standard…”(ii) by April 2001, every hospital should have “an agreed hospital-wide protocol for the identification, assessment and management of people likely to benefit from CR” and (iii) by April 2002, every hospital should have “clinical audit data no more than 12 months old describing all items listed in bold in paragraph 60”, (page 12, paragraph 60 in bold)” (Department of Health, 2000). The NFS was further enhanced with the advent of the NHS Improvement Plan in 2000 with the aim to further reform and invest in transforming the NHS with dramatic improvement in key areas including CVD treatment/rehabilitation. This UK policy is set to be achieved through the collaborated efforts of the Primary care trusts (PCTs), NHS Trusts (including ambulance an tertiary centers), and local networks of cardiac care. Since the NFS began, every year amendment have been addressed the current available NSF is 2009 and available for the DoH (Department of Health, 2004)(Department of Health, 2000).

Other UK policy frameworks have also complimented the improvement in long-term care for patients with CHD, included the Quality of Outcomes Framework (QOF) set up in 2004, which aims to gather information in order r the NHS Board to organize serviced which revolve around patients needs. With the emerging evidence that patient management with long-term conditions can prevent future adverse events and reduce hospital admissions the government is investing a lot of energy into providing the best service (NHS, 2004).

Cardiac Rehabilitation – cost effectiveness

In the mid 90’s in England and Wales the cost of CR was estimated to be per patient- session at around ?47 and at ?370- per patient per programme, this figure was much favored over the costs of hospital re-admission for patients with acute MI or an ischemic heart episode which were close to or in excess of ?2000, this cost effectiveness continued into 2000 (Department of Health, 2000) (Gray, 1997).

As part of the CR programme and evidence that cardiac liaison nurses, who can further improve patients lives can provide an essential bridge between primary and secondary care, the BHF also funded almost 50 new cardiac liaison nurses entering 2000, a certain aide to enhancing long term-term available care for CHD sufferers (Fearnside et al., 1999).

Improvements to long term care for CHD Patients as result of UK Policies.

There has been a decrease seen mortality rates since the 1970’s in the UK, with CVD mortality rates for individuals under 75 years, falling by 44% within the last decade. This has been attributed to the effectiveness of cardiological treatments and risk factor trends accounting for the decline in CHD mortality in England and Wales between 1981-2000. 58% of this mortality rate decline in Britain was suggested to be as result of reductions in the main risk factors, which primarily involved smoking. Treatment of patients with secondary prevention (i.e. CR) was the cause of the remaining 42% decrease in mortality rate. Within Europe the UK has one of the fastest rates of mortality decline in CVD (British Heart Foundation, 2010).

Cardiac rehabilitation – European measures

Bases on the UK ASPIRE study, the rest of Europe soon followed this initiative and in 1995-6 the European counterpart survey known as “EUROASPIRE 1” was carried out in nine of the European countries, which included; Czech Republic, Finland, France, Germany, Hungary, Italy, the Netherland, Slovenia and Spain. This work was as result of the collaboration of three of the major societies within Europe; European society of cardiology (ESC), European Atherosclerosis Society (EAC) and the European society of Hypertension (ESH) (Euroaspire, 1997).

Since the establishment of this survey the advent of EUROASPIRE II has evolved including UK, Greece, Ireland and Poland totaling 15 countries. Participating centres within UK included ones in Hull (Castle Hill and Hull Royal Infirmary) and London (Charing Cross Hosp, Hammersmith Hosp, Central Middlesex Hosp and West Middlesex Hosp). This study in 1999-2000, showed the UK centres reported the following statistics on risk factor history on admission and measurements of risk factors seen in patients; Smoking 97%, hypertension 87.9%, hyperlipidemia 69.2%, diabetes 87.7 %, weight 71.4 %, height 47.7%, blood pressure 98%, total cholesterol 65.1 % HDL-cholesterol 22.6% and triglycerides at 48.7%. The reported lifestyle advice given to patients in the UK to reduce risks of CHD and to take part in CR were as follows; stop smoking 63.5%, lose weight 50.3% special dieting to reduce blood pressure 8.6%, special diet to reduce blood cholesterol 32.7%, exercise 34.3 % and cardiac rehabilitation recommendations 35.4% (Euroaspire, 2001).

CVD – UK principle targets for the future

To summarize the main targets remain in England, Wales Scotland and Northern Ireland:

England, to “reduce CHD in patients less than 75 years by at least 2/5 by 2010, saving 200,000 lives and to reduce inequality gaps in death rates for CHD, stroke and related diseases between the fifth of areas with worst health and deprivation indicators and overall population in people under 75 years by 40% in 2010 (British Heart Foundation, 2010).

Wales – “reduce CHD mortality rates in 65-74 year olds for every 600/100,000 in 2002 to 400 per 100,000 in 2012 and to improve CHD mortality in all socioeconomic groups simultaneously for a more rapid improvement in neglected areas (British Heart Foundation, 2010).

Scotland- the aim is to “reduce mortality rates form CHD patients under 75 years by 60% between 1995 and 2010 and to reduce death rate from CHD in those aged under 75 years located in the most deprived regions. Finally no targets for Northern Ireland (British Heart Foundation, 2010)


It is evident to suggest that UK policy over the years since the mid 1980’s have reflected in studies carried out suggesting the huge benefit of secondary prevention/cardiac rehabilitation in the long term care of patients with CHD. Financial investments from the Department of health alongside the British Heart Foundation over the past three decades had resulted in a decline in the mortality and morbidity of one of the leading causes of death worldwide. As the UK are integrated into the European standard of care, UK policy not only has the benefit of Cardiology Societies within the UK but also benefits from knowledge, information and data analysis’s across the rest of Europe with the aim to further improve patients quality of life. There has been encouraging steps, improvement and refinement seen in the form of the NSF and the QOF, not only in ensuring the reduction of mortality rates but also to maintain a fair socioeconomic climate treating all CHD patients across the UK to the best and most effective care available. This paper hopes to have highlighted a positive outlook, based on the abundant evidence of UK policy reflected in statistical data in its attempts to alleviate mortality and to improve, assist and enhance long-term prospects for patients suffering from CHD.

References (part b)

Aspire, (1996), A British and Cardiac Society survey of the potential for the secondary prevention of coronary disease: Action on secondary prevention through intervention to reduce events, Heart, vol. 75, pp 334-342

British Heart Foundation, 2010, Coronary heart Disease Statistics 2010 [accessed 10/01/2011]

Department of Health, 2000, Coronary heart disease: national service framework for coronary heart disease – modern standards and service models, [accessed 10/01/2011]

Department of Health, 2004, The NHS Improvement Plan: Putting people at the heart of public services [accessed 10/01/2011]

Euroaspire, (1997), A European Society of Cardiology survey of secondary prevention of coronary heart disease, European Heart Journal, vol. 75, pp. 334-42.

Euroaspire, (2001), Lifestyle and risk factor management and use of drug therapies in coronary heart patients from 15 countries. Principle results from EUROASPIRE II Euro Heart Survey Program, European Heart Journal, Vol. 22, pp. 554-572.

Fearnside E, Hall S, Sutcliffe J and Barrett, (1999), Current provision of cardiac rehabilitation in England and Wales. Coronary Health Care, vol. 3, pp.121-127

Giannuzzi P, Saner H, Bjornstad H, Fioetti P, Mendes M, Cohen-Solal A, Dugmore L, Hambrecht R, Hellemans I, McGee H, Perk J, Vanhees L and Veress G. (2003), Secondary prevention through cardiac rehabilitation. Position paper of the working group on cardiac rehabilitation and exercise physiology of the European Society of Cardiology. European Heart Journal, vol. 24, pp 1273-1278.

Gray AM, Bowman GS and Thompson D., (1997), The Cost of Cardiac Rehabilitation Services in England and Wales, Journal of the Royal College of Physicians, vol. 31 (1), pp. 57-61.

Guyton and Hall (2006), Textbook of Medical Physiology. Eleventh edition,

Khunti K, Stone M, Paul S, Baines J, Gisborne L, Farooqi A, Luan X and Squire I., (2007), Disease Management program for secondary prevention of coronary heart disease and heart failure in primary care: a cluster randomized control trial, Heart, vol. 93; pp 1398-1405.

Medline Plus, 2010, Coronary heart disease, [accessed 10/01/2011]

NHS, 2004, About the Quality and Outcomes Framework (QOF), [accessed 10/01/2011]

Mera, Steven L. (1997), Understanding disease, pathology and prevention.

World Health Organization, (1993), Needs and action priorities in cardiac rehabilitation and secondary prevention in patients with coronary heart disease, Copenhagen: WHO Regional Office for Europe

Vanhees L, Martens M, Beloka S, Stevens A, Aram A and Gaita D., (2000), Cardiovascular prevention and rehabilitation, vol. 1, Cardiac rehabilitation: Europe, pp 30-33

Free Essays

What Role do Unconscious Factors Play in the Experience of Organisational Life, and how can Workers’ Appreciation of these Factors Lead to better Outcomes for Users?

1. Introduction

The following essay considers the role that unconscious factors play in organisational life, and looks at the extent to which awareness of these factors amongst workers can improve outcomes for users. The idea is considered both in relation to appropriate literature and also in relation to my own experience of a social work organisation, the placement I experienced in a children’s home. The ways in which social work practice can be oppressive and anti-oppressive, and the impact of both of these for the user, are also explored. My interest in this area has been informed by my experience in a care home for children (Adeza) as a student social worker. I worked with a wide range of client groups including children (and their families) under stress, children (and their families with mental health problems, children at risk and children with physical and mental disabilities. I had a wide range of duties including administrative functions, advising clients and supporting children in a variety of ways. I became aware of the ways in which unconscious attitudes can impact upon the way clients and other staff are treated through a phenomenon I later learned was called projection, that is, the psychological mechanism whereby worries and fears about oneself are seen as present in other people, and demonised. For example, some clients had internalised a set of notions about being inadequate parents, which were then projected onto staff at the home, in a variety of ways.

2. The Notion of the Unconscious

Understanding human needs, wants and motivations is a central part not only of organizational theory but also of human psychology generally. Various theories have been proposed to explain the variety of behaviours which characterise human beings, for example behaviourism, which reduces the role of the ‘mental’ and looks at human actions in terms of stimulus and response (Baran and Davis 2011), and Weber’s idea of work as salvation (Nelson and Quick 2010). However, the notion of the unconscious has been widely influential, and derives from work by Freud in the late 19th and early 20th Century.The idea is situated in the wider set of notions developed by Freud called psychoanalysis.Central to Freud’s idea is the notion that “powerful unconscious drives, mostly sexual and aggressive… motivate human behaviour and put people in conflict with social reality” (Saiyadain 2003, p. 32).For Freud, the unconscious is that of which we are unaware, but which can manifest itself through thoughts and behaviours. He separated out three levels of consciousness:

The conscious (everything one is aware of)
The preconscious (things one is not aware of, but which could be brought to consciousness through effort of will)
The unconscious (that of which one is unaware, and which one is normally powerless to bring to conscious awareness)

The unconscious includes desires, buried memories, desires and needs. Individuals can be motivated by unconscious forces, which make themselves manifest through behaviour, thoughts, feelings and words. Freud believed therapeutic work could be done by uncovering these unconscious forces and making the individual aware of their deeper motivations through a process of psychoanalysis (McKenna 2000).

Freud suggested a number of ways in which the contents of the unconscious work to influence human behaviour. These include regression, repression, sublimation and projection. Regression is the phenomenon whereby people return to earlier behaviour patterns (for example a stutter), repression means the ways in which unpleasant emotions are blocked from conscious awareness, sublimation denotes the way in which impulses (perhaps aggressive) which are unacceptable to the conscious mind are channelled into another activity, for example devotion to work or sport, while projection means the mechanism whereby thoughts or feelings which are not acceptable to the conscious mind are attributed to someone else (finding them lazy, for example) (Saiyadain 2003).

Intuitively, and based on my experience in my placement, I feel that there is evidence for the existence of the unconscious. For example, I have seen adolescent children regress to an earlier stage, displaying bed wetting and thumb sucking for example, particularly at times of great stress. However, Freud’s ideas have been subject to an intense critique, particularly that there is a lack of empirical evidence for them (Hersen and Thomas 2006). Additionally, it has been pointed out that the idea of the unconscious lacks predictive power: although it can function as a good explanation of behaviour, it cannot indicate how people will behave in the future (Abbott 2001). I can see that these are valid criticisms: however, as the next sections show, I feel the concept of the unconscious and its mechanisms invaluable in understanding people better, which I feel is a necessary part of delivering the person-centred care that is a key part of social care in the 21st Century (Joseph Rowntree Foundation 2011).

3. The Unconscious and Organisational Life

As well as being widely influential (though much debated) in psychology generally, the concept of the unconscious and its mechanisms has been incorporated into theories of organisational life. The key element to the idea of the unconscious is the notion that “much of the rational and taken-for-granted reality of everyday life expresses preoccupations and concerns that lie beneath the reality of conscious awareness” (Morgan 1998, p. 186). It follows that organisational theories need to take account of the hidden dynamics which influence the workplace. In addition, it has been suggested that theorists of organisational behaviour have been influenced by unconscious forces such as repression. Morgan 1998, for example, suggests that Taylor’s model of ‘scientific’ and rational management might have been rooted in his puritan background with strong routines and work ethic. Morgan also suggests that the predominant bureaucracy of modern work places might be a function of repression. Worker’s reactions to these types of workplace will depend upon their own mechanisms of regression. In other workplaces, organisational culture can often by dominated by self-centred attempts at wrestling control from others, or the playing out of “a phallic-narcissistic ethos” (Morgan 1998, p. 192) within the workplace. Often, the workplace might reproduce the traditional patriarchal family, with a dominant style associated with ‘male’ qualities of aggression, ambition and rigid rules.

One unconscious mechanism which I was particularly aware of in my placement was projection.In this, workers deal with internal turmoil by attributing the key elements of what is bothering them to someone else rather than themselves. For example, in an organisation, poor results might be blamed by one group (managers) on ground-level staff, and vice-versa (Rashid 1983). Projection has been succinctly defined as the “attribution of one’s own attitudes and beliefs onto others” (Borkowski 2009, p. 56). In order to avoid feelings of guilt or excess anxiety, workers might see their co-workers as possessing the qualities they most dislike in themselves (Borkowski 2009). While it allows the person doing the projecting to protect their self-esteem, the mechanism whereby co-workers, for example, are blamed for putting a person in a bad mood, are damaging to organisational efficiency (Borkowski 2009). It can lead to stereotyping and, through this, to oppressive working methods. stereotyping is a way of organising experience by applying common traits to certain groups of people (the elderly, ethnic minorities, children). While it allows abstract thought to take place more easily, it can lead to the association of negative traits with particular groups. Projection seems to be at work in stereotyping, whereby a group is seen to possess negative characteristics not held by the person ascribing the characteristics. It has been shown that these mechanisms can lead to worse health and social care for certain groups seen as ‘the other’ (Borkowski 2009). One example is that people working with abused children can be marginalised and rendered invisible, as society as a whole does not want to admit that such abuse exists. Nurses are also often forced to bear the brunt of negative projections from service users and other professionals. In addition, social work in general often suffers, as its existence underlines the presence of vulnerable and needy people, mortality and other key issues. These all evoke deep and complex feelings in others, and workers in these professions often bear the weight of others negative expectations, “issues of dependency, aggression and sexuality” Yelloly and Henkel 1995, p. 195).

Within social work, it has been acknowledged that certain forms of practice can be oppressive, particularly to service users but also to other workers. Anti-oppressive practice works to overturn ways of working which marginalise, scapegoat and downplay the people who they work for, both on a personal and micro- level, and at a wider social level. While anti-oppressive practice covers a wide range of activities, becoming aware of the extent to which people are marginalised through unconscious mechanisms such as projection is one key part (Balloch and Hill 2007). Becoming aware of the extent to which negative characteristics are projected onto others, either individuals or groups, is a central step in moving away from oppression. Today, immigrant groups can find themselves scapegoated for the wider problems of society, for example, both by individuals and by political groups (Shulman 2008). Anti oppressive practice offers a way for projection, stereotyping and discrimination to be combated in the workplace, through an attitude of criticality and reflection upon situations in the workplace. The process of uncovering oppression can be likened to that of becoming aware of unconscious processes, as well as uncovering motivations which derive from unexamined unconscious attitudes and mechanisms (Heenan 2011).

4. Understanding the Unconscious and Improved User Outcomes

The ways in which the unconscious operates in the organisational context, the negative impact it can have, and the opportunities it presents for ultimately improving user outcomes is illustrated by my experience working in a children’s home.I have concentrated above on the phenomenon of projection, because this was the unconscious mechanism which most appeared to be in existence during my placement. One child with whom I worked, supporting to live independently after care, would frequently express the opinion that the women staff with whom she came into contact were ‘useless’, were over-emotional, and were not as effective as male staff. I used to find this frustrating, particularly as she was female herself, until I put her case into the context of her background. One of a family of girls, with whom her mother was unable to cope, she had internalised negative feelings about women, developed a androgenous, tomboy-ish appearance herself, and projected doubts and fears about herself onto female staff.

There are also discusses about two related unconscious mechanisms (first identified by Melanie Klein), splitting and projective identification, both of which I experienced during my placement.Splitting often occurs in groups, and refers to the process whereby a situation is polarised and seen as ‘black’ and ‘white’, that is, with ‘good’ and ‘bad’ elements. It happens when people are unable to tolerate ambiguity (Zachar 2000). I saw this in group discussions between staff, when one manager who took a fairly strict line to discipline and adherence to regulations was demonised by staff informally after meetings. I felt (perhaps because I was an outsider) that although she might have expressed her ideas better, there was a great deal of sound advice in what she said. However, others seemed unable to see this, preferring to make her a ‘scapegoat’ for everything they disliked about the experience of working in the care home. I also saw this situation improve when a higher manager called a meeting in which we discussed communication styles used within the home.I also saw projective identification, where people unconsciously identify with another person or group, with one staff member, who seemed to project feelings of her own vulnerability (she had just gone through a difficult divorce) onto the female white children in our care. Her attitude towards this gender / ethnic group was markedly different, she would spend extra time with them, and buy small presents. I was present when this was noted by another staff member, who carefully suggested her experience might be leading to her favouritism. She took this suggestion very well, and her behaviour, I noticed, became fairer afterwards.

5. Conclusion

There are some problems with the notion of the unconscious, particularly its lack of predictive power and lack of empirical evidence. However, in terms of my placement in a children’s care home, I have found it a useful way of understanding why people – both staff and clients – behave in the way they do. It also seems to offer a useful tool for moving towards an anti-oppressive practice. In my experience, if people are made aware of the ways in which unconscious mechanisms operate, they are better able to see their oppressive actions, better able to understand why they are acting as they do, and as a consequence able to change the way they behave in a way which is beneficial to clients.

6. References

Abbott, T (2001) Social and personality development Routledge, UK

Balloch, S and Hill, M J (2007) Care, community and citizenship: research and practice in a changing policy context, The Policy Press, Bristol.

Baran, S J and Davis, D K (2011) Mass Communication Theory: Foundations, Ferment, and Future (6th edn.), Cengage Learning, Belmont, CA

Borkowski, N (2009) Organizational behavior, theory, and design in health care, Jones & Bartlett Learning, USA

Foster, A and Roberts, V Z (1998) Managing mental health in the community: chaos and containment, Routledge, UK

Heenan, D (2011) Social Work in Northern Ireland: Conflict and Change, The Policy Press, Bristol.

Joseph Rowntree Foundation (2011) ‘Transforming social care: sustaining person-centred support’, Joseph Rowntree Foundation, UK

McKenna, E F (2000) Business psychology and organisational behaviour (3rd edn.), Psychology Press, UK

Morgan, G (1998) Images of organization, Berrett-Koehler Publishers, California CA.

Nelson, D L and Campbell, J (2010) Organizational Behavior: Science, the Real World, and You (7th edn.), Cengage Learning, Belmont, CA.

Rashid, S A (1983) Organizational Behaviour, Taylor & Francis, UK

Saiyadain, M S (2003) Organisational Behaviour,m Tata McGraw-Hill Education, India.

Shulman, L (2008) The Skills of Helping Individuals, Families, Groups, and Communities (6th edn.), Cengage Learning, Belmont, CA.

Thomas, J C (2006) Personality and everyday functioning, John Wiley and Sons, Hoboken, NJ.

Yelloly, M and Henkel, M (1995) Learning and teaching in social work: towards reflective practice (2nd edn.), Jessica Kingsley Publishers, UK

Zachar, P (2000) Psychological Concepts and Biological Psychiatry: A Philosophical Analysis, John Benjamins Publishing Company, USA

Free Essays

Health and illness in later life, inequalities – gender, ethnicity and end of life


This Qualitative report outlines two interviewees later year’s experiences from two different cultural and ethnic backgrounds with the aim of examining the importance they attribute to their health status. A body of research reveal that there exist wide health inequalities between certain groups in the developed countries (Devaux & de Looper, 2012; U.S. Department of Health and Human Services, 2007 ; Van Doorslaer et al., 2003). These groups defining characteristics in include, ethnic, gender, age as well as economic status. Nonetheless, with all this definition of affected constituents by health inequality, the out come is a country where disadvantaged perish at the expense of the advantaged. This report takes a closer look at the intricacies involved with such classifications and the core issues leading to the rise in such deplorable conditions. It is in the light of these occurrences that this report aims at investigating health inequalities and health promotion taking into account gender, ethnicity and socio-economic as well as ageism and racism factors.


The information collected for this study was from two interviews. The first one was with Ms B is a 69 year old woman. The interview took place in the front room of her home. The second interview was with Ms A is a 64 years old Black African woman; the Interview took place in her home.

The subjects were referred to as Ms A and B for confidential purposes; their real names were not used, but every other detail is as was during the interview. Prior to the interviews, the interviewees had to sign consent forms issued by the institution the interviewer is affiliated. The consent form is made available by the faculty under which the interviewer belongs and is mainly a legally binding document to ensure confidentiality of the contents of the interview.

The two first interviews were with elderly women and because of the generational gap; they were both handled with the utmost respect. However, there are instances that Ms A was referred to as ma’am because of her cultural background as a show of humility and respect.


A close examination of Ms A and Ms B interview reveal information relevant to the aims and objectives of this study. First, Ms B has a GP, who is 8 minutes walk from her residence and has been useful for medical issues such as surgery and other medical advice (12) while Ms A claims she does not need a GP. Ms A believes that her spirituality is an alternative to the help she can get from a GP (8) and does not even remember the last time she visited a GP(9). Ms B has a male Doctor (66) and has been with him for a long time. She claims that he is elder-ish and avoids women issue by referring to her to other female consultants (69). Despite having received several invitations, Ms A has never consulted a GP and claims she is fine (12). She does not remember the last time she visited a GP for any medical issue or advice (15). On the other hand, Ms B claims she has received much information from her local GP; there was a time she had trouble emptying her bowel freely (20) and she sort for advice from her GP, who asked her to take plenty of fruits and vegetables (21). She gets helpful information on other medical conditions freely such as Flu and Diabetes from pamphlets (24) as well as the nurse (25). Ms B receives helpful information from her doctor, such as, where to purchase blood pressure kits and how best to use it(27).

Both Ms A and B are very active and have plenty of activities to do around their houses. Ms B spends much of her time around the house re-arranging her kitchen cupboard (32). She cooks (39), prepares her skirting board and also spends time relaxing, watching TV while eating her lamb chops (40). Ms A also finds time to arrange her things though she does not seem to devote most of her time in household work as compared to her ministry, she is still yet to arrange the things that she move in with since she was re-housed in October(19). Ms A is very busy with ministry work and does not sit to rest (26). Ms B gets good nutritional advice from her GP and eats right, Weetabix and dry raisins for breakfast (47) and a cup of tea and crackers for lunch with 2 fruits (48). For dinner, she prefers lamb chops, broad beans and carrots (50). Ms B, on the other hand, claims she is a light eater with her diet consisting of predominantly fruits (30). She also goes sometimes without food during her fasting periods (31).

Ms B enjoys quality time with her children and grand children often (52); she also picks up her granddaughter from school (53). Ms A finds pleasure in God, her family both biological and spiritual (33). She is a spiritual person and delights in serving and worshiping all the time (36). Ms B finds time in her schedule to go shopping (56) when it’s quiet (57) and avoids shopping on Saturdays (58). In addition, she still drives, but does not do long distance (60), she only drives to the supermarket, and when there is no traffic (62), she avoids using the road because it is tiring and keeps her away from reckless drivers (63). Compared to Ms A, Ms B enjoys meeting people as part of her ministry than shopping (39) and uses public transportation, as opposed to private means (42). She enjoys bus rides regardless of whether it is school rush hour or not (45).

Ms B has friends she spends time with from time to time, they go shopping have snacks together (72). She also has a good neighbour at the end of the street that she spends time with visiting a local Nursing home (74). Ms B’s friends are good companions (80) they talk about family and engage in other activities such as making tea (82). She does not engage in community activities (85) as she used to in 2008(86). Ms A, on the other hand, socializes with everyone she meets in the course of her ministry (51); however she claims that her social life is in the church where she does volunteer work (52). She gets spiritual support from her ministry (55) and many refer to her as mummy (56). Unlike Ms A, she engages in community activities such as the Easter love fest (59) where she brings drinks and snacks and distributes leaflets to neighbours (60).


Woodwarda and Kawachib (2000), reiterate a well known fact that health inequalities are socially, culturally and economically instigated. This paper aims at exposing evidence in health inequalities and the need for health promotion, as well as highlight gender,, ethnicity and socio-economic factors, Ageism and racism in the healthcare sector.

Adequate access to healthcare has been cited as a key factor determining a country’s commitment to reducing health inequalities and promotion. Devaux and de Looper (2012), explain that the need for General Practitioners can be analysed using variables such as age, gender and health status. In the current study, Ms B has a General Practitioner, who is 8 minutes walk from her residence, while, on the other hand Ms, A sees no need for one. Devaux and de Looper (2012) reveal in their study that people who are financially stable are more likely to visit a GP than those in the lower income level. Ms B in the interview is presented as more stable than Ms A financially. Ms B has time for shopping, cafes with friends, and she can also afford a healthy meal at the end of the day. She even has access to private transportation. Compared to Ms A, who is housed by the council (Shelter, 2013). Van Doorslaer et al. (2003) assert that income related health inequalities are persistent in Europe regardless of the fact that many countries have established easy access to physician services. They further posit that there is unequal opportunity in accessing health services across income groups. Ms A seems to be in the lower income category and much marginalized in regard to access to health services. This is a common trend in most developed economies especially in North America and Europe. In an examination of such inequalities, in self reported health and their impact on individual risk factors in the United States and Canada, McGrail et al.(2009), found that income distribution was responsible for more than 50 percent of income-related health inequalities. The same can be said of the United Kingdom where life expectancy is as high as in both the USA and Canada as a result of great preventive measures against killer diseases, yet the ubiquity of health inequality is constant (Graham & Kelly, 2004). They reveal that while the health of the general population seems to improve, those in the lower income bracket are far from this reality, and this has been a point of challenge to policy makers.

In addition, gender is one of the key causes of health inequalities.Ostrowska (2012), explains that notable differences between male and female health status is a common topic and has become a subject of increasing interest of researchers. According to them, researchers have recorded these differences in a bid to understand them within a bio-medical framework. Health inequalities in regard to gender divergence are indicative of the differences in social roles and status engraved in culturally created perception of femininity and masculinity. It is most likely that Ms A has continually ignored invitations to GP because of cost. It is most likely possible that she could be fine now, but the future is uncertain and more so in regard to her age. Health insurance coverage has become one of the key issues as far as women access to healthcare is concern. According to Kaiser Family Foundation (2013), health insurance coverage is a motivational factor for women and is effective in improving their health status by enabling access to preventive, primary, as well as, speciality healthcare. This could represent the case with Ms A, with medical cover; she would most likely at least visit her GP for a check up.

Racism has been one of the key issues associated with health inequality. Generally, it is said that Native and African American, as well as Pacific Islanders, have a shorter lifespan and dismal health outcomes including high infant mortality rates, diabetes, HIV/AIDS, stroke, deteriorating life expectancy compared to their white and Asian American counterparts (U.S. Department of Health and Human Services, 2007). The United Kingdom is also faced with this challenge as explains Nazroo (2003 ), who posit that there is high health inequality across ethnic groups in the US and UK, and this has been documented. Woolf et al.(2004), in reference to a study by Dr. David Satcher and Dr. Adelwale Troutman, close to 900, 000 of the deaths of African Americans would have been prevented if their health matched that of their white counterparts. Racial identity is not pathogenic, but is a social issue in many countries that are the basis of profiling. While it is true that not all people from these minority groups both in the US and UK are poor, most of them are and according to Smedley et al. (2003), health follows a pattern that the more the wealth, the better the health. Most of them work in jobs that are in the lower status and are also less educated than their white counterparts. This is a key reason why this population is persistent in the lower socio-economic strata compared to the other ethnic groups. Ms A is a black woman who is more concern with her spiritual condition than her health condition. She seems not to take cognizance of the fact that one she might need medical attention given her age, “health by choice.” Nonetheless, this could be none of her fault, as an African American, she is disadvantaged, she might not be able to afford the cost or even fail to take on appropriate medical cover (Nazroo, 2003 ). It has been noted in Britain that immediate action is needed to reform the pension plans to match in regard to the disparity between the rich and the poor, a state that could lead to thousands of poor people dying before they reach retirement (Copper, 2013).

Just as the ethnic minorities in the developed countries, the older generation is currently one of the constituencies with rising health challenges. It is a population that is experiencing health inequalities (Grundy & Sloggett, 2003 ). In England alone, there are 10 million people aged 65 and over (Thorpe, 2011). In this population, most of the are either sick or with some disability, thy account for 60 percent of hospital admissions (Thorpe, 2011). Grundy and Sloggett (2003 ), in their research used information from three rounds of the English Health Survey to understand the variations in wellbeing of those aged between 65-84 years. In their study, they used indicators based on self reports and data collected by a medical practitioner. The study revealed that socio-economic indicator and most prominent, income, was related to the increasing odds of diminishing health outcomes (Grundy & Sloggett, 2003 ). Ms B in the current study has already started experiencing the effects of aging and conscious of what is expected of her. She is 69 years and seeks regular medical advice from her GP and takes every precaution in order to live a healthy and rewarding life. Ms A, on the other hand, is 5 years younger than Ms B, she might not feel the impact of age on her, but as seen in the above paragraphs, she is bound to feel some of these effects, it is just a matter of time (Grundy & Sloggett, 2003 ).

The examination of gender, ethnicity, socio-economic, as well as ageism and racism variables as factors associated with health inequalities,, it is important also to consider the promotional aspect. Health promotion empowers people to consider and sustain healthy lifestyles thereby becoming better health managers (Family Health Teams, 2006). There needs to be promotion strategies that when implemented uses structural solutions that support change in behaviour. One of the areas needing work is for governments to focus on closing narrowing of the gap between the rich and the poor. However, it is not just the closing of the gap, but making available services that would positively impact the poor. Such remedies include; empowering and mobilizing the people to resort to healthier choices, such as making available healthy food for the masses (Shircore, 2009). In addition, the vulnerable populations need to be supported to change their behaviour, Shircore (2009), explain an important point that both physical and mental health are integral parts of quality of life and that evidence is clear that a healthy diets are beneficial to the both.

On the other hand, poor housing coupled with poor income adversely affect physical and mental health. In this regard, the need for effective social marketing is imperative in achieving the desired change with both the public and with decision-makers. To achieve this, one of the most effective ways as seen in the current study is to involve the GP in health promotion strategies (Family Health Teams, 2006). Ms B compared to Ms A had been receiving critically needed useful medical procedures because of her awareness of her health status. While Ms A, claimed, she did not need a GP and did not even remember the last time she visited a GP (9). Ms B had a Doctor (66) and had been with him for a long time. On the other hand, Ms B claims she has received much information from her local GP; there was a time she had trouble emptying her bowel freely (20) and she sort for advice from her GP, who asked her to take plenty of fruits and vegetables (21). She gets helpful information on other medical conditions freely such as Flu and Diabetes from pamphlets (24) as well as the nurse (25). Ms B receives helpful information from her doctor, such as where to purchase blood pressure kits and how to use of it in checking her blood pressure (27). The focus on patient education, counselling and support is an important health promotion strategy and should be given to every vulnerable person in the categories examined in this study.

Conclusion and recommendation

As explained by Ms A and Ms B’s economic and health conditions, there are wide disparities between minority groups and dominant populations, more so in developed countries. As an African woman, Ms A was oblivious to the fact that she would need medical at one point in life; such is the attitude that some people in minority groups face life. Nonetheless, there are others who regardless of what they know, are restricted by their economic state. As a matter of fact the common denominator across all this classification whether ethnic, gender, age, is economic stability or sustainability. It is the responsibility of the government and the entire stakeholder to ensure that necessary steps are taken to provide for the needs of these vulnerable groups so as to reduce the effects of such health inequalities. As seen above, certain subsidies can be given to the vulnerable groups to mitigate the effects of health inequalities as discussed.

The current study used two case studies to explain several variables. Further research is needed to zero in on specific details as it fails to do justice to all the variables presented, for depth and breadth of the issues investigated, the case studies fail to examine fully within the real-life context all the variables presented. On the gender issue, it would have been helpful if one of the interviewees was a male or in that case have more than two interviewees, the third of a different gender.


Copper, C., 2013. Britain’s poor ‘will die before they retire’ if pension reforms aren’t matched by health improvements. The Independent , 06 December.

Devaux, M. & de Looper, M., 2012. Income-Related Inequalities in Health Service Utilisation in 19 OECD Countries, 2008-2009”. OECD Health Working Papers.

Family Health Teams, 2006. Guide to Health Promotion and Disease Prevention. [Online] Ministry of Health Available at: HYPERLINK “” [Accessed 10 December 2013].

Graham, H. & Kelly, M.P., 2004. Health inequalities: concepts,frameworks and policy. [Online] Health Development Agency Available at: HYPERLINK “” [Accessed 10 December 2013].

Grundy, E. & Sloggett, A., 2003. Health inequalities in the older population: the role of personal capital, social resources and socio-economic. Social Science Med, 56(5), pp.935-47.

Kaiser Family Foundation, 2013. Women’s Health Insurance Coverage. [Online] Kaiser Family Foundation Available at: HYPERLINK “” l “footnote-89006-14” [Accessed 10 December 2013].

McGrail, K.M., Van Doorslaer, E., Ross, N.A. & Sanmartin, C., 2009. Income-Related Health Inequalities in Canada and the United States: A Decomposition Analysis. American Journal of Public Health, 99(10), pp.1856–63.

Nazroo, J.Y., 2003. The Structuring of Ethnic Inequalities in Health: Economic Position, Racial Discrimination, and Racism. American Journal of Public Health, 93(2), pp.277–84.

Ostrowska, A., 2012. Health inequalities–gender perspective. Przegl Lek., 69(2), pp.61-6.

Shelter, 2013. Who gets priority for council housing. [Online] Available at: HYPERLINK “” [Accessed 10 December 2013].

Shircore, R., 2009. Guide for World Class Commissioners Promoting Health and Well-Being: Reducing Inequalities. London: RSPH RSPH.

Smedley, B., Jeffries, M., Adelman, L. & Cheng, J., 2003. Race, Racial Inequality and Health Inequities: Separating Myth from Fact. [Online] Available at: HYPERLINK “” [Accessed 10 December 2013].

Thorpe, T., 2011. Healthy Lives, Healthy People: Our strategy for public health in England. [Online] Available at: HYPERLINK “” [Accessed 10 December 2013].

U.S. Department of Health and Human Services, 2007. Health Inequalities. [Online] Available at: HYPERLINK “” [Accessed 10 December 2013].

Va Doorslaer, E., Koolman, X. & Jones, A.M., 2003. Explaining income-related inequalities in doctor utilisation in Europe:a decomposition approach. [Online] Available at: HYPERLINK “” [Accessed 10 December 2013].

Woodwarda, A. & Kawachib, I., 2000. Why reduce health inequalitiesJournal of Epidemiol Community Health, 54, pp.923-929.

Woolf, S.H. et al., 2004. The health impact of resolving racial disparities: An analysis of US mortality data. American Journal of Public Health, 94(12), pp.2078-81.

Free Essays

Stress level among nurses that work in ER department in Nigeria and their work life balance.


It is undeniable that stress within the nursing profession has become increasingly concerning over the years, which is why is it is imperative to understand the effects this can have upon nurses. Accordingly, stress not only affects nurses mentally but it can also have an effect upon their performance and the care they provide to patients. This is a serious matter and unless stress is dealt with effectively, the nursing profession will be in a state of discontent. The burnout syndrome is widespread amongst Nigerian nurses; though the stress levels amongst Nigerian nurses working within emergency departments is evidently more prevalent than the stress levels of other departments. This signifies the importance of tackling stress by documenting the causes and extent of stress, in order for successful interventions to take place.

Proposed Plan of Work

It is vital that all nurses have a work-life balance in order to ensure that stress levels are significantly reduced. Yet it is very difficult to achieve this in practice and nurses are often being subjected to the burnout syndrome, which results from the chronic exposure to work-related stresses. Thus, burnout is defined as “a state of continual physical and mental exhaustion” (Simmons, 2012, p. 25), which leads to a disconnection from both work and home life. This can have serious consequences if not dealt with effectively, which is why more needs to be done to tackle workplace stresses. This is especially the case when it comes to emergency departments since nurses are under a lot more pressure in the job and are subjected to greater physical demands than other departments. Consequently, it is believed that “emergency departments should be screened regularly on job and organisational characteristics to identify determinants of stress-health outcomes that can be the target of preventive interventions” (Adriaenssens, 2011, p. 1). Essentially, it is therefore important that the stress level among nurses that work in Emergency departments in Nigeria are reduced and that a work-life balance is being attained by all nurses.

Research Aims and Objectives

The aims and objectives of this research are to determine the stress levels amongst Nigerian nurses in order to determine whether they are receiving a work-life balance. This will enable a determination to be made as to whether interventions are needed to reduce the stress levels and whether Nigerian nurses working in emergency departments are more prone to stress than those working in other departments. Consideration as to how these nurses cope with stress will also be established, followed by an assessment as to what improvements need to be made in order to prevent nurse shortage ensuing within the emergency department.

Research Questions

Is stress prevalent amongst nurses in general?

What are the levels of stress nurses within emergency departments subjected to and how does this compare with other departments?

Are nurses working within emergency departments in Nigeria more likely to suffer from stress than those working in other departments?

How do nurses cope with stress?

What is nurse burnout?

How serious is nurse burnout and in what ways can it be tackled?

Are poor working conditions one of the main factors causing stress?

Do Nigerian nurses working in emergency departments have a work-life balance?

What interventions are needed to reduce the stress levels of Nigerian nurses?

Is stress likely to result in nurse shortage?


The underlying objective of this study is to determine the effect stress has upon nurses in Nigerian emergency departments and to consider present stress levels, whilst also analysing the work-life balance of these nurses.

H1. Stress levels amongst Nigerian nurses are increased in emergency departments.

H2. Nurse burnout is one of the main causes of stress.

H3. Poor working conditions ultimately lead to stress.

H4. Stress is likely to result in nurse shortage.

H5. Nurses within emergency departments are subjected to higher levels of stress than nurses working in other departments.

H6. It is important that stress amongst nurses is being sufficiently tackled.

H7. Improvements to the working conditions of nurses would allow a work-life balance to be achieved.

Key Words

Nigerian Nurses

Stress Levels


Nigerian Emergency Departments

Working Conditions

Work-Life Balance




A quantitative research approach will be utilised for this assignment in order to develop theories and hypotheses pertinent to the observations being made about the stress levels of Nigerian nurses working in emergency departments. Measurement is one of the main aspects of quantitative research and for this reason it is important that definitive comparisons between empirical observation and mathematical expression of quantitative connections are made throughout this study. Data collected under this type of research consists of any data in numerical form such as statistics. Furthermore, quantitative data will also be collected from the use of questionnaires by asking participants various questions that are relevant to the hypothesis. Numerical data will then be collected and statistically analysed to answer the question using the data received. It is hoped that the data collected will help to determine the correlation between stress and health in nurses that work in emergency departments, whilst also considering how nurses cope with their personal life and the effects stress has on their work-life balance. The data that is to be analysed will be collected from applicable text books, journal articles, online databases and governmental reports. These will consist of both primary and secondary resources which will ensure that a deeper understanding of the subject matter can be acquired, whilst also obtaining an overall assessment of the stress levels amongst Nigerian nurses in emergency departments. An objective and subjective approach will be employed in doing so, as this will ensure that divergent viewpoints are incorporated into the study which will enable a critical evaluation to be made. The collection of immediate data will thus allow a proper assessment to be made as to the impact stress has upon nurses and an overview as to what changes ought to be made will be provided. The secondary data will enable the current phenomena surrounding the stress levels of Nigerian nurses to be analysed which will allow the requirements of the study to be satisfied. Although secondary data is considered to be less reliable than primary data, it is important that the study includes existing observations of the hypotheses.


Since it would be unrealistic to study every nurse working within an emergency department in Nigeria, it is essential that only a pool of participants is selected. Furthermore, whilst it must be ensured that this pool is small, because of the impracticalities that would arise from studying a large pool, it is important that the amount of nurses studied is sufficient enough for the research question to be answered appropriately. Accordingly, approximately 100 voluntary participants will be used for this study and will consist of nurses from a specialist governmental hospital in Nigeria namely; Gwagwalada clinic and maternity in Abuja. In considering whether this sample size is appropriate, a power and sample size estimation will need to be undertaken. Therefore, it will need to be assessed whether “there is the possibility of harmful effects from participating in the study” (Taylor and Kermode, 2006, p. 207). Consequently, it will need to be shown that the study will achieve the desired outcome (power) and that the number of people participating will help to achieve this (sample size). In addition, the data being collected must be measurable on the same scale and the sample size must not be too high. This is because, unnecessary time and expense would otherwise be utilised which would be detrimental to the study overall. Here, the power and sample size estimation has been satisfied since the data is of the same scale and measurement and the sample size does appear reasonable.


A questionnaire will be used for this study in order to determine the personal effects in which stress has upon the participants. In doing so, the Hospital Anxiety & Depression Scale (HADS) will be utilised so that the levels of anxiety and depression can easily be determined. The HADS was originally developed by Zigmond and Snaith (1983, pp. 361-370) and has been considered an effective way of measuring health (McDowell, 2006, p. 297) by looking at items on the questionnaire that relate to anxiety and depression. Once each item has been identified a score of 0-3 will then be given, which will allow a decision to be made as to the level of anxiety and depression that is prevalent amongst these nurses. The use of questionnaires is highly beneficial to this study as the impact in which stress has upon individual nurses in Nigeria will be more easily determined. In addition, the information that is gathered will be more applicable to the study and will help to address the concerns raised in the studies aims and objectives. Furthermore, the answers received will also be relevant to the hypotheses and a detailed account of the existing stress levels amongst nurses will be provided.


Steps to be taken in the research process;

Step 1: Determine the purpose of the research and identify the problem

Step 2: Determine who the research project is aimed and review current literature surrounding the issue

Step 3: Consider the requirements of the study and any limitations

Step 4: Investigate the topic by gathering relevant information to be analysed

Step 5: Consider what elements of the topic are the most important to the study

Step 6: Define the population that is to be studied

Step 7: Develop a data plan

Step 8: Collect the applicable data

Step 9: Analyse the data that has been collected

Step 10: Compare the data collected with existing data in order to determine whether hypotheses has been answered

Literature Review Summary

Nurses generally deal with life threatening conditions in all emergency departments and so are often faced with medical dilemmas which need to be dealt with immediately. Consequently, it is thus unsurprising that the working conditions can become rather strenuous, which ultimately leads to nurse burnout (Masters, 2009, p. 320). As a result of this, it is vital that various measures are implemented in all emergency departments so that the stress levels of nurses can be reduced. This will prevent nurse burnout from taking place and a work-life balance will be more easily ascertained. Whilst nurses are trained to deal with the difficulties they may face, it is important that the health and safety of nurses is also being given due consideration because “chronic stress takes a toll when there are additional stress factors like home stress, conflict at work, inadequate staffing, poor teamwork and poor supervision” (Kane, 2009, p. 28). Therefore, in order to avoid nurse burnout, it is necessary that all of these factors are avoided from the outset, since this would otherwise lead to inadequate care being provided to patients. Hence, it is therefore imperative that nurses have a work-life balance since this guarantees optimum performance (Nursing Times, 2011, p. 1). In order for a work–life balance to be achieved, it is important to firstly identify the causes of stress. This will allow effective changes to be implemented, which will help to avoid nurse burnout from being instigated in the first place.

Unless the problems surrounding stress are acknowledged by emergency departments, it will not be tackled effectively. Emergency departments within underdeveloped countries, such as Nigeria, do appear to have greater stress levels than those within developed countries. This illustrates how a lack of resources will ultimately lead to inadequate conditions for nurses and as put by (Lasebikan and Oyetunde, 2012, pp. 1-2); “A growing recognition of job stress leading to dissatisfaction among registered nurses in Nigerian hospitals has contributed to current problems with recruitment and retention of nurses.” In accordance with this, it is likely that stress within emergency departments will result in nurse shortages. This is because; nurses will not want to be subjected to stressful conditions, which is why the causes of stress need to be dealt with efficiently. Despite the awareness surrounding these issues, it is clear that nurse burnout does commonly occur throughout Nigerian hospitals. As absurd as this may seem, it is evident that stress is being insufficiently dealt with. Consequently, various measures therefore need to be implemented in order to reduce the levels of stress that occur within Nigerian emergency departments, yet it remains to be seen what measures will in fact be implemented.


Overall, it is evident that stress levels are prevalent amongst nurses within Nigerian emergency departments, which is largely due to the added pressure that nurses within these departments are being subjected to. Regardless of this, it seems as though stress can in fact be reduced provided that the problems associated with stress are properly dealt with. Whether this will ever be attained is questionable since it seems as though there has been an awareness of this problem for some time, yet Nigerian hospitals have still failed to implement adequate measures dealing with nurse burnout. Essentially, it is important that something is done to reduce the stress that currently persists as this may ultimately lead to nurse shortages within emergency departments. This would substantially affect the care that is currently provided to Nigerians and the emergency departments would be significantly affected as a result.

Data Analysis

Subsequent to all of the relevant data being collected, it will then need to be analysed so that a determination can be made as to whether stress levels within Nigerian emergency departments are high. In doing so, however, the data will first need to be cleaned through the inspection of each source so that a decision can be made as to whether the data should be used for the study: “the quality of the research should be judged in relation to the resources available and the effectiveness with which those resources have been used to investigate the particular topic in question” (Denscombe, 2009, p. 53). Once a thorough investigation of the collected data has been made, it can then be determined what data is most applicable to this particular study.


There are a number of ethical issues that will need to be addressed when undertaking this study since the fundamental issues surrounding this topic are extremely sensitive. As such, it is necessary to ensure that the confidentiality and anonymity of the participants of the study are maintained and that permission to use the data collected is first obtained (Dawson, 2009, p. 150). The ethical rules of conduct will also need to be conformed to, which means that any data collected must be used in a way that is “honest, unbiased, sincere, free from errors or negligence, open to critique and it must protect confidential communications” (Rensik, 2011, p. 1). This can be achieved by adopting a risk-analysis approach and by conforming to the BPS guidelines. A letter of introduction and an ethics checklist will also be completed and provided to the hospital in order to gain their consent to carry out the research.


Adriaenssens, J. (2011) A&E Staff Need Regular Stress Screening, Nursing Times, [Online] Available: [13 January 2013].

Dawson, C. (2009) Introduction to Research Methods: A Practical Guide for Anyone Undertaking a Research Project, How to Books Ltd, 4th Edition.

Denscombe, M. (2009) Ground Rules for Social Research: Guidelines for Good Practice. 2nd edn. McGraw-Hill International.

Kane, P. P. (2009) Stress Causing Psychosomatic Illness Among Nurses, Indian Journal of Occupational Environment Medicine, vol. 13, no. 1.

Lasebikan, V. O. and Oyetunde, M. O. (2012) Burnout among Nurses in a Nigerian General Hospital: Prevalence and Associated Factors, US National Library of Medicine National Institutes of Health, [Online] Available: [14 January 2013].

Masters, K. (2009) Role Development in Professional Nursing Practice, Jones & Bartlett Publishers, 2nd Edition.

McDowell, I. (2006) Measuring Health: A Guide to Rating Scales and Questionnaires, Oxford University Press.

Nursing Times. (2011) How’s Your Work-Life Balance[Online] Available: [14 January 2013].

Resnik, D. B. (2011) What is Ethics in Research and Why is it Important?’ [Online] Available: [14 January 2013].

Simmons, S. (2012) Striving for Work-Life Balance, American Journal of Nursing, vol. 112, no. 1.

Taylor, B. and Kermode, S. (2006) Nursing Research 3e, Cengage Learning in Australia, 3rd Edition.

Zigmond, A. S. and Snaith, R. P. (1983) The Hospital Anxiety and Depression Scale, Acta Psychiatrica Scandinavica, vol. 67, no. 6.

Free Essays

Streams of Silver 3. Night Life

The Cutlass grew busier as the night wore on. Merchant sailors crowded in from their ships and the locals were quick into position to feed upon them. Regis and Wulfgar remained at the side table, the barbarian wide-eyed with curiosity at the sights around him, and the halfling intent on cautious observation.

Regis recognized trouble in the form of a woman sauntering toward them. Not a young woman, and with the haggard appearance all too familiar on the dockside, but her gown, quite revealing in every place that a lady’s gown should not be, hid all her physical flaws behind a barrage of suggestions. The look on Wulfgar’s face, his chin nearly level with the table, Regis thought, confirmed the halfling’s fears.

“Well met, big man,” the woman purred, slipping comfortably into the chair next to the barbarian.

Wulfgar looked at Regis and nearly laughed out loud in disbelief and embarrassment.

“You are not from Luskan,” the woman went on. “Nor do you bear the appearance of any merchants now docked in port. Where are you from?”

“The north,” Wulfgar stammered. “The dale…Icewind.”

Regis hadn’t seen such boldness in a woman since his years in Calimport, and he felt that he should intervene. There was something wicked about such women, a perversion of pleasure that was too extraordinary. Forbidden fruit made easy. Regis suddenly found himself homesick for Calimport. Wulfgar would be no match for the wiles of this creature.

“We are poor travelers,” Regis explained, emphasizing the “poor” in an effort to protect his friend. “Not a coin left, but with many miles to go.”

Wulfgar looked curiously at his companion, not quite understanding the motive behind the lie.

The woman scrutinized Wulfgar once again and smacked her lips. “A pity,” she groaned, and then asked Regis, “Not a coin?”

Regis shrugged helplessly.

“A pity it is,” the woman repeated, and she rose to leave.

Wulfgar’s face blushed a deep red as he began to comprehend the true motives behind the meeting.

Something stirred in Regis, as well. A longing for the old days, running in Calimport’s bowery, tugged at his heart beyond his strength to resist. As the woman started past him, he grabbed her elbow. “Not a coin,” he explained to her inquiring face, “but this.” He pulled the ruby pendant out from under his coat and set it dangling at the end of its chain. The sparkles caught the woman’s greedy eye at once and the magical gemstone sucked her into its hypnotic entrancement. She sat down again, this time in the chair closest to Regis, her eyes never leaving the depths of the wondrous, spinning ruby.

Only confusion prevented Wulfgar from erupting in outrage at the betrayal, the blur of thoughts and emotions in his mind showing themselves as no more than a blank stare.

Regis caught the barbarian’s look, but shrugged it away with his typical penchant for dismissing negative emotions, such as guilt. Let the morrow’s dawn expose his ploy for what it was; the conclusion did not diminish his ability to enjoy this night. “Luskan’s night bears a chill wind,” he said to the woman.

She put a hand on his arm. “We’ll find you a warm bed, have no fear.”

The halfling’s smile nearly took in his ears.

Wulfgar had to catch himself from falling off of his chair.

* * *

Bruenor regained his composure quickly, not wanting to insult Whisper, or to let her know that his surprise in finding a woman gave her a bit of an advantage over him. She knew the truth, though, and her smile left Bruenor even more flustered. Selling information in a setting as dangerous as Luskan’s dockside meant a constant dealing with murderers and thieves, and even within the structure of an intricate support network it was a job that demanded a hardened hide. Few who sought Whisper’s services could hide their obvious surprise at finding a young and alluring woman practising such a trade.

Bruenor’s respect for the informant did not diminish, though, despite his surprise, for the reputation Whisper had earned had come to him across hundreds of miles. She was still alive, and that fact alone told the dwarf that she was formidable.

Drizzt was considerably less taken aback by the discovery. In the dark cities of the drow elves, females normally held higher stations than males, and were often more deadly. Drizzt understood the advantage Whisper carried over male clients who tended to underestimate her in the male-dominated societies of the dangerous northland.

Anxious to get this business finished and get back on the road, the dwarf came straight to the purpose of the meeting. “I be needing a map,” he said, “and been told that yerself was the one to get it.”

“I possess many maps,” the woman replied coolly.

“One of the north,” Bruenor explained. “From the sea to the desert, and rightly naming the places in the ways o’ what races live there!”

Whisper nodded. “The price shall be high, good dwarf,” she said, her eyes glinting at the mere notion of gold.

Bruenor tossed her a small pouch of gems. “This should pay for yer trouble,” he growled, never pleased to be relieved of money.

Whisper emptied the contents into her hand and scrutinized the rough stones. She nodded as she slipped them back into the pouch, aware of their considerable value.

“Hold!” Bruenor squawked as she began to tie the pouch to her belt. “Ye’ll be taking none o’ me stones till I be seeing the map!”

“Of course,” the woman replied with a disarming smile. “Wait here. I shall return in a short while with the map you desire.” She tossed the pouch back to Bruenor and spun about suddenly, her cloak snapping up and carrying a gust of the fog with it. In the flurry, there came a sudden flash, and the woman was gone.

Bruenor jumped back and grabbed at his axe handle. “What sorcerous treachery is this?” he cried.

Drizzt, unimpressed, put a hand on the dwarf’s shoulder. “Calm, mighty dwarf,” he said. “A minor trick and no more, masking her escape in the fog and the flash.” He pointed toward a small pile of boards. “Into that sewer drain.”

Bruenor followed the line of the drow’s arm and relaxed. The lip of an open hole was barely visible, its grate leaning against the warehouse wall a few feet farther down the alley.

“Ye know these kind better than meself, elf,” the dwarf stated, flustered at his lack of experience in handling the rogues of a city street. “Does she mean to bargain fair, or do we sit here, set up for her thievin’ dogs to plunder?”

“No to both,” answered Drizzt. “Whisper would not be alive if she collared clients for thieves. But I would hardly expect any arrangement she might strike with us to be a fair bargain.”

Bruenor took note that Drizzt had slipped one of his scimitars free of its sheath as he spoke. “Not a trap, eh?” the dwarf asked again, indicating the readied weapon.

“By her people, no,” Drizzt replied. “But the shadows conceal many other eyes.”

* * *

More eyes than just Wulfgar’s had fallen upon the halfling and the woman.

The hardy rogues of Luskan’s dockside often took great sport in tormenting creatures of less physical stature, and halflings were among their favorite targets. This particular evening, a huge, overstuffed man with furry eyebrows and beard bristles that caught the foam from his ever-full mug dominated the conversation at the bar, boasting of impossible feats of strength and threatening everybody around him with a beating if the flow of ale slowed in the least.

All of the men gathered around him at the bar, men who knew him, or of him, nodded their heads in enthusiastic agreement with his every word, propping him up on a pedestal of compliments to dispel their own fears of him. But the fat man’s ego needed further sport, a new victim to cow, and as his gaze floated around the perimeter of the tavern, it naturally fell upon Regis and his large, but obviously young friend. The spectacle of a halfling wooing the highest priced lady at the Cutlass presented an opportunity too tempting for the fat man to ignore.

“Here now, pretty lady,” he slobbered, ale spouting with every word. “Think the likes of a half-a-man’ll make the night for ye?” The crowd around the bar, anxious to keep in the fat man’s high regard, exploded into overzealous laughter.

The woman had dealt with this man before and she had seen others fall painfully before him. She tossed him a concerned look, but remained firmly tied to the pull of the ruby pendant. Regis, though, immediately looked away from the fat man, turning his attention to where he suspected the trouble most likely would begin – to the other side of the table and Wulfgar.

He found his worries justified. The proud barbarian’s knuckles whitened from the grasp he had on the table, and the seething look in his eye told Regis that he was on the verge of exploding.

“Let the taunts pass!” Regis insisted. “This is not worth a moment of your time!”

Wulfgar didn’t relax a bit, his glare never releasing his adversary. He could brush away the fat man’s insults, even those cutting at Regis and the woman. But Wulfgar understood the motivation behind those insults. Through exploitation of his less-able friends, Wulfgar was being challenged by the bully. How many others had fallen victim to this hulking slob? he wondered. Perhaps it was time for the fat man to learn some humility.

Recognizing some potential for excitement, the grotesque bully came a few steps closer.

“There, move a bit, half-a-man,” he demanded, waving Regis aside.

Regis took a quick inventory of the tavern’s patrons. Surely there were many, in here who might jump in for his cause against the fat man and his obnoxious cronies. There was even a member of the official city guard, a group held in high respect in every section of Luskan.

Regis interrupted his scan for a moment and looked at the soldier. How out of place the man seemed in a dog-infested spittoon like the Cutlass. More curious still, Regis knew the man as Jierdan, the soldier at the gate who had recognized Drizzt and had arranged for them to pass into the city just a couple of hours earlier.

The fat man came a step closer, and Regis didn’t have time to ponder the implications.

Hands on hips, the huge blob stared down at him. Regis felt his heart pumping, the blood coursing through his veins, as it always did in this type of on-the-edge confrontation that had marked his days in Calimport. And now, like then, he had every intention of finding a way to run away.

But his confidence dissipated when he remembered his companion.

Less experienced, and Regis would be quick to say, “less wise!” Wulfgar would not let the challenge go unanswered. One spring of his long legs easily carried him over the table and placed him squarely between the fat man and Regis. He returned the fat man’s ominous glare with equal intensity.

The fat man glanced to his friends at the bar, fully aware that his proud young opponent’s distorted sense of honor would prevent a first strike. “Well, look ye here,” he laughed, his lips turned back in drooling anticipation, “seems the young one has a thing to say.”

He started slowly to turn back on Wulfgar, then lunged suddenly for the barbarian’s throat, expecting that his change in tempo would catch Wulfgar by surprise.

But although he was inexperienced in the ways of taverns, Wulfgar understood battle. He had trained with Drizzt Do’Urden, an ever-alert warrior, and had toned his muscles to their sharpest fighting edge. Before the fat man’s hands ever came near his throat, Wulfgar had snapped one of his own huge paws over his opponent’s face and had driven the other into the fat man’s groin. His stunned opponent found himself rising into the air.

For a moment, onlookers were too amazed to react at all, except for Regis, who slapped a hand across his own disbelieving face and inconspicuously slid under the table.

The fat man outweighed three average men, but the barbarian brought him up easily over the top of his seven-foot frame, and even higher, to the full extension of his arms.

Howling in helpless rage, the fat man, ordered his supporters to attack. Wulfgar watched patiently for the first move against him.

The whole crowd seemed to jump at once. Keeping his calm, the trained warrior searched out the tightest concentration, three men, and launched the human missile, noting their horrified expressions just before the waves of blubber rolled over them, blasting them backward. Then their combined momentum smashed an entire section of the bar from its supports, knocking the unfortunate innkeeper away and sending him crashing into the racks holding his finest wines.

Wulfgar’s amusement was short-lived, for other ruffians were quickly upon him. He dug his heels in where he was, determined to keep his footing, and lashed out with his great fists, swatting his enemies aside, one by one, and sending them sprawling into the far corners of the room. Fighting erupted all around the tavern. Men who could not have been spurred to action if a murder had been committed at their feet sprang upon each other with unbridled rage at the horrifying sight of spilled booze and a broken bar.

Few of the fat man’s supporters were deterred by the general row, though. They rolled in on Wulfgar, wave after wave. He held his ground well, for none could delay him long enough for their reinforcements to get in. Still, the barbarian was being hit as often as he was connecting with his own blows. He took the punches stoically, blocking out the pain through sheer pride and his fighting tenacity that simply would not allow him to lose.

From his new seat under the table, Regis watched the action and sipped his drink. Even the barmaids were into it now, riding around on some unfortunate combatants’ backs, using their nails to etch intricate designs into the men’s faces. In fact, Regis soon discerned that the only other person in the tavern who wasn’t in the fight, other than those who were already unconscious, was Jierdan. The soldier sat quietly in his chair, unconcerned with the brawling beside him and interested only, it seemed, in watching and measuring Wulfgar’s prowess.

This, too, disturbed the halfling, but once again he found that he didn’t have time to contemplate the soldier’s unusual actions. Regis had known from the start that he would have to pull his giant friend out of this, and now his alert eyes had caught the expected flash of steel. A rogue in the line directly behind Wulfgar’s latest opponents had drawn a blade.

“Damn!” Regis muttered, setting down his drink and pulling his mace from a fold in his cloak. Such business always left a foul taste in his mouth.

Wulfgar threw his two opponents aside, opening a path for the man with the knife. He charged forward, his eyes up and staring into those of the tall barbarian. He didn’t even notice Regis dart out from between Wulfgar’s long legs, the little mace poised to strike. It slammed into the man’s knee, shattering the kneecap, and sent him sprawling forward, blade exposed, toward Wulfgar.

Wulfgar side-stepped the lunge at the last moment and clasped his hand over the hand of his assailant. Rolling with the momentum, the barbarian knocked aside the table and slammed into the wall. One squeeze crushed the assailant’s fingers on the knife hilt, while at the same time Wulfgar engulfed the man’s face with his free hand and hoisted him from the ground. Crying out to Tempus, the god of battle, the barbarian, enraged at the appearance of a weapon, slammed the man’s head through the wooden planks of the wall and left him dangling, his feet fully a foot from the floor.

An impressive move, but it cost Wulfgar time. When he turned back toward the bar, he was buried under a flurry of fists and kicks from several attackers.

* * *

“Here she comes,” Bruenor whispered to Drizzt when he saw Whisper returning, though the drow’s heightened senses had told him of her coming long before the dwarf was aware of it. Whisper had only been gone a half-hour or so, but it seemed much longer to the two friends in the alley, dangerously open to the sights of the crossbowmen and other thugs they knew were nearby.

Whisper sauntered confidently up to them. “Here is the map you desire,” she said to Bruenor, holding up a rolled parchment.

“A look, then,” the dwarf demanded, starting forward.

The woman recoiled and dropped the parchment to her side. “The price is higher,” she stated flatly. “Ten times what you have already offered.”

Bruenor’s dangerous glare did not deter her. “No choice is left to you,” she hissed. “You shall find no other who can deliver this unto you. Pay the price and be done with it!”

“A moment,” Bruenor said with sudden calm. “Me friend has a say in this.” He and Drizzt moved a step away.

“She has discovered who we are,” the drow explained, though Bruenor had already come to the same conclusion. “And how much we can pay.”

“Be it the map?” Bruenor asked.

Drizzt nodded. “She would have no reason to believe that she is in any danger, not down here. Have you the money?”

“Aye,” said the dwarf, “but our road is long yet, and I fear we’ll be needing what I’ve got and more.”

“It is settled then,” Drizzt replied. Bruenor recognized the fiery gleam that flared up in the drow’s lavender eyes. “When first we met this woman, we struck a fair deal,” he went on. “A deal we shall honor.”

Bruenor understood and approved. He felt the tingle of anticipation start in his blood. He turned back on the woman and noticed at once that she now held a dagger at her side instead of the parchment. Apparently she understood the nature of the two adventurers she was dealing with.

Drizzt, also noticing the metallic glint, stepped back from Bruenor, trying to appear unmenacing to Whisper, though in reality, he wanted to get a better angle on some suspicious cracks that he had noticed in the wall – cracks that might be the edgings of a secret door.

Bruenor approached the woman with his empty arms outstretched. “If that be the price,” he grumbled, “then we have no choice but to pay. But I’ll be seein’ the map first!”

Confident that she could put her dagger into the dwarf’s eye before either of his hands could get back to his belt for a weapon, Whisper relaxed and moved her empty hand to the parchment under her cloak.

But she underestimated her opponent.

Bruenor’s stubby legs twitched, launching him up high enough to slam his helmet into the woman’s face, splattering her nose and knocking her head into the wall. He went for the map, dropping the original purse of gems onto Whisper’s limp form and muttering, “As we agreed.”

Drizzt, too, had sprung into motion. As soon as the dwarf flinched, he had called upon the innate magic of his heritage to conjure a globe of darkness in front of the window harboring the crossbowmen. No bolts came through, but the angered shouts of the two archers echoed throughout the alley.

Then the cracks in the wall split open, as Drizzt had anticipated, and Whisper’s second line of defense came rushing through. The drow was prepared, scimitars already in his hands. The blades flashed, blunt sides only, but with enough precision to disarm the burly rogue that stepped out. Then they came in again, slapping the man’s face, and in the same fluidity of motion, Drizzt reversed the angle, slamming one pommel, and then the other, into the man’s temples. By the time Bruenor had turned around with the map, the way was clear before them.

Bruenor examined the drow’s handiwork with true admiration.

Then a crossbow quarrel ticked into the wall just an inch from his head.

“Time to go,” Drizzt observed.

“The end’ll be blocked, or I’m a bearded gnome,” Bruenor said as they neared the exit to the alley. A growling roar in the building beside them, followed by terrified screams, brought them some comfort.

“Guenhwyvar,” Drizzt stated, as two cloaked men burst out into the street before them and fled without looking back.

“Sure that I’d forgotten all about that cat!” cried Bruenor.

“Be glad that Guenhwyvar’s memory is greater than your own,” laughed Drizzt, and Bruenor, despite his feelings for the cat, laughed with him. They halted at the end of the alley and scouted the street. There were no signs of any trouble, though the heavy fog provided good cover for a possible ambush.

“Take it slow,” Bruenor offered. “We’ll draw less attention.”

Drizzt would have agreed, but then a second quarrel, launched from somewhere down the alley, knocked into a wooden beam between them.

“Time to go!” Drizzt stated more decisively, though Bruenor needed no further encouragement, his little legs already pumping wildly as he sped off into the fog.

They made their way through the twists and turns of Luskan’s rat maze, Drizzt gracefully gliding over any rubble barriers and Bruenor simply crashing through them. Presently, they grew confident that there was no pursuit, and they changed their pace to an easy glide.

The white of a smile showed through the dwarf’s red beard as he kept a satisfied eye cocked over his shoulder. But when he turned back to view the road before him, he suddenly dove down to the side, scrambling to find his axe.

He had come face up with the magical cat.

Drizzt couldn’t contain his laughter.

“Put the thing away!” Bruenor demanded.

“Manners, good dwarf,” the drow shot back. “Remember that, Guenhwyvar cleared our escape trail.”

“Put it away!” Bruenor declared again, his axe swinging at the ready.

Drizzt stroked the powerful cat’s muscled neck. “Do not heed his words, friend,” he said to the cat. “He is a dwarf, and cannot appreciate the finer magics!”

“Bah!” Bruenor snarled, though he breathed a bit easier as Drizzt dismissed the cat and replaced the onyx statue in his pouch.

The two came upon Half-Moon Street a short while later, stopping in a final alley to look for any signs of ambush. They knew at once that there had been trouble, for several injured men stumbled, or were carried, past the alley’s entrance.

Then they saw the Cutlass, and two familiar forms sitting on the street out in front.

“What’re ye doin’ out here?” Bruenor asked as they approached.

“Seems our big friend answers insults with punches,” said Regis, who hadn’t been touched in the fray. Wulfgar’s face, though, was puffy and bruised, and he could barely open one eye. Dried blood, some of it his own, caked his fists and clothes.

Drizzt and Bruenor looked at each other, not too surprised.

“And our rooms?” Bruenor grumbled.

Regis shook his head. “I doubt it.”

“And my coins?”

Again the halfling shook his head.

“Bah!” snorted Bruenor, and he stamped off toward the door of the Cutlass.

“I wouldn’t…” Regis started, but then he shrugged and decided to let Bruenor find out for himself.

Bruenor’s shock was complete when he opened the tavern door. Tables, glass, and unconscious patrons lay broken all about the floor. The innkeeper slumped over one part of the shattered bar, a barmaid wrapping his bloodied head in bandages. The man Wulfgar had implanted into the wall still hung limply by the back of his head, groaning softly, and Bruenor couldn’t help but chuckle at the handiwork of the mighty barbarian. Every now and then, one of the barmaids, passing by the man as she cleaned, gave him a little push, taking amusement at his swaying.

“Good coins wasted,” Bruenor surmised, and he walked back out the door before the innkeeper noticed him and set the barmaids upon him.

“Hell of a row!” he told Drizzt when he returned to his companions. “Everyone in on it?”

“All but one,” Regis answered. “A soldier.”

“A soldier of Luskan, down here?” asked Drizzt, surprised by the obvious inconsistency.

Regis nodded. “And even more curious,” he continued, “it was the same guard, Jierdan, that let us into the city.” Drizzt and Bruenor exchanged concerned looks.

“We’ve killers at our backs, a busted inn before us, and a soldier paying us more mind than he should,” said Bruenor.

“Time to go,” Drizzt responded for the third time.

Wulfgar looked at him incredulously. “How many men did you down tonight?” Drizzt asked him, putting the logical assumption of danger right out before him. “And how many of them would drool at the opportunity to put a blade in your back?”

“Besides,” added Regis before Wulfgar could answer, “I’ve no desire to share a bed in an alley with a host of rats!”

“Then to the gate,” said Bruenor.

Drizzt shook his head. “Not with a guard so interested in us. Over the wall, and let none know of our passing.”

* * *

An hour later, they were trotting easily across the open grass, feeling the wind again beyond the break of Luskan’s wall.

Regis summed up their thoughts, saying, “Our first night in our first city, and we’ve betrayed killers, fought down a host of ruffians, and caught the attention of the city guard. An auspicious beginning to our journey!”

“Aye, but we’ve got this!” cried Bruenor, fairly bursting with anticipation of finding his homeland now that the first obstacle, the map, had been overcome.

Little did he or his friends know, however, that the map he clutched so dearly detailed several deadly regions, one in particular that would test the four friends to their limits – and beyond.

Free Essays

Occupational stress and work-life balance in the public sector in Saudi Arabia


The context of the Kingdom of Saudi Arabia presents a unique set of challenges to female academic employees, because of a modern conundrum stressing the importance of globalization and therefore an increased support for the place of the female in non-traditional work environments. Simultaneously however, there is a stable support for conservative values underpinned by societal norms and traditions based on Saudi religion and culture. Therefore there is increased support for improved job performance in sectors that are not traditionally considered the realm of the female employee, because of the longevity required in order to develop a successful career path, such as academic jobs. At the same time however, women are empowered to follow these career paths whilst still maintaining traditional values perpetuated by religion and culture that hold dear family values and the moral ethos of the female as the matriarchal centre of the family nucleus.

There exists therefore a stress on female academic employees in Saudi Arabia which is multifaceted. Traditional values find the place of women in the workplace as a resisted ideal where conservative members of public organizations do not respect the authority and standing of female employees as highly as their male counterparts. This ingrained gender discrimination not only causes an emotional stress on female employees, but also prevents the commensurate career progression that is due to these employees, which is known as a ‘glass ceiling’ (Yamani, 1996). Whilst the private sector may be more persuasive to globalization and increased female quotas in these organizations, the public sector of Saudi Arabia represents a more traditional set of values which are deeply rooted in religion and culture which historically do not recognize the role of females in these organizations. Arguably therefore female academic employees in the public sector will feel these burdens in a more pronounced manner than their private sector counterparts.

The culture of Saudi Arabia adds a further pressure on these female employees to perform the matriarchal functions in their homes in addition to their employment commitments which adds another dimension to the occupational stress suffered by these women as they are now committed to perfecting a work-life balance. The central hypothesis of this research therefore seeks to investigate the relationship between the occupational stress and work-life balance of female academic employees in the public sector in Saudi Arabia.

Overview of Research

The study of occupational stress centers on stress at work. Stress is defined in terms of physical and physiological effects on a employee whether this be mental, physical or emotional strain. It also encompasses tension, situations or factors that can cause stress in a work environment. Occupational stress occurs when there is a discrepancy between the demands of the workplace and the individual’s ability to meet these demands (Henry & Evans, 2008). The nature of academic work is in itself problematic for inducing occupational stress due to the ‘never-ending’ nature of the work, with guilt associated with constantly needing to improve the performance of students and contribute to the body of knowledge currently available.

Sociologists have expressed increasing interest in the study of work-family conflict since the 1970’s where the majority of adults need to work for a living-wage and the result is the need to balance this need to work with the need to raise a family, whilst still maintaining traditional values. Paid employment conflicts with the family environment in a number of ways, intruding significantly on the leisure aspect of family life, but also attempting to balance the commitments of work and the family leads to stress trying to balance different aspects of individual’s lives. To a certain extent therefore, work and family commitments are incompatible with one another as hours of work detract from time available for the family and vice versa.

Traditionally women have been concentrated in narrow fields of employment where the balancing of work and family is made significantly easier through fewer working hours and less workplace responsibility. With globalization and the gender equality movement becoming more prevalent, even in traditional society, these roles have begun to change. Despite the increased advent of women in non-traditional work environments such as academics, there is still the same pressure on women to maintain their traditional roles within the family nucleus. Particularly in conservative societies, such as Saudi Arabia, it is becoming increasingly important for the balance to be maintained for the broader societal good. In a sense, the care and maintenance of the family in society is the responsibility of the woman and therefore a careful balancing act is of vital importance.

Organizational responses to work-life issues vary according to the type of employer in the organization in which the employee works. A family-responsive employer would provide flexibility in work programs that afford employees greater control over their working hours and considerate responses to meeting their family or personal obligations. This is often translated in fiscal responses such as adequate insurance and pension funds that allow for family support over and above that which may be the immediate concern of an individual in an organization. These are transmitted through organizational culture formally in the form of organizational policy and informally through supervisors and coworkers. Essentially this gauges the value and support available for work-life integration with the objectives of the organization.

Positioning of Research in Current Knowledge

The Saudi culture emphasizes the importance of family, and the first priority for women is to be a wife and a mother while paid work is a secondary issue. This research therefore aims to highlight the work-life considerations of Saudi women in the context of their cultural and religious values. Islam does not prohibit women from entering paid employment whenever there is a need for it, particularly in positions, that suit their feminine nature and in surrounding Gulf countries, the place of women in academics has been encouraged particularly in foundation phase education.

Previous research has indicated a number of unique and shared factors that help Saudi women maintain a balance between life and work (Bahkali, 2012). This research found that culture and religion, health insurance and transportation are considered unique factors to the female employees in Saudi Arabia. The women who worked in the education sector all recognized their work as being culturally acceptable. Part of this sector necessarily includes academic employees, however education generally refers to primary, secondary and tertiary education institutions, whereas the current study proposes examine the academic field as a whole rather than isolating this to traditional forms of academics in the form of teaching. In contrast, women who worked in the medical field stated they did not always feel comfortable because they do work in the same space as male colleagues. Arguably, when one moves towards more advanced levels of academic employ, this lack of comfort becomes more pronounced as the employment moves away from being matriarchal (lower levels of education dealing with children and adolescents have been noted to respond better to females). In Saudi Arabia, many in these fields do not have health insurance whereas most of them suffer from the issue of transportation.

In terms of family and personal lives, Saudi women workers do not consider childcare centers as important as entrusting their maids or nannies with their children and therefore, most Saudi women workers bring maids to care for their children whilst they are at work. In addition, some Saudi women are not satisfied with their work hours especially when work hours surpass lunch hours or work occurs at night. Finally, Saudi women workers can find help at home either from husband, mother or maid and this may reduce work family conflict that Saudi working women face.

Based on the findings of these previously conducted research papers, it is evident that this is a relevant gap in the current knowledge on occupational stress. The proposed research aims to further the current field of knowledge by conducting a specific inquiry into these factors as they relate to academic employment. If one considers the importance of education as a foundational pillar of society and development, adopting appropriate organizational behavior to mitigate organizational stress and therefore improve academic outcomes is an important and relevant study for sociological and corporate purposes.

This research therefore aims to use the underlying theoretical considerations of organizational stress and the difficulties of establishing and maintaining a work-life balance to study the effects of the unique Saudi experience on female academic employees in the public sector. To current knowledge, there have been no similar studies undertaken in this field and therefore the gap in knowledge is evident. By understanding the unique factors of this situation, helpful recommendations for the adjustment of organizational behavior of academic institutions can be made to mitigate these stresses and improve overall organizational efficiency.

Research Design & Methodology

The methodology proposed for the research is qualitative in nature, where the researcher aims to gain an understanding of the human behavior and the reasons that govern this behavior. The hypothesis of this research will be founded in academic literature sourced from a variety of secondary sources and thereafter supported by empirical evidence in the form of interviews conducted with relevant study participants. Thereafter this qualitative data will be analyzed in order to conclude recommendations and findings as to the nature of occupational stress and the work-life balance in the public sector for female academic employees.

Proposed Structure

The current research proposal has given a broad overview of the issues to be covered in the research, which will be conducted according to the following proposed structure:

Chapter 1: Introduction to the Study

1.1 Saudi Arabia Context

1.2 Religion and culture

1.3 Work by gender

Chapter 2: Methodology

Chapter 3: Considerations of Occupational Stress

3.1 Introduction to the study of occupational stress.

3.2 Stresses and strains experienced by academic employees: A literature review

3.3 A empirical study of stresses and strains experienced by academic employees

Chapter 4: Considerations of Work-Life Conflict

4.1 Work-Family Conflict

4.2 Hours of Work

4.3 Females Concentrated in Narrow Fields

4.4 Work-Life Balance

4.5 The Importance of Work-life Balance for Women

4.6 Organizational Response to Work-life Issues

Chapter 5: Female Academic Employment in the Public Sector in Saudi Arabia

5.1 The nature, predictors and outcomes of work-life conflict in academic employees in the public sector

Chapter 6: Discussion

Chapter 7: Conclusion and Recommendations


Modern challenges to traditional ideas of organizational structure, behavior and culture have an important place in modern academic literature. Through understanding the particular circumstances in a geographical region such as Saudi Arabia, as well as the challenges facing these employees, one can begin to develop a conceptual framework for streamlining organizational objectives and maximizing the performance of these employees. The current research therefore proposes to undertake a study which examines these factors through understanding of the relevant theoretical considerations, as well as the factors particular to this sector and geographical region.


Al-Dehailan, Salman Saleh (2007) The participation of women in Saudi Arabia’s economy: Obstacles and prospects.Doctoral thesis, Durham University

Alqahtani, S. (2006) The Education in Saudi Arabia critical view (1ed.). Riyadh, KSA.

Bahkali, W. (2012) The Issues of Work Life Balance for Saudi Women Workers: A dissertation. Masters Thesis, University of Waikato

Gurney, Sarah (2010) Gender, work-life balance and health amongst women and men in administrative, manual and technical jobs in a single organisation: a qualitative study. PhD thesis, University of Glasgow.

Henry, O. & Evans, A. (2008) Occupational Stress in Organizations and Its Effects on Organizational Performance. Journal of Management Research, 8(3).

Lakshmipriya, & Neena, S. (2008) Work Life Balance of Women Employees. [online] Available on: [Accessed 8 November 2012]

Lowe, G. (2006) Under Pressure: Implications of Work-Life Balance and Job Stress, Human Solutions TM Report. [online] Available on: [Accessed 8 November 2012]

Strauss, E. (2007) The Glass Ceiling: Women and Barriers in the Workplace. [online] Available on: barriers_pg2.html?cat=3 [Accessed 8 November 2012]

Travers, C. (2001) ‘Stress in teaching: past, present and future’ In Dunham, J. (Ed) Stress in workplace: past. Present and future. London: Whurr Publishers

Tytherleigh, M., Webba, C., Cooper, C. & Ricketts, A. (2007) Occupational stress in UK higher education institutions: a comparative study of all staff categories. Higher Education Research & Development, 24(1), pp. 41 – 61

Valcour, P. & Batt, R. (2003) Worf-Life Integration: Challenges and Organisational Responses. Human Resource Studies, Faculty Publication, 1(1)

Yamani, M. (1996) ‘Some Observations on women in Saudi Arabia.’ In M. Yamani (ed) Feminism and Islam: Legal and Literary Perspectives. New York: New York University Press.

Free Essays

Scenario Involving A One Sarah, An 86 Year Old Retired Nurse Who Refuses Medical Treatment For A Serious Life-Threatening Medical Condition


This essay discusses the legal and ethical issues arising from a scenario where Sarah, aged 86 who is a retired nurse has refused to undergo invasive medical treatment for a condition that is likely to lead to death. Having inquired and been informed of what the procedure will entail, she instead requested for only palliative care. According to the facts, Sarah’s pain was at point 6 on the Trust pain score. Most importantly, the facts are state that “Morphine 10mgs IV was keeping Sarah pain free; this was being given every 4 – 6 hours.” Impliedly Sarah’s mental capacity to consent or decline treatment is not vitiated by the pain she was previously feeling. She is competent and clear about her decision. However, family members disagree and think she is incompetent. Several human rights, legal and ethical issues arise and are discussed with reference to the Human Rights Act 1998 and the Mental Capacity Act 2005. The Human Rights Act 1998 made rights guaranteed by the European Convention on Human Rights (hereafter ‘ECHR’) enforceable in United Kingdom courts.

It is submitted that the scenario raises three human rights issues. Firstly is the right to life enshrined in Article 2 of the European Convention on Human Rights. It is open for the family members to argue that letting Sarah to die will violate her right to life (Pretty v United Kingdom [2002]).Sarah however, cannot argue that she has a right to die. Such an assertion was rejected by the European Court of Human Rights (Pretty v United Kingdom [2002]). Nevertheless, one has a right to reject medical treatment. Secondly, article 3 ECHR that forbids inhuman and degrading treatment could be invoked. If treated despite her refusal of treatment, Sarah may sue for violation of right not to be subjected to inhuman and degrading treatment (Herring, J, 2010, p. 146; R (N) v Dr. M., A Health authority Trust and Dr. O [2002].This right was also affirmed in the case of Trust A, Trust B v H (an Adult Patient) (Represented by her Litigation Friend, the Official Solicitor. As explained by the Court of Appeal, it is consent that gives a medical professional the legal ‘flak jacket’ or defence to a legal action against them (Herring, J, 2010; Re W [1992]). However, the family members could paternalistically argue that failure to treat Sarah and leaving her to die would violate article 8 of the European Convention on Human Rights which guarantees their right to family life (G v E (2010)); Paton v United Kingdom). However, as decided in Pretty’s case, Sarah’s rights will have to be respected however irrational they may be.Sarah’s choice to have palliative care and be transferred to a hospice to die is also arguable. It raises an issue of whether she has a right to make this choice.Court has held that the right to life does not mean that a patient is entitled to make a choice of the treatment they would like(R. (on the application of Burke) v General Medical Council [2005] para. 31). The NHS just like any other health care system has resource constraints and is not in position to give specific treatment to particular patients. Further, Sarah’s right to private life guaranteed by article 8 ECHR could also be engaged. The recommended treatment would be invasive and if given without her consent would be a breach of her privacy as affirmed by Evans v UK (2007). It is therefore submitted that the healthcare professionals should not act against Sarah’s wishes.

A central issue is whether Sarah had the right to refuse medical treatment. It is a fundamental principle of law that before treating a competent adult patient like Sarah, consent should be obtained (Herring, J, 2010, p. 146; McHale J. and Fox, M, 2007, p. 360; Jackson, E, 2010, p. 167). This had been recognised as early as 1767 in the case of Slater v Baker and Stapleton. Even before the enactment of the Human Rights Act, Lord Scarman in 1985 stated to the effect that a patient had a ‘basic human right’ to make her own medical decisions (Jackson, 2010, p. 182). In 1914 an American Judge, Cardozo, J had stated that “Every human being of adult years and sound mind has a right to determine what shall be done with his own body…”(Schloendorff v New York Hospital cited in Jackson, E. 2010, at p. 216-217.). An extreme statement of this rule is that competent adult patients have the right to make irrational and life-threatening decisions to refuse medical treatment (Jackson, E., 2010, p. 221; case). The General Medical Council in England has advised its members along same lines (British Medical Association, 2007, para. 25.5). The rule is based on the cardinal principle of patient autonomy and the right to self determination (Herring, J, p. 147; McHale, J, et al, 2007, 354-350). Applying the law to this scenario, it is emphatically submitted that Sarah had the right to make the decision.

Having resolved the question of whether she had the right to make the decision, the next important question is whether she had the mental capacity to do so and whether she did so in the right way.A patient can only exercise the right to consent to or refuse medical treatment if they have the capacity or competence to do so (Re F [1990]). While it is the law that everyone is presumed to have capacity unless it is established to the contrary (section 2(1) Mental Capacity Act 2005), the presumption of capacity to consent or refuse treatment is rebuttable. This is where other parties such as the healthcare professionals and family members may be involved. Nevertheless, it should be emphasised that even if the patient were incompetent, it does not follow that the family members can make the decision on her behalf (Herring, J, 2010, p. 150). To resolve the capacity issue, it is imperative to determine what legally is meant by lack of capacity. According to section 2(1) of the Mental Capacity Act 2005, which (Act) codified and improved on the common law rules governing consent, “a person lacks capacity in relation to a matter “if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain”. Though not expressly stipulated, the Mental Capacity Act presumption is with respect to adults who are over the age of 16 (Jackson, E., 2010; Johnston and Liddle, 2007, 94-97, at. 94). Owing to the presumption of capacity that applies to every adult including Sarah, it will be up to the dissenting family members prove that she is incapacitated. On the facts, Sarah was capable of comprehending and retaining, weighing and communicating a decision (Re C (refusal of Medical Treatment) [1994]; Mason, et al, 2011). In case there is reason for doubt, capacity has to be assessed again.

Arguably, the family members’ could rely on the fact that Sarah’s ailment is causing pain which may have rendered her temporarily incompetent to consent (section 2(2) of the Mental Capacity Act). Even according to the Mental Capacity Act Code of Practice (paragraphs 4.26) acute illness, severe pain or the effect of medication may affect someone’s ability to make decisions. The reply to this however is that since Sarah is being kept “pain-free” capacity is not affected. It is my contention that this reply would seriously weaken or even defeat the family members’ argument. Sarah’s advanced age cannot be used to imply incapacity. To do so would be contrary section 2(3) of the Mental Capacity Act 2005 (Jackson, E, 2010, p. 233).The family members’ argument may therefore fail.

All the available evidence suggests that Sarah was competent to decide. The burden will therefore be on the family to show that this was not the case. Sarah raised questions for the doctor to answer, got the answers and then made her decision which she communicated. She even anticipated that her family would not agree with her and prepared to explain to them. Arguably, she exceeded the standards of retention mentioned in section 3(3) of the Mental Capacity Act since her retention was more than temporary. She fully understood the nature and purpose of the recommended surgery (F v W. Berkshire HA, per Lord Brandon, [1989] 2 All ER 545). The family is thus most likely not to satisfy the burden of proving as required in the cases of Re MB (An Adult: Medical Treatment(1997)) and Re C (Adult: Refusal of Treatment).

Alternatively family members could argue that Sarah did not give ‘informed consent’ as required by English law (Jackson, 2010). However, considering that she is a retired nurse and that she asked and information was given, this ground of attack may not be accepted by the court. The specific questions she raised support the fact that she understood what was explained and hence her consent was from an informed point of view. Nevertheless, it could be argued that she did not get sufficient information. This is because she did not actually get a reply to the question of Intensive Care Unit. The doctor replied that this would depend on the anaesthetists. There is no evidence that their opinion was given to Sarah as required by Sidaway v Board of Governors of the Bethlem Royal Hospital and Maudsley Hospital [1985] (also Jackson, 2010; Montgommery, 2003). The family members could take the matter to the Court of Protection established under section 45 of the Mental Capacity Act 2005 for a decision. However, it would be advisable for the family to use persuasion. A patient has a right to change her mind at any time since consent is a continuing process. The law is less stringent on proving acceptance of treatment than on refusal arguably to promote sanctity of life and beneficence principles.

Yet another important legal aspect to consider is whether the ‘informed consent’ was given voluntarily-without any coercion or undue influence (In Re T (Adult: Refusal of Medical Treatment) 1993 Fam 95). As the facts stand, there is nothing to suggest that there was any undue influence or coercion. However, should the family talk to the patient and she changes their mind, this might be reason to prove that the consent has not been given voluntarily. This would then put the healthcare professionals at the risk of being sued for battery in case they go ahead to treat Sarah who has preferred to exercise her right to autonomy and bodily integrity (Jackson, E., 2010, p. 219). Any such actions would go against the principles laid down in the case of Re T (Adult Patient: Refusal of Medical Treatment case [2004] involving a Jehovah witness patient that changed their mind to refuse treatment after talking to the mother.Sarah is a competent adult and her decision is in line with the principles of patient autonomy and self determination as well as the right to bodily integrity. The fact that she has made what looks to the family members as an unwise or irrational decision is immaterial (section 1(4) Mental Capacity Act 2005). As observed in the Re T (Adult Patient: Refusal of Medical Treatment case [2004] the question of mental capacity should not be confused with the nature of the decision since the view of the patient may reflect difference in values rather than absence of competence. Though capacity should not be decided in reference to age, it is arguable that Sarah’s values may be different to those of other family members. She values not being subjected to intrusive medical treatment which is consistent with her right to bodily integrity. This does not mean she is incompetent.

Apart from the legal issues involved in this scenario there are also ethical issues arising. While the principle of autonomy has been upheld and should be applied to let Sarah’s decision stand,such would not be in tandem with utilitarianism. It does not look at the interests of the majority who are the family members who would like to keep their relative alive. These family members have to look after her even when she is on palliative care in the hospice. This gives credence to a possible argument that Sarah was unable to weigh the impact of her decisions on the rest of the family members.Further, her actions do not bring ‘happiness’ in the utilitarian sense (Jackson, E., 2010) at least to the family members who are the greatest number. But in this case, this is an elderly woman and arguably, she is entitled to be allowed to depart the way she chooses. This is one way of following the Kantian ethics because humanity should not be treated as a means but always as an end (Jackson, E., 2010, p. 12). Further, disregarding the wishes of Sarah in this case would mean that justice is not being done equally to her. Kant advocated for universal laws that apply the same way to everyone (Jackson, E, p. 12). Patient autonomy is an established and tested principle of law.

The other issue is to do with the principle of beneficence. Accepting not to treat Sarah is generally not good. Healthcare practitioners are supposed to do good which does not imply not taking any action. Beneficence looks at the concept of ‘good’ from the non-material point of view. Arguably, Sarah seems to be promoting different values, of dying with bodily integrity. In terms of virtue ethics, the patient autonomy principle of respecting Sarah’s decision to die when she has a chance to live is not the right decision. Her life at 86 cannot be said to lack the most basic human goods (Jackson, E, p. 13). Even from a deontological point of view, it is intrinsically wrong to let someone die because of promoting patient autonomy. It is contended that patient autonomy indirectly grants a ‘right to die’ contrary to the law. Finally using a consequentialist approach, resources should be concentrated where they promote the maximum possible welfare for the maximum number of people, notably promoting the quality of life rather than sanctity of life. It might mean that resources should be allocated to prevention rather than cure.

In conclusion, important human rights, legal and ethical issues have been raised and discussed. The central one was whether there was consent as required by law. It has been argued basing on the fact that the patient is being kept pain-free by morphine, and based on the presumption of capacity the family members have a weak case. Sarah has a right to decline treatment and she exercised it while (in our view) having the mental capacity to do so. While this goes against other ethical considerations, the paramount consideration is Sarah’s competent opinion, however irrational it may be. The scenario shows how contentious determining consent can be. Even where it looks clear, relatives may sue healthcare professionals pursuant to the Human Rights Act. Whether the challenges succeed is for the court to decide based on evidence.


Bartlett, P., and Sandland, R, (2007), Mental Health Law: Policy and Practice, Oxford University Press (Chapter 10, Mental Capacity).

Brazier, M., and Cave, E., (2007), Medicine, Patients and the Law, 4th Ed. Penguin Books

Jackson, E. (2010), Medical Law: Text, Cases and Materials, Oxford University Press, Oxford.

McHale, J, et al (2007), Health Care Law: Text and materials, Sweet and Maxwell.

Mason, J.K., et al, (2006), Mason and McCall Smith’s Law and Medical Ethics, Oxford University Press.

Montgommeryy, J, (2003), Health Care Law, Oxford University Press

Acts and Conventions

Convention for the Protection of Human Rights and Fundamental Freedoms
as amended by Protocols No. 11 and No. 14 (accessed on 15.06 2012 at:

Human Rights Act (1998)

Article 2 – the Right to Life
Article 3- Article 3- Right not to be subjected to degrading treatment
Article 8 – Right to Respect for Private and Family Life

– The Mental Capacity Act (2005)

Case Law

Airedale NHS Trust v Bland 1993 AC 789

Bethlem Royal Hospital and Maudsley Hospital [1985] AC 871

Chester v Afshar [2004] UKHL 41

Evans v UK (2007) 43 EHRR 21

F v W. Berkshire HA [1989] 2 All ER 545

Re JT [1998] 1FLR 48 (FD)

Markose v Epsom & St Helier NHS Trust [2004] EWHC 3130 (QB)

Paton v United Kingdom3 EHRR 408 1980

Pretty v United Kingdom [2002] 2 FLR 612

R v Lancashire HA ex parte A (2000) 2 FCR 525

(on the application of Burke) v General Medical Council [2005] Q.B. 424

Re B (Adult: Refusal of Medical Treatment) 2002 EWHC (Fam.)

Re C (Adult: Refusal of Treatment) 1993 Fam 95

Re F [1990] 2 A.C. 1

Re MB (An Adult: Medical treatment) [1997] 2 FLR 426

R (N) v Dr. M., A Health authority Trust and Dr. O [2002] EWHC 1911

Re T (Adult: Refusal of Medical Treatment) 1993 Fam 95

Re W [1992] 4 All ER 627, 633

Savage v South Essex partnership NHS Foundation trust (2006) EWHC 3562

Schoelendorff v New York hospital 211 N.Y. 125 1914

Slater v Baker and Stapleton [1767] 8 Geo 111 860

Trust A, Trust B v H (an Adult Patient) (Represented by her Litigation Friend, the Official Solicitor)[2006] EWHC 1230(Fam)


Mental Capacity Act Code of Practice; (accessed on 20.06.2012 at:

Journal articles

Johnston, C., and Liddle, J. (2007), The Mental Capacity Act 2006: a new framework forhealthcare decision making, Journal of Medical Ethics,2007; 33:94-97

MacLean, A., (2012), ‘From Sidaway to Pearce and beyond: is the legal regulation ofconsent any better following a quarter of a century of judicial scrutiny?’ Med. L. Rev. 2012, 20(1), 108-129

Mallardi, V, The origin of Informed Consent, (Abstract written in English, Article in Italian) giving historical origins of the doctrine of informed consent dating way back to ancient Greeks and Egyptians (accessed on 15.06.2012 at:

Shaw, J (1986), Informed consent: a German lesson (1986) International & Comparative Law Quarterly 864

Stein R, and Frances Swaine (2002), Ms B v An NHS Trust: the patient’s right to choose, 152 NLJ 642

Stirrat, G M and Gill, R, Autonomy in medical ethics after O’Neill, J Med Ethics 2005; 31:127–130

Free Essays

Why are corruption and clientelism such pervasive and enduring elements of political life in many African societies?


Africa with an average annual GDP/capita amounting to $1,560 is the poorest continent in the world, as Appendix 1 demonstrates (World Bank, 2012). Most countries of the region struggle with a number of socio-economic problems. African states are economically underdeveloped. They are characterized by low GDP/capita, high inflation and high unemployment rates. With the exception of seven oil-exporting countries[1], Africa states are relatively poor in natural resources. As most of them failed to industrialize, the major component of GDP in Africa remains agriculture. In result, they are global net importers. At the same time, most of them grapple with unstable exchange regime and huge national debts. At the social level, African countries are overpopulated and unable to provide free health care and education to their citizens. Hence, they are characterized by spreading diseases and high illiteracy rate. Further most of them fail to provide equal income redistribution. Hence, spreading poverty became a permanent feature of contemporary African states. Many scholars and African activists believe that corruption is a key obstacle to overcoming internal crises and to socio-economic progress on the African continent. Although international bodies and some national governments (i.e. Nigeria) have implemented anti-corruption strategies in the recent years, a little progress has yet been observed. In 2011, Transparency International has still listed all African states but Botswana as highly corrupted states (Appendix 2).

The following essay is an in-depth analysis of clientelism[2] and corruption problems in Africa, aiming to demonstrate why these problems remain inherent elements of political regimes in Africa. First, the following essay presents a short overview of the corruption problem on the African continent. Further, the essay examines why combating corruption is such a challenge in most African states. In conclusions, the essay presents policy recommendations.

Clientelism and corruption on the Africa continent

Without a doubt Africa is strongly affected by the corruption problem. One of the best known corruption cases comes from Nigeria. The former dictator, general Abacha, had been stealing national oil revenues and had transferred them into his private account in Switzerland. The issue was revealed in 2005 (after general’s death) and Nigeria started to recover their funds (Lovejoy, 2008). Nonetheless, Nigeria is not a sole example in Africa. The Corruption Perception Index, the most popular corruption measure used by Transparency International is low for all African countries but Botswana[3]. In 2011, fifty three African states reached CPI between 0 and 5 and hence, were qualified as highly corrupted states. Botswana with its CPI amounting to 6.1 is the only African country where the corruption level can be comparable to the corruption levels in the European states such as Portugal (6.2) and Spain (6.1) (Transparency International, 2011).

Also Gini Coefficient Index, an international measure of income inequality, indirectly indicates the scale of corruption in Africa, as it measures how equally the incomes (wealth) are distributed within the society. According to the World Bank data[4] (2011), Gini Coefficient ranges from 35.3 in Sudan to 63.1 in South Africa. Hence, Gini Coefficient points out that the African states are characterized by highly unequal income redistribution and significant level of corruption.

The roots of clientelism and corruption in Africa

As African states are highly diversified at the political and socio-economic levels, various factors contribute to a current level of corruption. Three of them need to be considered. First of all, corruption is deep-rooted in African history and tradition. The colonial states in Africa had been characterized by the centralization of economic and political power. The colonial institutions such as police or security services that were meant to uphold the law, in fact served the colonial elites (i.e. governors, administrators). The elites had a privileged access to the colonial resources. They lived expensive lives and selectively shared resources within the colonial society. Violence was commonly used to deal with dissatisfaction amongst the colonial workers. Not only did the colonial elites fail to develop a culture of hard work but also encouraged unequal resources redistribution and so-called petty corruption amongst lower-level civil servants such as bribes for routine services (Konold, 2007). The new governments in postcolonial Africa that often remained highly centralized modeled on their colonial predecessors. Instead of establishing new political regimes, they fitted into colonial political structures. Hence, the colonial political systems with rooted corruption have been followed in Africa for over 50 years and still exist in a number of authoritarian African states such as Chad, Zimbabwe or Sudan (Gumede, 2012; Szeftel, 2000). Moreover, some scholars (i.e. Huntington) postulate that corruption was deepened in the postcolonial Africa. The political and socio-economic modernization resulted in the creation of new sources of wealth and in the expansion of the governmental authorities. The postcolonial governments, following the colonial authorities’ behaviours, reaped private benefits and had further developed unequal wealth redistribution (Konold, 2007).

Second, some political regimes in Africa are not aware of negative consequences of some forms of corruption. During the 1978 elections in Nigeria, presidential candidates offered material incentives in order to gain political support. After election, President Shagari signed a valuable dam contract. The revenues that could have contributed to socio-economic transformations in Nigeria had to cover high costs of presidential campaign (Magrin and Vliet, 2009). Many scholars believed that political transformation into modern democracy was a key factor to corruption reduction in Africa (Konold, 2007). However, current levels of corruption in democratic and non-democratic regimes in Africa are comparable (Transparency International, 2011). While non-democratic regimes in Africa simply regard corruption as an inherent element of their political systems, democratic states often practice bad behaviours such as clientelism and do not seem to notice negative consequences of these behaviours. Further, in some African countries (i.e. Zambia) clientelism led to the extreme situations where the national governments are no longer able to make policy in national interest. It is known as “Big Man Syndrome” or “bigmanism” (Lindberg, 2010, p.2). In the countries where economic conditions are poor, the governments offer non-material incentives in order to gain support. These incentives are usually governmental employment which results in a large bureaucracy. Hence, the governments are focused on securing their interests rather than overall national interests. They seem to be unable to tackle corruption.

Another problem is an underdeveloped private sector, characteristic for most African countries. The national governments became responsible for creating a capitalist class and businesses in postcolonial Africa. However, politicians and governmental officials occupied the major positions in the newly privatized companies. In result, also private sector in contemporary Africa remains weak and dependent on state. It does not require the government to become more accountable (Gumede, 2012).

Finally, the international efforts towards corruption combating in Africa do not bring positive outcomes. The fight against corruption in Africa has involved a number of international bodies such as the World Bank, the International Monetary Fund, European Union or Transparency International. The global anti-corruption strategies launched in Africa over the past years focused on the reduction of incentives and opportunities for corruption. Moreover, the international aid to Africa became dependent on good governance in African states. However, the implementation and synchronization of the anti-corruption reforms remained poor. International bodies undermined also collective action problem (Persson, 2010, p.12), characteristic for Africa. As corruption is a common feature of African governments, African societies often do not believe that reporting corruption cases could bring any change and hence, do not cooperate with international bodies. A significant obstacle remain also Western countries (in particular Switzerland) that welcome huge amounts of money and goods from Africa and seem to ignore the fact that these money are gained through corruption. Instead of cooperation with international bodies on corruption combating, these states indirectly support corruption development in Africa (Ogongo, 2012).

Conclusions: policy recommendations

To conclude, clientelism and corruption remain significant problems of the contemporary African continent. Not only are clientelism and corruption deep-rooted in the African tradition but they also seem to be underestimated by the national governments. These governments often fail to recognize negative consequences of corruption and to take appropriate actions. Some governments lost their ability to act in the national interest and to tackle corruption. Also international organizations often fail to deliver a coherent support in corruption combating to African governments. Additionally, their role is often undermined by the Western countries, accepting corrupt money from Africa.

Many scholars and African activists postulate that the elimination of corruption incentives is simply not a sufficient element to successful poverty combating. The African governments have to gain confidence within the societies. Hence, only radical transformations at the political, social and economic levels can bring positive outcomes to corruption reduction in Africa. The World Bank identified five key elements of corruption reduction in Africa. These elements are an increase of political accountability, strengthening civil society participation, institutional restrain on power, competitive private sector and better public sector management (Persson, 2010).

The following policy recommendations seem to be a good start for corruption reduction in Africa. First, the African ruling parties must establish a new type of leadership both at the national and local levels. The new leadership style should be characterized by the honesty, competence and a set of values encouraging socio-economic development. Further, the ruling parties should publicly punish bad behaviours and reward positive steps taken by the governmental officials. This kind of action will restore moral authority of the national governments amongst the citizens and will help the society to follow the established rules. Moreover, African media should be actively involved in the corruption problem in Africa in order to condemn publicly corruption cases and promote a new system of values within African societies (Gumede, 2012).

Amundsen, , (1999). Political corruption: An Introduction to the issue. Bergen: Chr. Michelsen Institute
Gumede, W., (2012). Africans inherited corruption [online] Available from: The Sunday Independent <> (Accessed on 15/04/2012)
Konold, C., (2007). Perceived corruption, public opinion and social influence in Senegal. Working paper number 85. Michigan: University of Michigan
Lindberg, S., (2010). Some evidence on the demand side of private-public goods provision by MPs. London: Overseas Development Institute
Lovejoy, P., al., (2008). A country study. Nigeria. Washington: Federal Research Division
Magrin, G. and Vliet G., (2009). The use of oil revenues in Africa [In] Lesourne, J. (ed.), Governance of oil in Africa: unfinished business. Paris: IFRI, p.103-164
Ogongo, S., (2012). Reduce corruption in order to develop, author tells Africa [online] Available from: <> (Accessed on 15/04/2012)
Persson, A., (ed.), (2010). The failure of anti-corruption policies. A theoretical mischaracterization of the problem. Goteborg: University of Gothenburg
Szeftel, M., (2000). Clientelism, corruption and catastrophe. Review of African Political Economy, 85, p. 427-441
Transparency International, (2011). Corruption Perception Index 2011 [online] Available from: <> (Accessed on 15/04/2012)
The World Banka Database, (2011). [online] Available from: <> (Accessed on 15/04/2012)

Free Essays

What Role do Unconscious Factors Play in the Experience of Organisational Life, and how can Workers’ Appreciation of these Factors Lead to better Outcomes for Users?

1. Introduction

The following essay considers the role that unconscious factors play in organisational life, and looks at the extent to which awareness of these factors amongst workers can improve outcomes for users. The idea is considered both in relation to appropriate literature and also in relation to my own experience of a social work organisation, the placement I experienced in a children’s home. The ways in which social work practice can be oppressive and anti-oppressive, and the impact of both of these for the user, are also explored. My interest in this area has been informed by my experience in a care home for children (Adeza) as a student social worker. I worked with a wide range of client groups including children (and their families) under stress, children (and their families with mental health problems, children at risk and children with physical and mental disabilities. I had a wide range of duties including administrative functions, advising clients and supporting children in a variety of ways. I became aware of the ways in which unconscious attitudes can impact upon the way clients and other staff are treated through a phenomenon I later learned was called projection, that is, the psychological mechanism whereby worries and fears about oneself are seen as present in other people, and demonised. For example, some clients had internalised a set of notions about being inadequate parents, which were then projected onto staff at the home, in a variety of ways.

2. The Notion of the Unconscious

Understanding human needs, wants and motivations is a central part not only of organizational theory but also of human psychology generally. Various theories have been proposed to explain the variety of behaviours which characterise human beings, for example behaviourism, which reduces the role of the ‘mental’ and looks at human actions in terms of stimulus and response (Baran and Davis 2011), and Weber’s idea of work as salvation (Nelson and Quick 2010). However, the notion of the unconscious has been widely influential, and derives from work by Freud in the late 19th and early 20th Century.The idea is situated in the wider set of notions developed by Freud called psychoanalysis.Central to Freud’s idea is the notion that “powerful unconscious drives, mostly sexual and aggressive… motivate human behaviour and put people in conflict with social reality” (Saiyadain 2003, p. 32).For Freud, the unconscious is that of which we are unaware, but which can manifest itself through thoughts and behaviours. He separated out three levels of consciousness:

The conscious (everything one is aware of)
The preconscious (things one is not aware of, but which could be brought to consciousness through effort of will)
The unconscious (that of which one is unaware, and which one is normally powerless to bring to conscious awareness)

The unconscious includes desires, buried memories, desires and needs. Individuals can be motivated by unconscious forces, which make themselves manifest through behaviour, thoughts, feelings and words. Freud believed therapeutic work could be done by uncovering these unconscious forces and making the individual aware of their deeper motivations through a process of psychoanalysis (McKenna 2000).

Freud suggested a number of ways in which the contents of the unconscious work to influence human behaviour. These include regression, repression, sublimation and projection. Regression is the phenomenon whereby people return to earlier behaviour patterns (for example a stutter), repression means the ways in which unpleasant emotions are blocked from conscious awareness, sublimation denotes the way in which impulses (perhaps aggressive) which are unacceptable to the conscious mind are channelled into another activity, for example devotion to work or sport, while projection means the mechanism whereby thoughts or feelings which are not acceptable to the conscious mind are attributed to someone else (finding them lazy, for example) (Saiyadain 2003).

Intuitively, and based on my experience in my placement, I feel that there is evidence for the existence of the unconscious. For example, I have seen adolescent children regress to an earlier stage, displaying bed wetting and thumb sucking for example, particularly at times of great stress. However, Freud’s ideas have been subject to an intense critique, particularly that there is a lack of empirical evidence for them (Hersen and Thomas 2006). Additionally, it has been pointed out that the idea of the unconscious lacks predictive power: although it can function as a good explanation of behaviour, it cannot indicate how people will behave in the future (Abbott 2001). I can see that these are valid criticisms: however, as the next sections show, I feel the concept of the unconscious and its mechanisms invaluable in understanding people better, which I feel is a necessary part of delivering the person-centred care that is a key part of social care in the 21st Century (Joseph Rowntree Foundation 2011).

3. The Unconscious and Organisational Life

As well as being widely influential (though much debated) in psychology generally, the concept of the unconscious and its mechanisms has been incorporated into theories of organisational life. The key element to the idea of the unconscious is the notion that “much of the rational and taken-for-granted reality of everyday life expresses preoccupations and concerns that lie beneath the reality of conscious awareness” (Morgan 1998, p. 186). It follows that organisational theories need to take account of the hidden dynamics which influence the workplace. In addition, it has been suggested that theorists of organisational behaviour have been influenced by unconscious forces such as repression. Morgan 1998, for example, suggests that Taylor’s model of ‘scientific’ and rational management might have been rooted in his puritan background with strong routines and work ethic. Morgan also suggests that the predominant bureaucracy of modern work places might be a function of repression. Worker’s reactions to these types of workplace will depend upon their own mechanisms of regression. In other workplaces, organisational culture can often by dominated by self-centred attempts at wrestling control from others, or the playing out of “a phallic-narcissistic ethos” (Morgan 1998, p. 192) within the workplace. Often, the workplace might reproduce the traditional patriarchal family, with a dominant style associated with ‘male’ qualities of aggression, ambition and rigid rules.

One unconscious mechanism which I was particularly aware of in my placement was projection.In this, workers deal with internal turmoil by attributing the key elements of what is bothering them to someone else rather than themselves. For example, in an organisation, poor results might be blamed by one group (managers) on ground-level staff, and vice-versa (Rashid 1983). Projection has been succinctly defined as the “attribution of one’s own attitudes and beliefs onto others” (Borkowski 2009, p. 56). In order to avoid feelings of guilt or excess anxiety, workers might see their co-workers as possessing the qualities they most dislike in themselves (Borkowski 2009). While it allows the person doing the projecting to protect their self-esteem, the mechanism whereby co-workers, for example, are blamed for putting a person in a bad mood, are damaging to organisational efficiency (Borkowski 2009). It can lead to stereotyping and, through this, to oppressive working methods. stereotyping is a way of organising experience by applying common traits to certain groups of people (the elderly, ethnic minorities, children). While it allows abstract thought to take place more easily, it can lead to the association of negative traits with particular groups. Projection seems to be at work in stereotyping, whereby a group is seen to possess negative characteristics not held by the person ascribing the characteristics. It has been shown that these mechanisms can lead to worse health and social care for certain groups seen as ‘the other’ (Borkowski 2009). One example is that people working with abused children can be marginalised and rendered invisible, as society as a whole does not want to admit that such abuse exists. Nurses are also often forced to bear the brunt of negative projections from service users and other professionals. In addition, social work in general often suffers, as its existence underlines the presence of vulnerable and needy people, mortality and other key issues. These all evoke deep and complex feelings in others, and workers in these professions often bear the weight of others negative expectations, “issues of dependency, aggression and sexuality” Yelloly and Henkel 1995, p. 195).

Within social work, it has been acknowledged that certain forms of practice can be oppressive, particularly to service users but also to other workers. Anti-oppressive practice works to overturn ways of working which marginalise, scapegoat and downplay the people who they work for, both on a personal and micro- level, and at a wider social level. While anti-oppressive practice covers a wide range of activities, becoming aware of the extent to which people are marginalised through unconscious mechanisms such as projection is one key part (Balloch and Hill 2007). Becoming aware of the extent to which negative characteristics are projected onto others, either individuals or groups, is a central step in moving away from oppression. Today, immigrant groups can find themselves scapegoated for the wider problems of society, for example, both by individuals and by political groups (Shulman 2008). Anti oppressive practice offers a way for projection, stereotyping and discrimination to be combated in the workplace, through an attitude of criticality and reflection upon situations in the workplace. The process of uncovering oppression can be likened to that of becoming aware of unconscious processes, as well as uncovering motivations which derive from unexamined unconscious attitudes and mechanisms (Heenan 2011).

4. Understanding the Unconscious and Improved User Outcomes

The ways in which the unconscious operates in the organisational context, the negative impact it can have, and the opportunities it presents for ultimately improving user outcomes is illustrated by my experience working in a children’s home.I have concentrated above on the phenomenon of projection, because this was the unconscious mechanism which most appeared to be in existence during my placement. One child with whom I worked, supporting to live independently after care, would frequently express the opinion that the women staff with whom she came into contact were ‘useless’, were over-emotional, and were not as effective as male staff. I used to find this frustrating, particularly as she was female herself, until I put her case into the context of her background. One of a family of girls, with whom her mother was unable to cope, she had internalised negative feelings about women, developed a androgenous, tomboy-ish appearance herself, and projected doubts and fears about herself onto female staff.

There are also discusses two related unconscious mechanisms (first identified by Melanie Klein), splitting and projective identification, both of which I experienced during my placement.Splitting often occurs in groups, and refers to the process whereby a situation is polarised and seen as ‘black’ and ‘white’, that is, with ‘good’ and ‘bad’ elements. It happens when people are unable to tolerate ambiguity (Zachar 2000). I saw this in group discussions between staff, when one manager who took a fairly strict line to discipline and adherence to regulations was demonised by staff informally after meetings. I felt (perhaps because I was an outsider) that although she might have expressed her ideas better, there was a great deal of sound advice in what she said. However, others seemed unable to see this, preferring to make her a ‘scapegoat’ for everything they disliked about the experience of working in the care home. I also saw this situation improve when a higher manager called a meeting in which we discussed communication styles used within the home.I also saw projective identification, where people unconsciously identify with another person or group, with one staff member, who seemed to project feelings of her own vulnerability (she had just gone through a difficult divorce) onto the female white children in our care. Her attitude towards this gender / ethnic group was markedly different, she would spend extra time with them, and buy small presents. I was present when this was noted by another staff member, who carefully suggested her experience might be leading to her favouritism. She took this suggestion very well, and her behaviour, I noticed, became fairer afterwards.

5. Conclusion

There are some problems with the notion of the unconscious, particularly its lack of predictive power and lack of empirical evidence. However, in terms of my placement in a children’s care home, I have found it a useful way of understanding why people – both staff and clients – behave in the way they do. It also seems to offer a useful tool for moving towards an anti-oppressive practice. In my experience, if people are made aware of the ways in which unconscious mechanisms operate, they are better able to see their oppressive actions, better able to understand why they are acting as they do, and as a consequence able to change the way they behave in a way which is beneficial to clients.

6. References

Abbott, T (2001) Social and personality development Routledge, UK

Balloch, S and Hill, M J (2007) Care, community and citizenship: research and practice in a changing policy context, The Policy Press, Bristol.

Baran, S J and Davis, D K (2011) Mass Communication Theory: Foundations, Ferment, and Future (6th edn.), Cengage Learning, Belmont, CA

Borkowski, N (2009) Organizational behavior, theory, and design in health care, Jones & Bartlett Learning, USA

Foster, A and Roberts, V Z (1998) Managing mental health in the community: chaos and containment, Routledge, UK

Heenan, D (2011) Social Work in Northern Ireland: Conflict and Change, The Policy Press, Bristol.

Joseph Rowntree Foundation (2011) ‘Transforming social care: sustaining person-centred support’, Joseph Rowntree Foundation, UK

McKenna, E F (2000) Business psychology and organisational behaviour (3rd edn.), Psychology Press, UK

Morgan, G (1998) Images of organization, Berrett-Koehler Publishers, California CA.

Nelson, D L and Campbell, J (2010) Organizational Behavior: Science, the Real World, and You (7th edn.), Cengage Learning, Belmont, CA.

Rashid, S A (1983) Organizational Behaviour, Taylor & Francis, UK

Saiyadain, M S (2003) Organisational Behaviour,m Tata McGraw-Hill Education, India.

Shulman, L (2008) The Skills of Helping Individuals, Families, Groups, and Communities (6th edn.), Cengage Learning, Belmont, CA.

Thomas, J C (2006) Personality and everyday functioning, John Wiley and Sons, Hoboken, NJ.

Yelloly, M and Henkel, M (1995) Learning and teaching in social work: towards reflective practice (2nd edn.), Jessica Kingsley Publishers, UK

Zachar, P (2000) Psychological Concepts and Biological Psychiatry: A Philosophical Analysis, John Benjamins Publishing Company, USA

Free Essays

Work-life conflict


Work-life conflict is among the human resource challenges that adversely affects the productivity of employees and leads to physical and psychological health issues. This paper provides an in-depth discussion of this issue, addressing its causes and consequences. It also refers to psychological theories on work-life balance to provide a more in-depth understanding of the issue. To ensure that there is a work-life balance; organisations have to implement strategies that help employees to cope with their family and workplace responsibilities. Some of these strategies, as well as legal requirements for employers, have also been discussed in this paper.


Employees play a vital role in any organisation. Thus, it is vital for human resource managers to ensure that employee productivity is optimal. One of the factors that may affect employee productivity is work-life conflict (McNamara, et al., 2011). It is defined as an inter-role struggle, where work and family burdens are conjointly incompatible, such that the demands on one end make it difficult to fulfil the demands on the other end (Messersmith, 2007). For organisations that intend to maintain their competitive advantage, it is vital for them to create a work environment allows for a balance between family or life responsibilities and workplace responsibilities. Whereas this is known by many employers across the globe, there are still many cases of work-life conflicts in many organisations. Employees also play a role in ensuring that they have a balance between their work and families (Yuileet al., 2012). For instance, there are employees who are excessively obsessed with their workplace. This therefore limits the time for their family and social life (Rantanen, et al., 2011). This paper discusses the issue of work-life conflict, its common nature, the causes and consequences of the challenge, the psychological understanding of the challenge as well as key policy and legal consequences from the occurrence.

Work-life Conflict

As aforementioned, this conflict occurs as a result of an incompatibility of demands that work and family place on an individual (Messersmith, 2007). This conflict is bi-directional, meaning that it the productivity of employees at the workplace and also adversely impacts on the delivery of family responsibilities (Rantanen, et al., 2011). According to Robbins and Judge (2012), work-life conflict has two main components. One of these is the practical component that comprises of scheduling issues, where individuals cannot be in more than one place at a time. The other component is the stress that occurs as a result of overloading employees with many responsibilities (Robbins & Judge, 2012).

The issue of work-life conflict can be classified into several categories. These include role overload, family to work interference and work to family interference (Turner et al., 2014). Role overload is experienced when demands in terms of energy and time – both in their families and at the workplace – are too much for an employer to handle comfortably (Lapierre et al., 2012). Work to family interference occurs when workplace commitments make it challenging to fulfil family responsibilities. Family to work interference refers to the interference of family responsibilities with workplace productivity (ten Brummelhuis et al., 2010).

Commonness of Work-life Conflict

Even though the technological developments that have taken place within the past decade are expected to have made organisations more flexible in scheduling to reduce work-life conflict, this issue is still rampant in the United Kingdom. For instance, the maximum working hours per week in the UK are 48. However, as established by Crush (2011), there were more than four million Britons working for more 48 hours in 2011. It was also established that more than five million Britons work for an average of more than seven hours per week without payment. In a survey that was carried out by Robert Walters, a recruitment agency, it was found that approximately 30% of human resource professionals, lawyers and financial risk professionals work for more than 50 hours weekly (Crush, 2011). Even though it is impossible to estimate the commonness of all forms of work-life conflicts in the United Kingdom, the mentioned statistics indicate that this issue affects many companies. In terms of gender, Lyness and Judiesch (2014) argue that women are faced with more work-life conflict issues as compared to men based on the fact that they typically have more family roles than their male counterparts.

Causes of Work-life Conflict

The different types of work-life conflicts have different causes. One of these is an overload of roles both at their workplaces and in their families, which may be too heavy and taxing to an employee. This makes it practically impossible for the employee to satisfy the role demands on either side of the conflict (Makela & Suutari, 2011). Whereas employers are responsible for overloads at the workplace in most cases, it may also be as a result of an increased ambition by employees, who may take up a lot of work-related responsibilities to achieve certain monetary goals or promotions (Yuile et al., 2012). Conflicts may also occur due to the interference of an individual’s work by family demands and responsibilities, where tasks emanating from the family infiltrate into the responsibilities that are demanded from the employee at the workplace (Yuile et al., 2012). This often happens to single parents who end up having so many responsibilities to their children such that it often leads to their arriving at work late or having to think more about their families while at work than they concentrate on their jobs. This may drain the employee’s energy, time and financial resources (Inman et al., 2014 ).

Consequences of Work-life Conflict

There are many effects that arise from work-life conflict, which all lead to reduced performances in both family and workplace responsibilities. Several researches that have been carried out on of work-life conflict have established that it has a negative impact on both physical and psychological health of individuals. For instance, McNamara et al., (2011) established that work-life conflicts cause burnouts that are more related to emotional exhaustion. They also established that it leads to physical health issues like fatigue, poor appetite and high blood pressure, among others. In another research that was carried out by Makela and Suutari (2011), it was established that increased work-life conflicts increase depression and stress. Even though many researchers argue that there work-life conflict has adverse impacts on employees, Sullivan, Yeo, Roman, Bell Jr, and Sosa (2013) argue that the intensity of these impacts varies with the individuals being subjected. For instance, he established that married people are more affected than those who are single.

Psychological Theories relating to Work-life Conflict

Based on the interest that this subject has elicited in researchers, several theoretical frameworks that can be used to understand work-life conflict and work-life balance have been suggested. One of these is overall appraisal and components approach (Tyson, 2012). The overall appraisal approach is referred to as a general assessment of an individual’s life situation. It explains work-life balance as a “satisfaction and good functioning at work and home, with a minimum of role conflict” (Clark, 2000, p751). It also considers work-life balance as the sufficiency of family and work resources to facilitate effective participation on both sides. Though it has helped in understanding work-life conflict of balance, this theoretical approach has been criticised for being too general in addressing this issue without pointing out the specific components of work-life conflict. The components approach, on the other hand, is based on an understanding that work-life conflict occurs as a result of several facets, which include involvement, satisfaction and time (Grzywacz & Marks, 2000). Thus, for there to be a balance, there has to be a balance in time devotion, psychological investment and satisfaction, both at the workplace and at home.

How to Prevent Work-life Conflict

Based on the theoretical frameworks that have been mentioned above, it can be argued that it is vital to ensure a work-life balance (Clark, 2000). The management has a role to play in this regard in improving the lives of their employees so as to improve the results of the organisations that they work for. One approach that can be used is introducing alternative working arrangements for employees. This may be done through the introduction of flexibility at work, such as the times of arrival and departure, or even occasionally shuffling work schedules for employees (Ford et al., 2007). This reduces the stress caused by boredom and routines that easily culminate in work-related stress, and get into new and positive changes of their new roles at work (Lyonette et al., 2007). There is however a possibility that the initial stages of routine change might reduce employee productivity as employees may need some time to adjust into their new schedules and roles.

Organisations can also provide work-life benefits to employees, so as to enable them have ample times with their families and consequently produce better results for the organization as they perform better at work (Inman et al., 2014). Such employer benefit mechanisms may include being given personal days off especially when the employee has been consistent at work for a long time and has achieved greatly for the firm, as an appreciation (Tyson, 2012). It may also include the provision of facilities that would enable persons to carry out their work responsibilities while at the same time having the confidence that their family matters are well taken care of such as the provision of day care facilities in the office, or the creation of a gym at the gym (Yuile et al., 2012).

Besides the mechanisms that organisations may lay in order to aid their suffering employees from mental problems brought about by work-life imbalances, employees may themselves also create measures that may enable them create effective work-life balances (Grzywacz & Marks, 2000). For instance, employees may create the social support systems or programs that enable colleagues to guide, support and counsel each other.

Key policy and legal requirements that employers must consider

Employers in all organisations are bound by legal mechanisms and government policies that obligate them to do certain things and sanction them against doing others (Sanseau & Smith, 2012). For instance, with reference to the Employment Rights Act 1996 c. 18 Part V, employers are legally bound by the fact that they are meant to create conducive atmosphere for their employees as they carry out their duties (, 1996). All employees have a right to work under surroundings that augur well with their trade of work and they must be protected from physical and emotional harm that may emanate from their duties (Lyness & Judiesch, 2014).

Another legal binding is the ‘working hour directive’ (Directive 2003/88/EC). Employers are bound by the legal provisions that require working hours to be at a maximum of 48 hours a week, unless employees willingly choose to work for more (European Parliament, 2003). Any employer who requires his employees to work beyond these hours time must provide overtime remuneration. Such working hours must also be understood to include breaks in between them to allow employees to work better (Yuile et al., 2012). This provision was enacted to ensure that workers are able to even out and balance their work and private lives, where more time is left for the workers to spend with their families in order to improve their psychological situations (European Parliament, 2003).

There is the holiday entitlement act requires employers in the UK to allow their employees to take a 5.6 week annual leave every year (, 2014). In addition to this, there are also paternity and maternity leaves that employees are entitled to. These leaves allow them to keep off work to rejuvenate their minds (Hill et al 2010). Employers must therefore ensure that such leave is adhered to and consequently the employees are in a better position to improve their work-life conflicts as they spend more time with their families. Certain organisations go to the extent of paying for holiday for their employees, especially their top management employees, during these periods of leave (Makela & Suutari, 2011).


This paper has addressed several aspects of work-life conflicts at the workplace. These include its causes, consequences and approaches that companies can use in overcoming this challenge. It has also referred to some theoretical frameworks to help in creating an understanding of this subject. As argued in this paper, work-life conflicts have a major impact on the productivity of employees. This conflict is brought about by several factors which include the heavy workloads that individuals may be accustomed to at their homes and workplaces, work to family interferences and family to work interferences. All these affect the physical and mental capacities of employees, affecting their ability to handle their workplace and family responsibilities. In order to avoid these adverse consequences, organisations need to adopt various mechanisms to ensure that there is a work-life balance among employees. Employers are also legally bound to ensure that their employees are not overworked at the expense of their families.


Armstrong, M. (2008). Strategic Human Resource Management: A Guide to Action. London: Kogan Page.

Clark, S. (2000). Work/family border theory: a new theory of work/family balance. Human Relations, 53, 747-770.

Crush, P. (2011, 6 18). What happened to our work-life-balance. The Guardian .

European Parliament. (2003). Directive 2003/88/EC of the European Parliament and of the Council of 4 November 2003 concerning certain aspects of the organisation of working time. Retrieved 6 19, 2014, from

Ford, M. T., Heinen, B. A., & Langkamer, K. L. (2007). Work and family satisfaction and conflict: a meta-analysis of cross-domain relations. Journal of Applied Psychology, 92 (1), 57. (2014). Holidays, time off, sick leave, maternity and paternity leave. Retrieved 6 20, 2014, from

Grzywacz, J. G., & Marks, N. F. (2000). Reconceptualizing the work-family interface: an ecological perspective on the correlates of positive and negative spillover between work and family. Journal of Occupational Health Psychology, 5, 111-126.

Inman, M., O’Sullivan, ?N., & Murton, ?A. (2014 ). Unlocking Human Resource Management. New Jersey: Routledge.

Lapierre, L. M., Hammer, L. B., Truxillo, D. M., & Murphy, L. A. (2012). Family interference with work and workplace cognitive failure: The mitigating role of recovery experiences. Journal of Vocational Behavior, 81 (2), 227-235. (1996). Employment Rights Act 1996. Retrieved 6 20, 2014, from

Lyness, K. S., & Judiesch, M. K. (2014). Gender egalitarianism and work–life balance for managers: Multisource perspectives in 36 countries. Applied Psychology, 63 (1), 96-129.

Lyonette, C., Crompton, R., & Wall, K. (2007). Gender, Occupational Class and Work–Life Conflict: a Comparison of Britain and Portugal. Community, Work and Family, 10 (3), 283-308.

Makela, L., & Suutari, V. (2011). Coping with work?family conflicts in the global career context. Thunderbird International Business Review, 53 (3), 365-375.

McNamara, M., Bohle, P., & Quinlan, M. (2011). Precarious employment, working hours, work-life conflict and health in hotel work. Applied ergonomics, 42 (2), 225-232.

Messersmith, J. (2007). Managing work?life conflict among information technology workers. Human Resource Management, 46 (3), 429-451.

Rantanen, J., Kinnunen, U., Mauno, S., & Tillemann, K. (2011). Introducing theoretical approaches to work-life balance and testing a new typology among professionals. In Creating Balance(pp. 27-46). Berlin: Springer Berlin Heidelberg.

Robbins, S. P., & Judge, T. A. (2012). Organizational Behavior. New Jersey: Prentice Hall.

Sanseau, P. Y., & Smith, M. (2012). Regulatory change and work-life integration in France and the UK. Personnel Review, 41 (4), 470-486.

Sullivan, M. C., Yeo, H., Roman, S. A., Bell Jr, R. H., & Sosa, J. A. (2013). Striving for Work-Life Balance: Effect of Marriage and Children on the Experience of 4402 US General Surgery Residents. Annals of surgery, 257 (3), 571-576.

ten Brummelhuis, L. L., Bakker, A. B., & Euwema, M. C. (2010). Is family-to-work interference related to co-workers’ work outcomesJournal of Vocational Behavior, 77 (3), 461-469.

Turner, N., Hershcovis, M. S., Reich, T. C., & Totterdell, P. (2014). Work–family interference, psychological distress, and workplace injuries. Journal of Occupational and Organizational Psychology, 3(8), 57-71.

Tyson, S. (2012). Essentials of Human Resource Management. Oxford: Routledge.

Yuile, C., Chang, A., Gudmundsson, A., & Sawang, S. (2012). The role of life friendly policies on employees’ work-life balance. Journal of Management and Organisation, 18 (1), 53-63.

Free Essays

Although the foetus has no right to life, its interests are adequately protected by English law.


The right to life is a moral principle that is based upon the premise that all individuals have a right not to be killed by another human being. This concept that is central to the debates surrounding abortion since it is often contested whether unborn children should also have the right to life. Those in favour of abortion often take the view that a foetus is not sufficiently human to be capable of acquiring a right to life, whilst those in opposition believe that a foetus is human and that its right to life should therefore be protected. There is currently no direct right to life that is provided to a foetus, yet the law in the UK does make some attempt to protect its interests. This essay will focus on the interests that are provided to foetus’ in order to consider whether adequate protection is in place. In doing so, it will be examined whether every woman should have a right to abortion on demand or whether the interests of the foetus should be given due consideration. Accordingly, it will be shown that because there are arguments for and against the interests of the foetus, it is necessary for the law to strike a balance between the two competing interests. This does appear to have been achieved to a certain degree since the interests of the mother are being preserved, whilst also providing some protection to the foetus.

The right to life

The right to life is provided to all individuals under Article 2 of the European Convention of Human Rights (ECHR) 1951, as incorporated by the Human Rights Act (HRA) 1998. Whether or not a foetus has a right to life, however, is a highly contested topic because although the foetus does not have a right to life per se, it appears as though its interests are still being protected by the law to a certain extent.[1] On the one hand, it is believed that all women should have the right to do as they wish with their own bodies and that they should therefore have a right to abortion, yet on the other it is believed that the interests of a foetus should be provided with adequate protection.[2] The law in England does seem to have attempted to strike a balance between these two competing interests by permitting abortion, whilst at the same time imposing some restrictions. Under English law (Human Fertilisation and Embryology Act 1990) abortion is permitted until the 24th week of a pregnancy. Whilst this provides women with the right to choose what to do with their own bodies, it prevents them from having abortions in the later stages of pregnancy. Because abortion is not legally available at the request of the woman, it has been argued by the Abortion Rights Campaign that; “women’s access to abortion can be and is still threatened.”[3] This is because, once a woman has decided that she wants to have an abortion, she will first be required to persuade two doctors to agree to her decision taking into consideration certain restrictive legal criteria.[4]

Therefore, even though women are capable of having an abortion up until the 24th week of pregnancy, it will be the doctors that make the final decision. And, if they do not agree that the relevant criterion has been satisfied, they will not have to carry out the abortion. This protection is in place to enable the rights of the unborn child to be ascertained in circumstances which would render an abortion unlawful. However, the extent to which such rights are being adequately protected is in fact arguable. Confliction continues to arise in this area because of the difficultly in striking a balance between the rights of the foetus and the rights of the mother. It cannot be said that this balance is currently being achieved as there remains strong opposition of both viewpoints. As pointed out by Mason and Laurie; “attitudes to abortion depend almost entirely on where the holder stands in respect of, on the one hand, the foetal interests in life and, on the other, a woman’s right to control her own body.”[5] Consequently, because the difference in opinions is based upon moral values rather than empirical facts, it is unlikely that such confliction will ever be resolved.[6] In effect, it is unlikely that a solid understanding of the rights in this area will ever be made as the controversy surrounding abortion will continue to exist.

The Foetus’ Right to Life

It is believed that the Abortion Act 1967 violates Article 2 of the Convention on the Rights of the Child on the basis that a child’s rights are not being adequately protected if women are able end their pregnancy if they so wish.[7] Section 1 of the 1967 Act provides that; “a person shall not be guilty of an offence under the law relating to abortion when a pregnancy is terminated by a registered medical practitioner.” In effect, women will not be found guilty of an offence is they decide to have an abortion. Whilst this section does appear to undermine the rights of the foetus, the fact that the termination must be conducted by a registered medical practitioner acting in good faith suggests that some form of protection will still be in place. Furthermore, as put by Herring; “for an abortion to be lawful, the abortion must comply with the requirements of the 1967 Abortion Act.”[8] Section 1 will therefore only apply if certain provisions can also be satisfied. Nevertheless, because abortions are rarely ever refused, it could be said that the provisions under Article 2 are being undermined and that the interests of the foetus are not, in reality, being adequately protected. In view of this, it has therefore been argued by Foster that the 1967 Act is not being used in the way that Parliament intended and that abortion are instead being used as another form of contraception.[9] This demonstrates how abortion is easily accessible to women, which limits the protection that is currently being provided to the foetus. It is likely that doctors will only refuse to conduct an abortion if the woman’s pregnancy has gone past the 24 week threshold or if the circumstances are exceptional.

This signifies how the rights of unborn children are not being preserved, yet it is debatable whether further protections ought to be in place. The right to life is an extremely sensitive subject since it basically provides a right to every human being not be killed.[10] However, much complexity exists when considering the right to life in the context of unborn children. It is difficult to determine whether the mother’s rights should prevail over the rights of the unborn child or vice versa. However, it has been said that the right to life is a human right that is “inviolable and must be protected at all costs.”[11] If this statement was to be taken strictly, every abortion would be considered a violation of one’s human rights and would not be permitted. However, in order to ensure that the rights of the mother are also being protected it is necessary that abortions are permitted in certain circumstances. This would ensure that a balance is attained between the two competing interests by allowing abortions to take place only if it is deemed necessary. Consequently, abortions should not be used carelessly as another form of contraception and this would means that the rights of the mother are being given greater consideration than the rights of the foetus. Abortions should therefore not be as accessible as they currently are and should only be permitted in limited situations. It is unclear what extent the interests of the foetus are actually being considered and it seems as though the right to life is being violated by the abortion process and so further protections may need to be provided to the foetus so that the rights of unborn children are given the same considerations as the mother.

At present, it appears as though the rights of the mother prevail over the rights of the foetus, despite the restrictions that are in place. In order to ensure that the foetus right to life is being protected, it is necessary to impose further restrictions upon the mother’s ability to have an abortion. At present, a mother is capable of aborting a foetus for various reasons including the fact that the child will suffer from a disability. Many people do not agree that this should be a reason to end the life of a foetus, though it is legal in the UK for a woman to abort a baby on grounds of disability up to birth. As a result of this many parents opt for an abortion if pre-natal screening reveals that their baby is suffering from a disability. Moreover, it has also been suggested that the parents are even put under pressure to do so.”[12] The Society for the Protection of Unborn Children strongly disagrees with this approach and believes that; “a person with a disability has the right to life along with every other member of society: aborting a baby because he or she has, or even might have, a disability, is the ultimate form of discrimination.”[13] It cannot be said that the foetus’ right to life is being upheld as a result of this since they can be terminated at any point if they are found to have a disability. Not only does this undermined their right to life but it also discriminates against them on the grounds of their disability. As such, the provisions under the Disability Discrimination Act 1995 are too not being complied with. In Vo v France,[14] however, it was made clear that Article 2 of the Convention is “silent as to the temporal limitations of the right to life, and in particular does not define ‘everyone’ whose life is protected by the Convention.”

Effectively, it is clear that because Article 2 does not provide a definition as to who shall be protected, it is likely that the rights of the foetus will continue to be restricted. Jackson does not believe that the moral status of the foetus should be sufficiently wide enough to make abortion unlawful,[15] however, and it seems as though the European Court of Justice is also reluctant as identified in Open Door and Dublin Well Woman v Ireland.[16] Furthermore, in the case of X v United Kingdom[17] the ECJ also stated that the right to life would be subject to an implied limitation in order to respect the mother’s life even if this was at the expense of the foetus’ right to life under Article 2. Furthermore, it was also expressed in Paton v United Kingdom[18] that; “the life of the foetus is intimately connected with, and cannot be regarded in isolation from, the life of the pregnant woman.” This limited the rights of the foetus even further as it was demonstrated that the right to life under Article 2 was not available even though the abortion was not considered necessary to protect the life of the mother. This was also identified in H v Norway,[19] which illustrates that even if an abortion occurred as a result of the mother’s choice and there lacked any specific reason for terminating the pregnancy, Article 2 will still not be capable of providing protection to a foetus if this is at the expense of the mothers rights. This seems to indicate that unborn children are not actually provided with any rights despite the fact that Article 2 initially seemed to protect such interests. The termination of a pregnancy will continue to be a morally and ethically complex issue, particularly if the reason for aborting relates to a foetal abnormality.[20] It has been pointed out that a clear legal framework is needed because of the complexities that exist in this area, though it was noted that this continues to prove extremely difficult to create.[21]

The Rights of the Mother

Whilst it is believed by many that the rights of the foetus should be given due consideration, it is equally argued that the rights of women should be considered foremost when deciding whether an abortion is lawful or not. This was shown in Roe v Wade[22] where it was made clear by the Court that a person has a right to abortion unless the foetus has become viable. This means that the foetus does not become a human being until it is capable of living outside the mother’s womb without any artificial aid.[23] Although this decision was made by a Court in the US, it sparked a significant amount of debate. It was argued on the one hand that a foetus becomes a child whilst it is still in the womb and that the decision whether or not to allow abortion to take effect should not be based upon whether a foetus has the capacity to enjoy life as a person.[24] It has been said that the decision in this case effectively allows an abortion on demand to take place.[25] On the other hand, however, it has been expressed by Loveland that; “the judgment neither produced abortion on demand nor allowed states to prevent late-stage terminations.”[26] The decision in Planned Parenthood v Casey[27] imposed further limitations on the rights of the mother when it was found that the viability period would be reduced from 24 weeks to 22 weeks. It is questionable whether this was sufficient in ensuring that the right to life of the foetus under Article 2 was being provided with greater protection since the rights of the mother will continue to prevail in the majority of situations.

It could be said that it is necessary for the mother’s rights to be ascertained over the rights of the unborn child because women should be regarded as individuals as opposed to being merely containers for the foetus. In accordance with this, greater consideration should be given to the rights of the mother, though some protections should also be available for the unborn.[28] Arguably, it is important that both the rights of the mother and the unborn child shall be considered, though much more weight ought to be given to the mother’s interests as she is already considered a viable person. It has been contended by Herring that; “women who want an abortion should not be required to continue with the pregnancy.”[29] Therefore, although Article 2 expressly states that the right to life is to apply to “everyone”, the extent to which this applies to the foetus is arguable in view of the confliction that exists between the rights of the mother and the rights of the foetus. In A-G’s Reference (No 3 of 119)[30] it was noted that a foetus is not regarded as a “person” and will therefore not be directly protected by Article 2 of the Convention. It was further added that the only right to life in which a foetus has is implicitly limited by the mother’s rights and interests. This suggests that a foetus will only be provided with the right to life indirectly from the mothers right under Article 2. It is unclear whether this completely undermines a foetus’ right to life, though it seems likely given that that Article 2 will not be violated if a pregnancy is terminated. The Courts have expressed great reluctance to elucidate on this matter, by assessing whether Article 2 will provide rights to the foetus or not, because of the existing moral and ethical considerations.

As a result, great complexity continues to exist within this area of the law and unless Article 2 is more clearly defined, complexity will continue to ensue. Yet, because of the moral issues that are prevalent throughout, it seems as though a single approach would not be workable. Therefore, the decision as to whether an abortion should be permitted or not will continue to be decided on a case by case basis. As such, it will depend primarily upon the circumstances of each case. This allows a certain degree of flexibility to exist which is necessary given that each case will differ from the next. However, it is likely that the rights of the mother will continue to be favoured over the rights of the unborn child. Nevertheless, because of the politics that surround abortion, the European Court of Human Rights has been said to be “wary of making a general rule concerning the legal status of the foetus, preferring to leave this question to the margin of appreciation.”[31] It cannot be said that this is acceptable given the ambiguity that arises within this area. But because there is no right or wrong answer as to whether the rights of the mother should prevail over the rights of the foetus the legal status of the foetus could not be defined by the Courts without attracting opposition. It could be said that the UK has made some attempt to identify the rights of the foetus despite the fact that no right to life exists, yet the extent to which these interests are being protected will be likely to remain debated. When the case of Vo was brought before the ECHR they appeared to focus more on the question as to when life begins as well the nature and characteristics of the foetus, as opposed to focusing on the relationship between the mother and her potential child and the others right to reproductive freedom and autonomy.[32]

Therefore, the approach taken by the ECHR should have been based upon the recognition of foetal interests as well as the loss of a mother’s relationship. Whilst this would not have addressed all of the difficulties that arise in this area, it would have provided some recognition as to the interests of the foetus. Much more needs to be done if foetal interests are to be provided with greater protected, whilst at the same time maintaining the rights of the mother. The rights of the mother appear to be protected in favour of the rights of the foetus, yet it has been said that this ensure the human dignity of the mother is being preserved.[33] This is because if a mother was not provided with the choice to terminate a pregnancy, it is likely that their human dignity would be violated. Whilst this this may be at the expense of the rights enshrined in Article 2, it is deemed necessary in protecting the mother’s interests.

Balancing the Rights

It is doubtful that the rights of the foetus and the rights of the mother are being balanced since the rights of the foetus continue to be undermined. Whilst there are some protections in place to preserve the interests of the foetus, these do not appear sufficient and so it seems as though tighter restrictions ought to be implemented to ensure that abortion is not easily accessible. This would allow for a more acceptable balance to be attained because at present it seems to be largely one-sided. If abortion was only permitted in extreme circumstances, it would not be capable of being used as another form of contraception and the interests of the foetus would be better recognised. On the contrary, it is argued that further limitations would limit the mothers freedom to choose and their own rights would be undermined if Article 2 was to provide express rights to unborn children. Therefore, whilst abortion should still be permitted, limitations should be imposed so that the rights of the foetus are given better protection. It is unclear whether judges should be left to make a decision on whether an abortion is lawful or not since opinions will differ significantly on this subject. Thus, it cannot be said that judges should be left to decide upon moral issues. Whilst one judge may agree with abortion, another judge may not as individuals have different perceptions on what is and what is not morally right. This is why the courts have been quite reluctant to use a single approach when deciding upon the interests of a foetus and it seems that the matter is better left undefined.

This was identified by Sandel when it was argued that there are differences of opinions as to whether abortion is morally reprehensible and therefore worthy of prohibition, whilst many avoid passing judgment on the morality of these practices.[34] The ECHR appears to have adopted the latter approach, by failing to provide a decision on the legal status of foetus’. This lack of definition may actually be in the interests of the foetus since rights are capable of being provided that may not have been had a definition been in place. The determination as to whether abortion should be a mother’s choice or not will be capable of being assessed differently in all cases. This is necessary given the diverging opinions that exist since it will continue to be argued by many that Article 2 should provide a right to “anyone” including unborn children, whilst others will continue to be of the view that the decision should be left with the freedom of choice as protected under Article 13 of the Convention. The current practice that is being adopted in striking a balance between the two competing interests does appear to be the most plausible approach to take since each case will be determined by its facts. This could, however, lead to judicial activism occurring, which appears to have happened in the Roe case above which was described by Thielen as “an incredible reach of judicial activism.”[35] Judicial activism occurs when a ruling is said to be based upon political or personal considerations as opposed to being based upon existing law.[36] Therefore, if when Courts are provided with the ability to decide upon matters concerning abortion, judicial activism is likely to emerge which undermines social policy and, in some instances, human rights. Still, as put forward by Ewing and Gearty; “English judges have shown a powerful engagement with the rights of the unborn in the past,”[37] yet whether violations of one’s human rights are arising out of this is likely and it seems quite difficult for a balance to be achieved between the rights of the unborn with the rights of the mother.


This area is extremely controversial and because of this it is difficult for legislators as well as the judiciary to make a decision as to whether a foetus does have rights. Many people are of the view that every woman should have the right to choose whether or not to have an abortion, yet not all agree with this. Instead, it is argued that women are capable of using abortion as a form of contraception because of how easily accessible it is. Whilst there are some restraints in place to prevent this from happening, such as the requirement to obtain permission from two doctors, it cannot be said that such measures are effective. This is because it is highly unlikely that an abortion would be refused unless the stages of pregnancy have gone past the 24 week threshold. Furthermore, because women are permitted to have an abortion past this stage if the unborn child is suffering from a disability, the rights of the foetus are being undermined even further. It is therefore questionable whether the current law is effective in preserving the interests of the foetus since the law has not made it difficult for abortions to be performed. Therefore, it could be said that further restrictions are needed so as to balance the rights of the mother with the rights of the unborn child. Conversely, because there is a limit on the number of weeks a person can abort a foetus, it could be said that their interests are being adequately protected to a certain degree. Whether this is sufficient, however, is likely to remain a contestable subject for many years to come as there will continue to be differing opinions as to whether abortion should be so easily available. In effect, there are both strengths and weaknesses for right to abortion, yet it is questionable whether the strengths do in fact outweigh the weaknesses.



A-G’s Reference (No 3 of 119) [1998] AC 245
H v Norway (1992) 73 D & R 155
Open Door and Dublin Well Woman v Ireland (1992) 14 EHRR 244
Paton v United Kingdom (1980) 3 EHRR 408
Planned Parenthood v Casey (1992) 404 U.S. 833
Roe v Wade (1973) 410 U.S. 113
Vo v France Judgement of 8 July 2004 40 EHRR 12
X v United Kingdom (1980) 19 D & R 244


Abortion Act 1967

Disability Discrimination Act 1995

European Convention of Human Rights 1951

Human Fertilisation and Embryology Act 1990

Human Rights Act 1998


Herring, J. Law Express: Medical Law (Revision Guide), Longman, 2nd Edition, (2009).
Herring, J. Medical Law and Ethics, OUP Oxford, 3rd Edition, (2010).
Hope, T., Savulescu, J. and Hendrick, J. Medical Ethics and Law: The Core Curriculum, Churchill Livingstone, 2nd Edition, (2008).
Kaczor, C., The Ethics of Abortion: Women’s Rights, Human Life, and the Question of Justice, (Routledge: London, 2013).
Kennedy, I., Grubb, A., Laing, J. and McHale, J. Principles of Medical Law, OUP Oxford, 3rd Edition, (2010).
Jackson, E. Medical Law: Text, Cases and Materials (Text, Cases and Materials), OUP Oxford, 2nd Edition, (2009).
Mason, K. and Laurie, G. Mason and McCall Smith’s Law and Medical Ethics, OUP Oxford, 8th Edition, (2010).


Abortion Rights Campaign, Why women need a modern abortion, law and better services, Available [Online] at:
BBC, Women’s Rights Arguments in Favour of Abortion, Ethics Guide, (1992), Available [Online] at:
K.D and Gearty. CA, Terminating Abortion RightsNew Law Journal, 142 NLJ 1969, Issue 6579, (04 December, 1992).
C, Forty Years On, New Law Journal, 157 NLJ 1517, Issue 7295, (02 November, 2007).
Frankenburg, G., ‘Human Rights and the Belief in a Just World’ International Journal of Constitutional Law, Volume 12, Issue 1.
Holetzky, S. What is Judicial Activism(04 February, 2010), Available [Online] at:
Human Rights, Right to Life: Not just an abortion issue, Available [Online] at:
I, A Vacancy in the Supreme Court, New Law Journal, 144 NLJ 537, Issue 6644, (22 April, 1994).
McCrudden, C. Human Dignity and Judicial Interpretation of Human Rights, European Journal of International Law, EJIL 2008 19 (655), Issue 4, (01 September, 2008).
O’Donovan, K. Commentary, Medical Law Review, Med Law Rev 2006 14 (115), (01 March, 2006).
Sandel, M. J. Symposium: Law, Community, and Moral Reasoning Moral Argument and Liberal Toleration: Abortion and Homosexuality, California Law Review, 77 Calif. L. Rev. 521, (May, 1989).
The Society for the Protection of Unborn Children, SPUC, Abortion and disability or eugenic abortion, Available [Online] at:
Thielen, D. Overturn Roe v Wade, Liberal and Loving It, (2005), Available [Online] at:
Wicks, E., Wyldes, M. and Kilby, M. Late Termination of Pregnancy for Foetal Abnormality: Medical and Legal Perspectives, Medical Law Review, Med Law Rev 2004.12 (285), (01 September, 2004).

Free Essays

How the teachings of Muhammad ibn Abd al-Wahhab influenced everyday life in Saudi Arabia


Commins (2006, p. 97) asserts that the teachings of Muhammad ibn Abd al-Wahhab have influenced the contemporary political and cultural environment in Saudi Arabia. This religious movement, commonly referred to as the Wahhabi movement started in central Arabia in the mid-18th Century and grew because of the preaching and scholarship of Muhammad ibn Abd al-Wahhab. According to Zayd (2006, p. 41), Muhammad ibn Abd al-Wahhab was a scholar of Islamic jurisprudence who received his education in Mesopotamia and Hijaz and then returned to Najd (central Arabia) to advocate for Islamic reforms. This paper explores how his teachings influenced the everyday life in Saudi Arabia.

Allen (2006, p.89) says that Muhammad ibn Abd al-Wahhab was concerned with the practices of the people of Najd, which he regarded as polytheistic and wanted them to stop the practices. He wanted reforms that would remove all practices that were added to Islam after the death of Mohammad. He was against practices like using votive and sacrificial offerings, veneration of caves, stones and trees, celebration of birthdays of prophets, praying to saints and making pilgrimages to special mosques and tombs. These were common practices in Najd and the people here regarded them as being in compliance with Islamic teachings. However, to Muhammad ibn Abd al-Wahhab they were polytheistic. He was concerned with these practices because he perceived them as being lax in terms of adherence to Islamic law. In addition to this, he was also concerned with the fact that the people were reluctant to perform religious devotions like disregard to obligatory prayers, not showing care to the widows and orphans, rampant adultery and failure to give women their fair share of inheritance. These practices formed the basis of his preaching as he was determined to make the people change their ways of life and start living in full compliance with Islamic laws.

Weston (2008, p. 11) asserts that his teachings revolved around the breaches of Islamic laws and emphasised the need to comply with all customary practices like jahiliya. He initially encountered opposition but eventually overcame it by forming an alliance with Muhammad ibn Saud, a local chieftain. This alliance ensured that his influence endured through difficult times because Muhammad ibn Saud was very powerful in southern Najd. Muhammad ibn Abd al-Wahhab and his descendants converted the alliance that was initially for political loyalty into religious obligation that had to be followed by everyone. In his teachings, he insisted that all Muslims must present an oath of allegiance (bayah) to Muslim leaders when alive so that they can get redemption when they die. He emphasised that Muslim leaders must be given unquestionable allegiance from the people as long as they are providing leadership that is in full conformity with Islamic laws. He held the perception that the purpose of the Muslim community was to be a living embodiment of Islamic laws (Hegghammer & Lacroix 2011, p. 64). The responsibility of ensuring that the community knows and conforms to the laws of God lay squarely on the legitimate rulers. Muhammad ibn Abd al-Wahhab and his followers then started a jihad targeting the backsliding Muslims in the region to ensure that there is total obedience to Muslim rulers and God. This was the beginning of religious intolerance in Saudi Arabia.
Fatah (2008, p. 77) claims that the key message in the teachings of Muhammad ibn Abd al-Wahhab was tawhid (oneness of God). Tawhid is very important in Saudi Arabia and it is emphasised by both state and religious leaders. It is for this reason that its adherents call the movement as the call for unity (ad dawa lil tawhid). He was against third party intercession and all prayer rituals because he considered them as leading to shirk. This is why he objected Sufi mysticism, celebrating the birthdays of prophets and Shia mourning ceremonies which were considered as religious festivals. As a consequence grave marking, building of tombs and any other shrines are forbidden in Wahhabism. However this is partly practised in Saudi Arabia because the shrine of Prophet Muhammad is in the country and Muslims go there to pay pilgrimage.
They only accept authority from the Sunna and Quran and disregard any reinterpretation of the two books on issues that were already settled by the previous jurists. They totally remain opposed to reinterpretation but give allowance for interpreting the areas not decided by the earlier jurists. Livingstone (2011, p. 50) suggests that they literally interpret the Sunna and Quran and aim towards enforcing parochial Najd practices. The religious and political leadership work collectively in ensuring that there is conformity in behaviour throughout the country.
Life in Saudi Arabia is guided by Wahhabism as the government remains committed to ensuring that there is full compliance with Islamic laws (Brym & Lie 2010, p. 31). In addition to this, the government has supported the Wahhabi literal interpretations of right and wrong behaviour. Prayer performance in a ritually correct and punctual manner is required of all men. Livingstone (2011, p.54) says that all the believers are forbidden from taking wine because literally, the Quran forbids it. They have extended this ban to include all intoxicating drinks and stimulants like tobacco. Both men and women are required to dress modestly in accordance with the Quran. These conservative regulations have direct influence on all aspects of life in Saudi Arabia. The leaders of Saudi Arabia support the conservative religious establishment and monitor closely the people who present potential threats to their regimes (Lacroix & Holoch 2011, p. 96).
In the Middle East, Saudi Arabia ranks as one of the most conservative and restrictive countries with those who do not subscribe to the Islamic religion barred from practicing their faith even in private (DeLong-Bas 2007, p. 66). It is this harsh, conservative and restrictive environment that has led to radicalisation of some people in Saudi Arabia as they have no tolerance to other religious faiths. In school the religious curriculum teaches students that there are two types of people; the first one is the Salafis (Wahhabis) who are the chosen ones and will go to heaven because they are the winners. The other group are Muslims, Jews, Christians and all other religions. These ones are either, enervators, or deniers of God (kafirs) or they put their gods next to God (mushrak). The Sunni Muslims are called enervators because they do things that are proscribed by Salafis like celebrating the birthday of Prophet Mohammed (Husain 2009, p. 15). All these groups of people are not accepted by the Saudi Arabians as Muslims and as such, they are supposed to be hated, persecuted and even killed. This is what the government is encouraging and has led the Saudi Arabians to be intolerant to any other dissenting views on religion because of the rapid radicalisation and fundamentalism (Allen 2006, p. 77).
This paper has shown that the teachings of Muhammad ibn Abd al-Wahhab influenced everyday life in Saudi Arabia. His teachings, which were originally intended to bring reforms to the Islamic faith, have gone to the extent of radicalising the people of Saudi Arabia. As the paper indicates, they have no tolerance for other religions. To them, the people of other religions should be hated, persecuted and even killed. This is what is fuelling fundamentalism and radicalism in Saudi Arabia and has already brought about extreme terrorists like Osama bin laden among others.


Allen, C. (2006). God’s terrorists: the Wahhabi cult and the hidden roots of modern Jihad. Cambridge: Da Capo Press.
Brym, R. J., & Lie, J. (2010). Sociology: Your compass for a new world, the brief edition. Belmont, California: Wadsworth Cengage Learning.
Commins, D. (2006). The Wahhabi mission and Saudi Arabia. London : Tauris.
DeLong-Bas, N. J. (2007). Wahhabi Islam: From revival and reform to global jihad. London: I.B. Tauris.
Fatah, T. (2008). Chasing a mirage: The tragic illusion of an Islamic state. Mississauga, Ont: John Wiley & Sons Canada.
Hegghammer, T., & Lacroix, S. (2011). The Meccan rebellion: The story of Juhayman al-?Utaybi revisited. Bristol, England: Amal Press.
Husain, E. (2009). The Islamist: Why I became an Islamic fundamentalist, what I saw inside, and why I left. New York, N.Y: Penguin Books USA.
Lacroix, S., & Holoch, G. (2011). Awakening Islam: The politics of religious dissent in contemporary Saudi Arabia. Cambridge, Mass: Harvard University Press.
Livingstone, D. (2011). Terrorism and the illuminati: A three-thousand-year history. Joshua Tree, CA: Progressive Press.
Weston, M. (2008). Prophets and princes: Saudi Arabia from Muhammad to the present. Hoboken, N.J: Wiley.
Zayd, N. A. (2006). Reformation of Islamic thought: A critical historical analysis. Amsterdam: Amsterdam Univ. Press.

Free Essays

The Short Second Life of Bree Tanner Acknowledgments

As always, I am very grateful to al the people who made this book possible: my boys, Gabe, Seth, and Eli; my husband, Pancho; my parents, Stephen and Candy; my very supportive girlfriends Jen H., Jen L., Meghan, Nic, and Shel y; my ninja agent, Jodi

Reamer; my “baffy,” Shannon Hale; al my friends and mentors at Little, Brown, most especial y David Young, Asya Muchnick, Megan Tingley, Elizabeth Eulberg, Gail Doobinin, Andrew Smith, and Tina McIntyre; and, saving the best for last, my readers.

You’re the best audience anyone could have.

Thank you!

Free Essays

The Short Second Life of Bree Tanner Chapters 16

“She has surrendered,” the redhead explained.

“Surrendered?” Jane snapped.

I peeked up to see the dark-cloaks exchanging glances. The redhead had said that he’d never seen anyone surrender before. Maybe the dark-cloaks hadn’t, either.

“Carlisle gave her the option,” the redhead said. He seemed to be the spokesperson for the yel ow-eyes, though I thought Carlisle might be the leader.

“There are no options for those who break the rules,” Jane said, her voice dead again.

My bones felt like ice, but I didn’t feel panicked anymore. It al seemed so inevitable now.

Carlisle answered Jane in a soft voice. “That’s in your hands. As long as she was wil ing to halt her attack on us, I saw no need to destroy her. She was never taught.”

Though his words were neutral, I almost thought he was pleading for me. But, as he had said, my fate was not up to him.

“That is irrelevant,” Jane confirmed.

“As you wish.”

Jane was staring at Carlisle with an expression that was half confusion and half frustration. She shook her head, and her face was unreadable again.

“Aro hoped that we would get far enough west to see you, Carlisle,” she said. “He sends his regards.”

“I would appreciate it if you would convey mine to him,” he answered.

Jane smiled. “Of course.” Then she looked at me again, with the corners of her mouth stil slightly holding the smile. “It appears that you’ve done our work for us today… for the most part. Just out of professional curiosity, how many were there?

They left quite a wake of destruction in Seattle.”

She spoke of jobs and professionals. I was right, then, that it was her profession to punish. And if there were punishers, then there must be rules. Carlisle had said before, We follow their rules, and also, There is no law against creating vampires if you control them. Riley and my creator had been afraid but not exactly surprised by the arrival of the dark-cloaks, these Volturi. They knew about the laws, and they knew they were breaking them. Why hadn’t they told us? And there were more Volturi than just these four. Someone named Aro and probably many more. There must have been a lot for everyone to fear them so much. Carlisle answered Jane’s question. “Eighteen, including this one.”

There was a barely audible murmur among the four darkcloaks.

“Eighteen?” Jane repeated, a note of surprise in her voice. Our creator had never told Jane how many of us she’d created. Was Jane real y surprised, or just faking it?

“Al brand-new,” Carlisle said. “They were unskil ed.”

Unskil ed and uninformed, thanks to Riley. I was beginning to get a sense of how these older vampires viewed us. Newborn, Jasper had cal ed me. Like a baby.

“Al ?” Jane snapped. “Then who was their creator?”

As if they hadn’t already been introduced. This Jane was a bigger liar than Riley, and she was so much better at it than he was.

“Her name was Victoria,” the redhead answered.

How did he know that when even I didn’t? I remembered that Riley had said there was a mind reader in this group. Was that how they knew everything? Or was that another of Riley’s lies?

“Was?” Jane asked.

The redhead jerked his head toward the east like he was pointing. I looked up and saw a cloud of thick lilac smoke bil owing from the side of the mountain.

Was. I felt a similar kind of pleasure to what I’d felt imagining the big vampire shredding Raoul. Only much, much greater.

“This Victoria,” Jane asked slowly. “She was in addition to the eighteen here?”

“Yes,” the redhead confirmed. “She had only one other with her. He was not as young as this one here, but no older than a year.”

Riley. My fierce pleasure intensified. If – okay, when – I died today, at least I didn’t leave that loose thread. Diego had been avenged. I almost smiled.

“Twenty,” Jane breathed. Either this was more than she had expected, or she was a kil er actress. “Who dealt with the creator?”

“I did,” the redhead said coldly.

Whoever this vampire was, whether he kept a pet human or no, he was a friend of mine. Even if he were the one to kil me in the end, I would stil owe him.

Jane turned to stare at me with narrowed eyes.

“You there,” she snarled. “Your name.”

I was dead anyway, according to her. So why give this lying vampire anything she wanted? I just glared at her. Jane smiled at me, the bright, happy smile of an innocent child, and suddenly I was on fire. It was like I’d gone back in time to the worst night of my life. Fire was in every vein of my body, covering every inch of my skin, gnawing through the marrow of every bone. It felt like I was buried in the middle of my coven’s funeral bonfire, with the flames on every side. There wasn’t a single cel in my body that wasn’t blazing with the worst agony imaginable. I could barely hear myself scream over the pain in my ears.

“Your name,” Jane said again, and as she spoke the fire disappeared. Gone like that, as if I’d only been imagining it.

“Bree,” I said as fast as I could, stil gasping though the pain wasn’t there anymore.

Jane smiled again and the fire was everywhere. How much pain would it take before I would die of it? The screams didn’t even feel like they were coming from me anymore. Why wouldn’t someone rip my head off? Carlisle was kind enough for that, wasn’t he? Or whoever their mind reader was. Couldn’t he or she understand and make this stop?

“She’l tel you anything you want to know,” the redhead growled. “You don’t have to do that.”

The pain vanished again, like Jane had turned off a light switch. I found myself facedown on the ground, panting as if I needed air.

“Oh, I know,” I heard Jane say cheerful y. “Bree?”

I shuddered when she cal ed my name, but the pain didn’t start again.

“Is his story true?” she asked me. “Were there twenty of you?”

The words flew out of my mouth. “Nineteen or twenty, maybe more, I don’t know! Sara and the one whose name I don’t know got in a fight on the way….”

I waited for the pain to punish me for not having a better answer, but instead Jane spoke again.

“And this Victoria – did she create you?”

“I don’t know,” I admitted fearful y. “Riley never said her name. I didn’t see that night… it was so dark, and it hurt!” I flinched. “He didn’t want us to be able to think of her. He said that our thoughts weren’t safe.”

Jane shot a glance at the redhead, then looked at me again.

“Tel me about Riley,” Jane said. “Why did he bring you here?”

I recited Riley’s lies as quickly as I could. “Riley told us that we had to destroy the strange yel ow-eyes here. He said it would be easy. He said that the city was theirs, and they were coming to get us. He said once they were gone, al the blood would be ours. He gave us her scent.” I pointed in the human’s direction. “He said we would know that we had the right coven, because she would be with them. He said whoever got to her first could have her.”

“It looks like Riley was wrong about the easy part,” Jane said, a hint of teasing in her tone.

It seemed like Jane was pleased with my story. In a flash of insight, I understood that she was relieved Riley hadn’t told me or the others about her little visit to our creator. Victoria. This was the story she wanted the yel ow-eyes to know – the story that didn’t implicate Jane or the dark-cloaked Volturi. Wel, I could play along. Hopeful y the mind reader was already in the know.

I couldn’t physical y take revenge on this monster, but I could tel the yel ow-eyes everything with my thoughts. I hoped. I nodded, agreeing with Jane’s little joke, and sat up because I wanted the mind reader’s attention, whoever that was. I continued with the version of the story that any other member of my coven would have been able to give. I pretended I was Kevin. Dumb as a bag of rocks and total y ignorant.

“I don’t know what happened.” That part was true. The mess on the battlefield was stil a mystery. I’d never seen any of Kristie’s group. Did the secret howler vampires get them? I would keep that secret for the yel ow-eyes. “We split up, but the others never came. And Riley left us, and he didn’t come to help like he promised. And then it was so confusing, and everybody was in pieces.” I flinched at the memory of the torso I’d hurdled.

“I was afraid. I wanted to run away.” I nodded at Carlisle. “That one said they wouldn’t hurt me if I stopped fighting.”

This wasn’t betraying Carlisle in any way. He’d already told Jane as much.

“Ah, but that wasn’t his gift to offer, young one,” Jane said. She sounded like she was enjoying herself. “Broken rules demand a consequence.”

Stil pretending I was Kevin, I just stared at her as if I were too stupid to understand.

Jane looked at Carlisle. “Are you sure you got al of them?

The other half that split off?”

Carlisle nodded. “We split up, too.”

So it was the howlers that got Kristie. I hoped that, whatever else they were, the howlers were real y, real y terrifying. Kristie deserved that.

“I can’t deny that I’m impressed,” Jane said, sounding sincere, and I thought that this was probably the truth. Jane had been hopeful that Victoria’s army would do some damage here, and we’d clearly failed.

“Yes,” the three vampires behind Jane al agreed quietly.

“I’ve never seen a coven escape this magnitude of offensive intact,” Jane continued. “Do you know what was behind it? It seems like extreme behavior, considering the way you live here. And why was the girl the key?” Her eyes flicked to the human for just a moment.

“Victoria held a grudge against Bel a,” the redhead told her. So the strategy final y made sense. Riley just wanted the girl dead and didn’t care how many of us died to get it done. Jane laughed happily. “This one” – and she smiled at the human the way she’d smiled at me – “seems to bring out bizarrely strong reactions in our kind.”

Nothing happened to the girl. Maybe Jane didn’t want to hurt her. Or maybe her horrible talent only worked on vampires.

“Would you please not do that?” the redhead asked in a control ed but furious voice.

Jane laughed again. “Just checking. No harm done, apparently.”

I tried to keep my expression Kevin-ish and not betray my interest. So Jane couldn’t hurt this girl the way she’d hurt me, and this was not a normal thing for Jane. Though Jane was laughing about it, I could tel it was driving her crazy. Was this why the human girl was tolerated by the yel ow-eyes? But if she was special in some way, why didn’t they just change her into a vampire?

“Wel, it appears that there’s not much left for us to do,” Jane said, her voice a dead monotone again. “Odd. We’re not used to being rendered unnecessary. It’s too bad we missed the fight. It sounds like it would have been entertaining to watch.”

“Yes,” the redhead retorted. “And you were so close. It’s a shame you didn’t arrive just a half hour earlier. Perhaps then you could have fulfil ed your purpose here.”

I fought a smile. So the redhead was the mind reader, and he’d heard everything I’d wanted him to hear. Jane wasn’t getting away with anything.

Jane stared back at the mind reader with a blank expression. “Yes. Quite a pity how things turned out, isn’t it?”

The mind reader nodded, and I wondered what he was hearing in Jane’s head.

Jane turned her blank face to me now. There was nothing in her eyes, but I could feel that my time had run out. She’d gotten what she needed from me. She didn’t know that I’d also given the mind reader everything I could. And protected his coven’s secrets, too. I owed him that. He’d punished Riley and Victoria for me.

I glanced at him from the corner of my eye and thought, Thanks.

“Felix?” Jane said lazily.

“Wait,” the mind reader said loudly.

He turned to Carlisle and spoke quickly. “We could explain the rules to the young one. She doesn’t seem unwil ing to learn. She didn’t know what she was doing.”

“Of course,” Carlisle said eagerly, looking at Jane. “We would certainly be prepared to take responsibility for Bree.”

Jane’s face looked like she wasn’t sure if they were joking, but if they were joking, they were funnier than she’d given them credit for.

Me, I was touched to the core. These vampires were strangers, but they’d gone out on this dangerous limb for me. I already knew it wasn’t going to work, but stil .

“We don’t make exceptions,” Jane told them, amused. “And we don’t give second chances. It’s bad for our reputation.”

It was like she was discussing someone else. I didn’t care that she was talking about kil ing me. I knew the yel ow-eyes couldn’t stop her. She was the vampire police. But even though the vampire cops were dirty – real y dirty – at least the yel ow-eyes knew it now.

“Which reminds me…,” Jane went on, her eyes locking on the human girl again and her smile widening. “Caius wil be so interested to hear that you’re stil human, Bel a. Perhaps he’l decide to visit.”

Still human. So they were going to change the girl. I wondered what they were waiting for.

“The date is set,” said the little vampire with the short black hair and the clear voice. “Perhaps we’l come to visit you in a few months.”

Jane’s smile disappeared like someone had wiped it off. She shrugged without looking at the black-haired vampire, and I got the feeling that as much as she might have hated the human girl, she hated this smal vampire ten times as much. Jane turned back to Carlisle with the same vacant expression as before. “It was nice to meet you, Carlisle – I’d thought Aro was exaggerating. Wel, until we meet again…”

This would be it, then. I stil didn’t feel afraid. My only regret was that I couldn’t tel Fred more about al of this. He was going almost total y blind into this world ful of dangerous politics and dirty cops and secret covens. But Fred was smart and careful and talented. What could they do to him if they couldn’t even see him? Maybe the yel ow-eyes would meet Fred someday. Be nice to him, please, I thought at the mind reader.

“Take care of that, Felix,” Jane said indifferently, nodding at me. “I want to go home.”

“Don’t watch,” the redheaded mind reader whispered. I closed my eyes.

Free Essays

The Short Second Life of Bree Tanner Chapters 15

“Come with us. Don’t make one rash move or I will take you down.”

I felt angry again as he glared at me, and a smal part of me wanted to snarl and show my teeth, but I had a feeling he was looking for just that kind of excuse.

Jasper paused as if he’d just thought of something. “Close your eyes,” he commanded.

I hesitated. Had he decided to kil me after al ?

“Do it!”

I gritted my teeth and shut my eyes. I felt twice as helpless as I had before.

“Fol ow the sound of my voice and don’t open your eyes. You look, you lose, got it?”

I nodded, wondering what he didn’t want me to see. I felt some relief that he was bothering to protect a secret. There was no reason to do so if he was just going to kil me.

“This way.”

I walked slowly after him, careful to give him no excuses. He was considerate in the way he led, not walking me into any trees, at least. I could hear the way the sound changed when we were in the open; the feel of the wind was different, too, and the smel of my coven burning was stronger. I could feel the warmth of the sun on my face, and the insides of my eyelids were brighter as I sparkled.

He led me closer and closer to the muffled crackle of the flames, so close that I could feel the smoke brush my skin. I knew he could have kil ed me at any time, but the nearness of the fire stil made me nervous.

“Sit here. Eyes closed.”

The ground was warm from the sun and the fire. I kept very stil and tried to concentrate on looking harmless, but I could feel his glare on me, and it made me agitated. Though I was not mad at these vampires, who I truly believed had only been defending themselves, I felt the oddest stirrings of fury. It was almost outside myself, as if it were some leftover echo from the battle that had just taken place.

The anger didn’t make me stupid, though, because I was too sad – miserable to my core. Diego was aways in my mind, and I couldn’t help thinking about how he must have died. I was sure there was no way he would have voluntarily told Riley our secrets – secrets that had given me a reason to trust Riley just enough until it was too late. In my head, I saw Riley’s face again – that cold, smooth expression that had formed as he’d threatened to punish any of us who wouldn’t behave. I heard again his macabre and oddly detailed description – when I take you to her and hold you as she tears off your legs and then slowly, slowly burns off your fingers, ears, lips, tongue, and every other superfluous appendage one by one. I realized now that I’d been hearing the description of Diego’s death.

That night, I’d been sure that something had changed in Riley. Kil ing Diego was what had changed Riley, had hardened him. I believed only one thing that Riley had ever told me: he had valued Diego more than any of the rest of us. Had even been fond of him. And yet he’d watched our creator hurt him. No doubt he’d helped her. Kil ed Diego with her.

I wondered how much pain it would have taken to make me betray Diego. I imagined it would have taken quite a lot. And I was sure it had taken at least that much to make Diego betray me.

I felt sick. I wanted the image of Diego screaming in agony out of my head, but it wouldn’t leave.

And then there was screaming there in the field. My eyelids fluttered, but Jasper snarled furiously and I clenched them together at once. I’d seen nothing but heavy lavender smoke.

I heard shouting and a strange, savage howling. It was loud, and there was a lot of it. I couldn’t imagine how a face would have to contort to create such a noise, and the not knowing made the sound more frightening. These yel ow-eyed vampires were so different from the rest of us. Or different from me, I guess, since I was the only one left. Riley and our creator were long gone by now.

I heard names cal ed, Jacob, Leah, Sam. There were lots of distinct voices, though the howls continued. Of course Riley had lied to us about the number of vampires here, too. The sound of the howling tapered off until it was just one voice, one agonized, inhuman yowling that made me grit my teeth. I could see Diego’s face so clearly in my mind, and the sound was like him screaming.

I heard Carlisle talking over the other voices and the howling. He was begging to look at something. “Please let me take a look. Please let me help.” I didn’t hear anyone arguing with him, but for some reason his tone made it sound like he was losing the dispute.

And then the yowling reached a strident new pitch, and suddenly Carlisle was saying “thank you” in a fervent voice, and under the yowl there was the sound of a lot of movement by a lot of bodies. Many heavy footsteps coming closer.

I listened harder and heard something unexpected and impossible. Along with some heavy breathing – and I’ve never heard anyone in my coven breathe like that – there were dozens of deep thumping noises. Almost like… heartbeats. But definitely not human hearts. I knew that particular sound wel . I sniffed hard, but the wind was blowing from the other direction, and I could only smel the smoke.

Without a warning sound, something touched me, clapped down firmly on either side of my head.

My eyes started open in panic as I lurched up, straining to jerk free of this hold, and instantly met Jasper’s warning gaze about two inches from my face.

“Stop it,” he snapped, yanking me back down on my butt. I could only just hear him, and I realized that his hands were sealed tight against my head, covering my ears entirely.

“Close your eyes,” he instructed again, probably at a normal volume, but it was hushed for me.

I struggled to calm myself and shut my eyes again. There were things they didn’t want me to hear, either. I could live with that – if it meant I could live.

For a second I saw Fred’s face behind my eyelids. He had said he would wait for one day. I wondered if he would keep his word. I wished I could tel him the truth about the yel ow-eyes, and how much more there seemed to be that we didn’t know. This whole world that we real y knew nothing about. It would be interesting to explore that world. Particularly with someone who could make me invisible and safe.

But Diego was gone. He wouldn’t be coming to find Fred with me. That made imagining the future faintly repugnant. I could stil hear some of what was going on, but just the howling and a few voices. Whatever those weird thumping sounds had been, they were too muted now for me to examine them.

I did make out the words when, a few minutes later, Carlisle said, “You have to…” – his voice was too low for a second, and then – “… from here now. If we could help we would, but we cannot leave.”

There was a growl, but it was oddly unmenacing. The yowling became a low whine that disappeared slowly, as if it was moving away from me.

It was quiet for a few minutes. I heard some low voices, Carlisle and Esme among them, but also some I didn’t know. I wished I could smel something – the blindness combined with the muted sound left me straining for some source of sensory information. But al I could smel was the horribly sweet smoke. There was one voice, higher and clearer than the others, that I could hear most easily.

“Another five minutes,” I heard whoever it was say. I was sure it was a girl who was speaking. “And Bel a wil open her eyes in thirty-seven seconds. I wouldn’t doubt that she can hear us now.”

I tried to make sense of this. Was someone else being forced to keep her eyes shut, like me? Or did she think my name was Bel a? I hadn’t told anyone my name. I struggled again to smel something.

More mumbling. I thought that one voice sounded off – I couldn’t hear any ring to it at al . But I couldn’t be sure with Jasper’s hands so securely over my ears.

“Three minutes,” the high, clear voice said.

Jasper’s hands left my head.

“You’d better open your eyes now,” he told me from a few steps away. The way he said this frightened me. I looked around myself quickly, searching for the danger hinted at in his tone.

One whole field of my vision was obscured by the dark smoke. Close by, Jasper was frowning. His teeth were gritted together and he was looking at me with an expression that was almost… frightened. Not like he was scared of me, but like he was scared because of me. I remembered what he’d said before, about my putting them in danger with something cal ed a Volturi. I wondered what a Volturi was. I couldn’t imagine what this scarred-up, dangerous vampire would be afraid of. Behind Jasper, four vampires were spaced out in a loose line with their backs to me. One was Esme. With her were a tal blonde woman, a tiny black-haired girl, and a dark-haired male vampire so big that he was scary just to look at – the one I’d seen kil Kevin. For an instant I imagined that vampire getting a hold on Raoul. It was a strangely pleasant picture. There were three more vampires behind the big one. I couldn’t see exactly what they were doing with him in the way. Carlisle was kneeling on the ground, and next to him was a male vampire with dark red hair. Lying flat on the ground was another figure, but I couldn’t see much of that one, only jeans and smal brown boots. It was either a female or a young male. I wondered if they were putting the vampire back together. So eight yel ow-eyes total, plus al that howling before, whatever strange kind of vampire that had been; there had been at least eight more voices involved. Sixteen, maybe more. More than twice as many as Riley had told us to expect. I found myself fiercely hoping that those black-cloaked vampires would catch up to Riley, and that they would make him suffer.

The vampire on the ground started to get slowly to her feet – moving awkwardly, almost like she was some clumsy human. The breeze shifted, blowing the smoke across me and Jasper. For a moment, everything was invisible except for him. Though I was not as blind as before, I suddenly felt much more anxious, for some reason. It was like I could feel the anxiety bleeding out of the vampire next to me.

The light wind gusted back in the next second, and I could see and smel everything.

Jasper hissed at me furiously and shoved me out of my crouch and back onto the ground.

It was her – the human I’d been hunting just a few minutes ago. The scent my whole body had been focused toward. The sweet, wet scent of the most delicious blood I’d ever tracked. My mouth and throat felt like they were on fire. I tried wildly to hold on to my reason – to focus on the fact that Jasper was just waiting for me to jump up again so that he could kil me – but only part of me could do it. I felt like I was about to pul into two halves trying to keep myself here. The human named Bel a stared at me with stunned brown eyes. Looking at her made it worse. I could see the blood flushing through her thin skin. I tried to look anywhere else, but my eyes kept circling back to her.

The redhead spoke to her in a low voice. “She surrendered. That’s one I’ve never seen before. Only Carlisle would think of offering. Jasper doesn’t approve.”

Carlisle must have explained to that one when my ears were covered.

The vampire had both his arms around the human girl, and she had both hands pressed to his chest. Her throat was just inches from his mouth, but she didn’t look frightened of him at al . And he didn’t look like he was hunting. I had tried to wrap my head around the idea of a coven with a pet human, but this was not close to what I had imagined. If she’d been a vampire, I would have guessed that they were together.

“Is Jasper al right?” the human whispered.

“He’s fine. The venom stings,” the vampire said.

“He was bitten?” she asked, sounding shocked by the idea. Who was this girl? Why did the vampires al ow her to be with them? Why hadn’t they kil ed her yet? Why did she seem so comfortable with them, like they didn’t scare her? She seemed like she was a part of this world, and yet she didn’t understand its realities. Of course Jasper was bitten. He’d just fought – and destroyed – my entire coven. Did this girl even know what we were?

Ugh, the burn in my throat was impossible! I tried not to think about washing it away with her blood, but the wind was blowing her smel right in my face! It was too late to keep my head – I had scented the prey I was hunting, and nothing could change that now.

“He was trying to be everywhere at once,” the redhead told the human. “Trying to make sure Alice had nothing to do, actual y.” He shook his head as he looked at the tiny blackhaired girl. “Alice doesn’t need anyone’s help.”

The vampire named Alice shot a glare at Jasper.

“Overprotective fool,” she said in her clear soprano voice. Jasper met her stare with a half smile, seeming to forget for a second that I existed.

I could barely fight the instinct that wanted me to make use of his lapse and spring at the human girl. It would take less than an instant and then her warm blood – blood I could hear pumping through her heart – would quench the burn. She was so close –

The vampire with the dark red hair met my eyes with a fierce warning glare, and I knew I would die if I tried for the girl, but the agony in my throat made me feel like I would die if I didn’t. It hurt so much that I screamed out loud in frustration. Jasper snarled at me, and I tried to keep myself from moving, but it felt like the scent of her blood was a giant hand yanking me off the ground. I had never tried to stop myself from feeding once I had committed to a hunt. I dug my hands into the ground looking for something to hold on to but finding nothing. Jasper leaned into a crouch, and even knowing I was two seconds from death, I couldn’t focus my thirsty thoughts. And then Carlisle was right there, his hand on Jasper’s arm. He looked at me with kind, calm eyes. “Have you changed your mind, young one?” he asked me. “We don’t want to destroy you, but we wil if you can’t control yourself.”

“How can you stand it?” I asked him, almost begging. Wasn’t he burning, too? “I want her.” I stared at her, desperately wishing the distance between us was gone. My fingers raked uselessly through the rocky dirt.

“You must stand it,” Carlisle said solemnly. “You must exercise control. It is possible, and it is the only thing that wil save you now.”

If being able to tolerate the human the way these strange vampires did was my only hope for survival, then I was already doomed. I couldn’t stand the fire. And I was of two minds about survival anyway. I didn’t want to die, I didn’t want pain, but what was the point? Everyone else was dead. Diego had been dead for days.

His name was right on my lips. I almost whispered it aloud. Instead, I gripped my skul with both hands and tried to think about something that wouldn’t hurt. Not the girl, and not Diego. It didn’t work very wel .

“Shouldn’t we move away from her?” the human whispered roughly, breaking my concentration. My eyes snapped back to her. Her skin was so thin and soft. I could see the pulse in her neck.

“We have to stay here,” said the vampire she was clinging to. “They are coming to the north end of the clearing now.”

They? I glanced to the north, but there was nothing but smoke. Did he mean Riley and my creator? I felt a new thril of panic, fol owed by a little spasm of hope. There was no way she and Riley could stand against these vampires who had kil ed so many of us, was there? Even if the howly ones were gone, Jasper alone looked capable of dealing with the two of them. Or did he mean this mysterious Volturi?

The wind teased the girl’s scent across my face again, and my thoughts scattered. I glared at her thirstily. The girl met my stare, but her expression was so different from what it should have been. Though I could feel that my lips were curled back from my teeth, though I trembled with the effort to stop myself from springing at her, she did not look afraid of me. Instead she seemed fascinated. It almost looked like she wanted to speak to me – like she had a question she wanted me to answer.

Then Carlisle and Jasper began to back away from the fire – and me – closing ranks with the others and the human. They al were staring past me into the smoke, so whatever they were afraid of was closer to me than it was to them. I huddled tighter to the smoke in spite of the nearby flames. Should I make a run for it? Were they distracted enough that I could escape? Where would I go? To Fred? Off on my own? To find Riley and make him pay for what he’d done to Diego?

As I hesitated, mesmerized by that last idea, the moment passed. I heard movement to the north and knew I was sandwiched between the yel ow-eyes and whatever was coming.

“Hmm,” a dead voice said from behind the smoke. In that one syl able I knew exactly who it was, and if I hadn’t been frozen solid with mindless terror I would have bolted. It was the dark-cloaks.

What did this mean? Would a new battle begin now? I knew that the dark-cloaked vampires had wanted my creator to succeed in destroying these yel ow-eyes. My creator had clearly failed. Did that mean they would kil her? Or would they kil Carlisle and Esme and the rest here instead? If it had been my choice, I knew who I would want destroyed, and it wasn’t my captors.

The dark-cloaks ghosted through the vapor to face the yel ow-eyes. None of them looked in my direction. I held absolutely stil .

There were only four of them, like last time. But it didn’t make a difference that there were seven of the yel ow-eyes. I could tel that they were as wary of these dark-cloaks as Riley and my creator had been. There was something more to them than I could see, but I could definitely feel it. These were the punishers, and they didn’t lose.

“Welcome, Jane,” said the yel ow-eyed one who held the human.

They knew each other. But the redhead’s voice was not friendly – nor was it weak and eager to please like Riley’s had been, or furiously terrified like my creator’s. His voice was simply cold and polite and unsurprised. Were the dark-cloaks this Volturi, then?

The smal vampire who led the dark-cloaks – Jane, apparently – slowly scanned across the seven yel ow-eyes and the human, and then final y turned her head toward me. I glimpsed her face for the first time. She was younger than me, but much older, too, I guessed. Her eyes were the velvet color of dark red roses. Knowing it was too late to escape notice, I put my head down, covering it with my hands. Maybe if it were clear that I didn’t want to fight, Jane would treat me as Carlisle had. I didn’t feel much hope of that, though.

“I don’t understand.” Jane’s dead voice betrayed a hint of annoyance.

Free Essays

The Short Second Life of Bree Tanner Chapters 14

“I heard someone get hurt – Kristie needs me more than Raoul,” he explained quickly.

“Are you… leaving us?”

Riley’s face changed. It was like I could see his shifting tactics written on his features. His eyes widened, suddenly anxious.

“I’m worried, Bree. I told you that she was going to meet us, to help us, but I haven’t crossed her trail. Something’s wrong. I need to find her.”

“But there’s no way you can find her before Raoul gets to the yel ow-eyes,” I pointed out.

“I have to find out what’s going on.” He sounded genuinely desperate. “I need her. I wasn’t supposed to do this alone!”

“But the others…”

“Bree, I have to go find her! Now! There are enough of you to overwhelm the yel ow-eyes. I’l get back to you as soon as I can.”

He sounded so sincere. I hesitated, glancing back the way we had come. Fred would be halfway to Vancouver by now. Riley hadn’t even asked about him. Maybe Fred’s talent was stil in effect.

“Diego’s down there, Bree,” Riley said urgently. “He’l be part of the first attack. Didn’t you catch his scent back there?

Did you not get close enough?”

I shook my head, total y confused. “Diego was there?”

“He’s with Raoul by now. If you hurry, you can help him get out alive.”

We stared at each other for a long second, and then I looked south after Raoul’s path.

“Good girl,” Riley said. “I’l go find her and we’l be back to help clean up. You guys have got this! It might be over by the time you get there!”

He took off in a direction perpendicular to our original path. I clenched my teeth at how sure he seemed of his way. Lying to the end.

But it didn’t feel like I had a choice. I headed south in a flatout sprint again. I had to go get Diego. Drag him away if it came to that. We could catch up with Fred. Or take off on our own. We needed to run. I would tel Diego how Riley had lied. He would see that Riley had no intention of helping us fight the battle he’d set up. There was no reason to help him anymore. I found the human’s scent and then Raoul’s. I didn’t catch Diego’s. Was I going too fast? Or was the human’s scent just overpowering me? Half my head was absorbed in this strangely counterproductive hunt – sure, we would find the girl, but would we be ready to fight together when we did? No, we’d be clawing each other apart to get to her.

And then I heard the snarling and screaming and screeching explode from ahead and I knew the fight was happening and I was too late to beat Diego there. I only ran faster. Maybe I could stil save him.

I smel ed the smoke – the sweet, thick scent of vampires burning – carried back to me on the wind. The sound of mayhem was louder. Maybe it was almost done. Would I find our coven victorious and Diego waiting?

I dashed through a heavy fringe of smoke and found myself out of the forest in a huge grassy field. I leaped over a rock, only to realize in the instant I flew past it that it was a headless torso. My eyes raked the field. There were pieces of vampires everywhere, and a huge bonfire smoking purple into the sunny sky. Out from under the bil owing haze, I could see dazzling, glittering bodies darting and grappling as the sounds of vampires being torn apart went on and on.

I looked for one thing: Diego’s curly black hair. No one I could see had hair so dark. There was one huge vampire with brown hair that was almost black, but he was too big, and as I focused I watched him tear Kevin’s head off and pitch it into the fire before leaping on someone else’s back. Was that Jen?

There was another with straight black hair that was too smal to be Diego. That one was moving so fast I couldn’t tel if it was a boy or a girl.

I scanned quickly again, feeling horribly exposed. I took in the faces. There weren’t nearly enough vampires here, even counting those that were down. I didn’t see any of Kristie’s group. There must have been a lot of vampires burned already. Most of the vampires stil standing were strangers. A blond vampire glanced at me, meeting my gaze, and his eyes flashed gold in the sunlight.

We were losing. Bad.

I started backing toward the trees, not moving fast enough because I was stil looking for Diego. He wasn’t here. There was no sign he had ever been here. No trace of his scent, though I could distinguish the smel s of most of Raoul’s team and many strangers. I had made myself look at the pieces, too. None of them belonged to Diego. I would have recognized even a finger.

I turned and real y ran for the trees, suddenly positive that Diego’s presence here was just another of Riley’s lies. And if Diego wasn’t here, then he was already dead. This fel into place for me so easily that I thought I must have known the truth for a while. Since the moment that Diego had not fol owed Riley through the basement door. He’d already been gone.

I was a few feet into the trees when a force like a wrecking bal hit me from behind and threw me to the ground. An arm slipped under my chin.

“Please!” I sobbed. And I meant please kill me fast. The arm hesitated. I didn’t fight back, though my instincts were urging me to bite and claw and rip the enemy apart. The saner part of me knew that wasn’t going to work. Riley had lied about these weak, older vampires, too, and we’d never had a chance. But even if I’d had a way to beat this one, I wouldn’t have been able to move. Diego was gone, and that glaring fact kil ed the fight in me.

Suddenly I was airborne. I crashed into a tree and crumpled to the ground. I should have tried to run, but Diego was dead. I couldn’t get around that.

The blond vampire from the clearing was staring intently at me, his body ready to spring. He looked very capable, much more experienced than Riley. But he wasn’t lunging at me. He wasn’t crazed like Raoul or Kristie. He was total y in control.

“Please,” I said again, wanting him to get this over with. “I don’t want to fight.”

Though he stil held himself ready, his face changed. He looked at me in a way I didn’t total y get. There was a lot of knowledge in that face, and something else. Empathy? Pity, at least.

“Neither do I, child,” he said in a calm, kind voice. “We are only defending ourselves.”

There was such honesty in his odd yel ow eyes that it made me wonder how I had ever believed any of Riley’s stories. I felt… guilty. Maybe this coven had never planned to attack us in Seattle. How could I trust any part of what I’d been told?

“We didn’t know,” I explained, somehow ashamed. “Riley lied. I’m sorry.”

He listened for a moment, and I realized that the battlefield was quiet. It was over.

If I’d been in any doubt over who the winner was, that doubt was gone when, a second later, a female vampire with wavy brown hair and yel ow eyes hurried to his side.

“Carlisle?” she asked in a confused voice, staring at me.

“She doesn’t want to fight,” he told her.

The woman touched his arm. He was stil tensed to spring.

“She’s so frightened, Carlisle. Couldn’t we…”

The blond, Carlisle, glanced back at her, and then he straightened up a little, though I could see he was stil wary.

“We have no wish to harm you,” the woman said to me. She had a soft, soothing voice. “We didn’t want to fight any of you.”

“I’m sorry,” I whispered again.

I couldn’t make sense of the mess in my head. Diego was dead, and that was the main thing, the devastating thing. Other than that, the fight was over, my coven had lost and my enemies had won. But my dead coven was ful of people who would have loved to watch me burn, and my enemies were speaking to me kindly when they had no reason to. Moreover, I felt safer with these two strangers than I’d ever felt with Raoul and Kristie. I was relieved that Raoul and Kristie were dead. It was so confusing.

“Child,” Carlisle said, “wil you surrender to us? If you do not try to harm us, we promise we wil not harm you.”

And I believed him.

“Yes,” I whispered. “Yes, I surrender. I don’t want to hurt anybody.”

He held out his hand encouragingly. “Come, child. Let our family regroup for a moment, then we’l have some questions for you. If you answer honestly, you have nothing to fear.”

I got up slowly, making no movements that could be considered threatening.

“Carlisle?” a male voice cal ed.

And then another yel ow-eyed vampire joined us. Any sort of safety I’d felt with these strangers vanished as soon as I saw him.

He was blond, like the first, but tal er and leaner. His skin was absolutely covered in scars, spaced most thickly together on his neck and jaw. A few smal marks on his arm were fresh, but the rest were not from the brawl today. He had been in more fights than I could have imagined, and he’d never lost. His tawny eyes blazed and his stance exuded the barely contained violence of an angry lion.

As soon as he saw me he coiled to spring.

“Jasper!” Carlisle warned.

Jasper pul ed up short and stared at Carlisle with wide eyes. “What’s going on?”

“She doesn’t want to fight. She’s surrendered.”

The scarred vampire’s brow clouded, and suddenly I felt an unexpected surge of frustration, though I had no idea what I was frustrated with.

“Carlisle, I…” He hesitated, then continued, “I’m sorry, but that’s not possible. We can’t have any of these newborns associated with us when the Volturi come. Do you realize the danger that would put us in?”

I didn’t understand exactly what he was saying, but I got enough. He wanted to kil me.

“Jasper, she’s only a child,” the woman protested. “We can’t just murder her in cold blood!”

It was strange to hear her speak like we both were people, like murder was a bad thing. An avoidable thing.

“It’s our family on the line here, Esme. We can’t afford to have them think we broke this rule.”

The woman, Esme, walked between me and the one who wanted to kil me. Incomprehensibly, she turned her back to me.

“No. I won’t stand for it.”

Carlisle shot me an anxious glance. I could see that he cared a lot for this woman. I would have looked the same way at anyone behind Diego’s back. I tried to appear as docile as I felt.

“Jasper, I think we have to take the chance,” he said slowly.

“We are not the Volturi. We fol ow their rules, but we do not take lives lightly. We wil explain.”

“They might think we created our own newborns in defense.”

“But we didn’t. And even had we, there was no indiscretion here, only in Seattle. There is no law against creating vampires if you control them.”

“This is too dangerous.”

Carlisle touched Jasper’s shoulder tentatively. “Jasper. We cannot kil this child.”

Jasper glowered at the man with the kind eyes, and I was suddenly angry. Surely he wouldn’t hurt this gentle vampire or the woman he loved. Then Jasper sighed, and I knew it was okay. My anger evaporated.

“I don’t like this,” he said, but he was calmer. “At least let me take charge of her. You two don’t know how to deal with someone who’s been running wild so long.”

“Of course, Jasper,” the woman said. “But be kind.”

Jasper rol ed his eyes. “We need to be with the others. Alice said we don’t have long.”

Carlisle nodded. He held his hand out to Esme, and they headed past Jasper back toward the open field.

“You there,” Jasper said to me, his face a glower again.

Free Essays

The impact of hosting the World Expo 2020 on Dubai’s future economic, social and cultural life


This proposal outlines the following research question: in what ways, positive or negative, will the World Expo 2020 affect Dubai, the surrounding region, and the world in generalThis is an interesting topic for two primary reasons. The first is the personal workplace experience of the author, which involved a position at Dubai Media Incorporated (Dubai TV) conducting analysis about current affairs in the UAE region. The second is the fact that this is a landmark moment in the history of Dubai, the UAE, and the Middle in general, as it is the first time that an international exposition has been held in the region. It is possible that it will lead to the development of new forms of culture; the old may be reformulated and developed in unique ways, but it may also be fused with ideas and institutions from abroad to create novel cultural hybrids.
This idea of bringing regions of the Middle East together with the rest of the world was explicitly supported by Sheikh Mohammed bin Rashid Al Maktoum, Dubai’s leader, who argued for the importance of ‘a renewed vision of progress and development based on a shared purpose and commitment’ (Expo 2020 Dubai, UAE, 2013). The possibility that the Expo 2020 will be a crucible for interacting creative forces across the world is, moreover, encapsulated in Dubai’s chosen theme: ‘Connecting Minds, Creating the Future’ (Big News Network, 2013).

Research questions

This research will aim to answer the following questions:
What factors are likely to contribute to the success or failure of the World Expo 2020?

What are the social, economic, and cultural changes that Dubai is a likely to experience?

How will be Dubai’s future in the global stage change as a result of this event?

How might Dubai use the World Expo 2020 as a marketing tool?

How might Dubai use the symbolic economy to aid its cultural and urban regeneration and shape its new urban identity?

Will Expo 2020 commentary and press show Dubai in a positive or negative light?

Literature review

Due to the very recent nature of the announcement, there is almost no literature dealing directly with the relationship between Dubai and the Expo 2020. However, there has been considerable commentary in the form of political and economic punditry, much of which is academic. Piers Schreiber, Vice President of Corporate Communications & Public Affairs at the Jumeirah Group, claimed that ‘the Expo will create up to 270,000 jobs in the region, bringing great economic and social benefits’ (cited in Wilson, 2013). Among these are an injection of roughly ˆ17.7 billion into the economy and a migration of talent from abroad (Wilson, 2013). These estimations are supported by the forecasting group Oxford Economics, which claims that the event will contribute nearly $40 billion to Dubai’s GDP and create 277,000 new jobs over the next seven years (Big News Network, 2013). A similar argument is put forward by Rose and Spiegel (2009), whose work suggests that ‘mega events’ lead to a substantial increase in trade (approx. 30%); however, they also show that ‘unsuccessful bids to host the Olympics have a similar positive impact on exports…trade is attributable to the signal a country sends when bidding to host the games, rather than the act of actually holding a mega-event’ (p1).
Although Sheik Mohammed has claimed that the “Dubai Expo 2020 will breathe new life into the ancient role of the Middle East as a melting pot for cultures and creativity” (Big News Network, 2013), the goal of cultural diversity has been questioned due to the strong emphasis on boosting an ‘Islamic economy’, which suggests continuity more than change (Wilson, 2013).
Based on comparisons with other ‘mega events’, it is often argued that the effects of the Expo 2020 are likely to be negative for Dubai. Rose and Spiegel (2009), for example, stress that much of the evidence for the benefits of mega events is commissioned by groups with biasing agendas (e.g., Humphreys and Plummer, 1995; Fuller and Clinch, 2000, both cited in Rose and Spiegel, 2009). The same is argued by Nitsch and Wendland (2013), who also point to the large initial investment in facilities and infrastructure associated with mega events, which can place a considerable burden on the local or national economy; there tends also to be a dramatic and unpredictable effect on property prices. The conclusion of Nitsch and Wendland (2013) is that mega events tend to have an overwhelmingly negative effect on population growth (i.e., a population decline), as measured relative to a control group.
However, Nitsch and Wendland (2013), and Rose and Spiegel (2009), point to the difficulty of estimating the impact of major events. Problems quantifying the effects, especially on phenomena such as labour markets, are often exacerbated by the fact that many studies are commissioned ex ante by biased groups. Moreover, in conducting analyses such as this, it is difficult to find an adequate sample size due to the infrequency of mega events. Then there are problems with the intangibility of cultural and social spillover effects, as well as the economic multiplier (Rose and Spiegel, 2009).


The effects of the Expo 2020 are best assessed using a variety of methodological approaches, employing both quantitative and qualitative methods. From the quantitative side there will be content analysis-case studies and statistical analyses. From the qualitative, there will be surveys, questionnaires, and interviews. In terms of research philosophy (or methodology, strictly speaking), this research will take both an objectivist and a subjectivist approach (Crotty, 1998).
It would be advantageous to use what Nitsch and Wendland (2013: 4) call a ‘difference-in-differences methodology’. This draws ‘before and after’ comparisons, and in this case would entail looking at the effect of former Expos on host nations and cities and extrapolating about the probable effects on Dubai.


Crotty, M. (1998) The foundation of Social Research: Meaning and Perspective in Research Progress. Sage Publications: London
Big News Network (Nov 2013) Dubai wins right to host Expo 2020 [Retrieved 03/02/2014].
Nitsch, V. and Wendland, N. (2013) The IOC’s Midas Touch: Summer Olympics and City Growth, CESIFO WORKING PAPER NO. 4378, Centre for Economic Studies & Ifo Institute.
Expo 2020 Dubai, UAE (2013) Our Bid [Retrieved 03/02/2014]
Rose, A. K. and Spiegel, M. M. (2009) The Olympic Effect, NBER Working Paper No. 14854, The National Bureau of Economic Research [Retrieved 03/02/2014].

Wilson, J. A. J. (Dec 2013) Global Islamic Economy Summit and World Expo 2020 boost Dubai’s Halal credentials, The Huffington Post [Retrieved 03/02/2014].

Free Essays

The Short Second Life of Bree Tanner Chapters 13

Fred raised an eyebrow and relaxed just slightly. I glanced behind us. What had Riley been looking at?

Nothing had changed – just some family pictures of dead people, a smal mirror, and a cuckoo clock. Hmm. Was he checking the time? Maybe our creator had given him a deadline, too.

“‘Kay, guys, I’m going out,” Riley said. “You don’t have to be afraid today, I promise.”

The light burst into the basement through the open door, magnified – as only I knew – by Riley’s skin. I could see the bright reflections dance on the wal .

Hissing and snarling, my coven backed into the corner opposite from Fred’s. Kristie was in the very back. It looked like she was trying to use her gang as a kind of shield.

“Relax, everybody,” Riley cal ed down to us. “I am absolutely fine. No pain, no burn. Come and see. C’mon!”

No one moved closer to the door. Fred was crouched against the wal beside me, eyeing the light with panic. I waved my hand a tiny bit to get his attention. He looked up at me and measured my total calm for a second. Slowly he straightened up next to me. I smiled encouragingly.

Everyone else was waiting for the burn to start. I wondered if I had looked that sil y to Diego.

“You know,” Riley mused from above, “I’m curious to see who is the bravest one of you. I have a good idea who the first person through that door is going to be, but I’ve been wrong before.”

I rol ed my eyes. Subtle, Riley.

But of course it worked. Raoul started inching his way toward the stairs almost immediately. For once, Kristie was in no hurry to compete with him for Riley’s approval. Raoul snapped his fingers at Kevin, and both he and the Spider-Man kid reluctantly moved to flank him.

“You can hear me. You know I’m not fried. Don’t be a bunch of babies! You’re vampires. Act like it.”

Stil, Raoul and his buddies couldn’t get farther than the foot of the stairs. None of the others moved. After a few minutes, Riley came back. In the indirect light from the front door, he shimmered just a tiny bit in the doorway.

“Look at me – I’m fine. Seriously! I’m embarrassed for you. C’mere, Raoul!”

In the end, Riley had to grab Kevin – Raoul ducked out of the way as soon as he could see what Riley was thinking – and drag him upstairs by force. I saw the moment when they made it into the sun, when the light brightened from their reflections.

“Tel them, Kevin,” Riley ordered.

“I’m okay, Raoul!” Kevin cal ed down. “Whoa. I’m al … shiny. This is crazy!” He laughed.

“Wel done, Kevin,” Riley said loudly.

That did it for Raoul. He gritted his teeth and marched up the stairs. He didn’t move fast, but soon he was up there sparkling and laughing with Kevin.

Even from then on, the process took longer than I would have predicted. It was stil a one-by-one thing. Riley got impatient. It was more threats than encouragement now. Fred shot me a look that said, You knew this?

Yes, I mouthed.

He nodded and started up the stairs. There were stil about ten people, mostly Kristie’s group, huddled against the wal . I went with Fred. Better to come out right in the middle. Let Riley read into that what he would.

We could see the shining, disco-bal vampires in the front yard, staring at their hands and each other’s faces with rapt expressions. Fred moved into the light without slowing, which I thought was pretty brave, al things considered. Kristie was a better example of how wel Riley had indoctrinated us. She clung to what she knew regardless of the evidence in front of her.

Fred and I stood a little space from the others. He examined himself careful y, then looked me over, then stared at the others. It struck me that Fred, though real y quiet, was very observant and almost scientific in the way he examined evidence. He’d been evaluating Riley’s words and actions al along. How much had he figured out?

Riley had to force Kristie up the stairs, and her gang came with her. Final y we al were out in the sun, most people enjoying how very pretty they were. Riley rounded everyone up for one more quick practice session – mostly, I thought, to get them to focus again. It took them a minute, but everyone started to realize that this was it, and they got quieter and more fierce. I could see that the idea of a real fight – of being not only al owed but encouraged to rip and burn – was almost as exciting as hunting. It appealed to people like Raoul and Jen and Sara. Riley focused on a strategy he’d been trying to dril into them for the last few days – once we’d pinpointed the yel oweyes’ scent, we were going to divide in two and flank them. Raoul would charge them head-on while Kristie attacked from the side. The plan suited both their styles, though I wasn’t sure if they were going to be able to fol ow this strategy in the heat of the hunt.

When Riley cal ed everyone together after an hour of practice, Fred immediately started walking backward toward the north; Riley had the others facing south. I stayed close, though I had no idea what he was doing. Fred stopped when we were a good hundred yards away, in the shade of the spruce trees on the fringe of the forest. No one watched us move away. Fred was eyeing Riley, as if waiting to see if he would notice our retreat.

Riley began speaking. “We leave now. You’re strong and you’re ready. And you’re thirsty for it, aren’t you? You can feel the burn. You’re ready for dessert.”

He was right. Al that blood hadn’t slowed the return of the thirst at al . In fact, I wasn’t sure, but I thought it might be coming back faster and harder than usual. Maybe overfeeding was counterproductive in some ways.

“The yel ow-eyes are coming in slowly from the south, feeding along the way, trying to get stronger,” Riley said. “She’s been monitoring them, so I know where to find them. She’s going to meet us there, with Diego” – he cast a significant glance toward where I’d just been standing, and then a quick frown that disappeared just as quickly – “and we wil hit them like a tsunami. We wil overwhelm them easily. And then we wil celebrate.” He smiled. “Someone’s going to get a jump on the celebration. Raoul – give me that.” Riley held out his hand imperiously. Raoul reluctantly tossed him the bag with the shirt. It seemed like Raoul was trying to lay claim to the girl by hogging her scent.

“Take another whiff, everybody. Let’s get focused!”

Focused on the girl? Or the fight?

Riley himself walked the shirt around this time, almost like he wanted to make sure everyone was thirsty. And I could see from the reactions that, like me, the burn was back for them al . The scent of the shirt made them scowl and snarl. It wasn’t necessary to give us the scent again; we forgot nothing. So this was probably just a test. Just thinking about the girl’s scent had venom pooling in my mouth.

“Are you with me?” Riley bel owed.

Everyone screamed his or her assent.

“Let’s take them down, kids!”

It was like the barracuda again, only on land this time. Fred didn’t move, so I stayed with him, though I knew I was wasting time I needed. If I were going to get to Diego and pul him away before the fighting could start, I would need to be near the front of the attack. I looked after them anxiously. I was stil younger than most of them – faster.

“Riley won’t be able to think of me for about twenty minutes or so,” Fred told me, his voice casual and familiar, like we’d had a mil ion conversations in the past. “I’ve been gauging the time. Even a good distance away, he’l feel sick if he tries to remember me.”

“Real y? That’s cool.”

Fred smiled. “I’ve been practicing, keeping track of the effects. I can make myself total y invisible now. No one can look at me if I don’t want them to.”

“I’ve noticed,” I said, then paused and guessed, “You’re not going?”

Fred shook his head. “Of course not. It’s obvious we’re not being told what we need to know. I’m not going to be Riley’s pawn.”

So Fred had figured it out on his own.

“I was going to take off sooner, but then I wanted to talk to you before I left, and there hasn’t been a chance til now.”

“I wanted to talk to you, too,” I said. “I thought you should know that Riley’s been lying about the sun. This four-day thing is a total crock. I think Shel y and Steve and the others figured it out, too. And there’s a lot more politics going on with this fight than he’s told us. More than one set of enemies.” I said it fast, feeling with terrible urgency the movement of the sun, the time passing. I had to get to Diego.

“I’m not surprised,” Fred said calmly. “And I’m out. I’m going to explore on my own, see the world. Or I was going on my own, but then I thought maybe you might want to come, too. You’d be pretty safe with me. No one wil be able to fol ow us.”

I hesitated for a second. The idea of safety was hard to resist in that exact moment.

“I’ve got to get Diego,” I said, shaking my head. He nodded thoughtful y. “I get it. You know, if you’re wil ing to vouch for him, you can bring him along. Seems like sometimes numbers come in handy.”

“Yes,” I agreed fervently, remembering how vulnerable I’d felt in the tree alone with Diego as the four cloaks had advanced. He raised an eyebrow at my tone.

“Riley is lying about at least one more important thing,” I explained. “Be careful. We aren’t supposed to let humans know about us. There are some kind of freaky vampires who stop covens when they get too obvious. I’ve seen them, and you don’t want them to find you. Just keep out of sight in the day, and hunt smart.” I looked south anxiously. “I have to hurry!”

He was processing my revelations solemnly. “Okay. Catch up to me if you want. I’d like to hear more. I’l wait for you in Vancouver for one day. I know the city. I’l leave you a trail in…”

He thought for a second and then chuckled once. “Riley Park. You can fol ow it to me. But after twenty-four hours I’m taking off.”

“I’l get Diego and catch up to you.”

“Good luck, Bree.”

“Thanks, Fred! Good luck to you, too. I’l see you!” I was already running.

“I hope so,” I heard him say behind me.

I sprinted after the scent of the others, flying along the ground faster than I’d ever run before. I was lucky that they must have paused for something – for Riley to yel at them, I was guessing – because I caught them sooner than I should have. Or maybe Riley had remembered Fred and stopped to look for us. They were running at a steady pace when I reached them, semidisciplined like last night. I tried to slide into the group without drawing attention, but I saw Riley’s head flip around once to scan those trailing behind. His eyes zeroed in on me, and then he started running faster. Did he assume Fred was with me?

Riley would never see Fred again.

It wasn’t five minutes later when everything changed. Raoul caught the scent. With a wild growl he was off. Riley had us so worked up that it took only the tiniest spark to set off an explosion. The others near Raoul had the scent, too, and then everyone went crazy. Riley’s harping on this human had overshadowed the rest of his instructions. We were hunters, not an army. There was no team. It was a race for blood. Even though I knew there were a lot of lies in the story, I couldn’t total y resist the scent. Running at the back of the pack, I had to cross it. Fresh. Strong. The human had been here recently, and she smel ed so sweet. I was strong with al the blood we’d drunk last night, but it didn’t matter. I was thirsty. It burned.

I ran after the others, trying to keep my head clear. It was al I could do to hold back a little, to stay behind the others. The closest person to me was Riley. He was… holding back, too?

He shouted orders, mostly the same thing repeated.

“Kristie, go around! Move around! Split off! Kristie, Jen! Break off! ” His whole plan of the two-pronged ambush was selfdestructing as we watched. Riley sped up to the main group and grabbed Sara’s shoulder. She snapped at him as he hurled her to the left. “Go around!” he shouted. He caught the blond kid whose name I’d never figured out and shoved him into Sara, who clearly wasn’t happy with that. Kristie came out of the hunting focus long enough to realize she was supposed to be moving strategical y. She gave one fierce gaze after Raoul and then started screeching at her team.

“This way! Faster! We’l beat them around and get to her first! C’mon!”

“I’m spear point with Raoul!” Riley shouted at her, turning away.

I hesitated, stil running forward. I didn’t want to be part of any “spear point,” but Kristie’s team was already turning on each other. Sara had the blond kid in a headlock. The sound of his head tearing off made my decision for me. I sprinted after Riley, wondering if Sara would pause to burn the boy who liked to play Spider-Man.

I caught up enough to see Riley ahead and fol owed at a distance until he got to Raoul’s team. The scent made it hard to keep my mind on the things that mattered.

“Raoul!” Riley yel ed.

Raoul grunted, not turning. He was total y absorbed by the sweet scent.

“I’ve got to help Kristie! I’l meet you there! Keep your focus!”

I jerked to a stop, frozen with uncertainty.

Raoul kept on, not showing any response to Riley’s words. Riley slowed to a jog, then a walk. I should have moved, but he probably would have heard me try to hide. He turned, a smile on his face, and saw me.

“Bree. I thought you were with Kristie.”

I didn’t respond.

Free Essays

The Short Second Life of Bree Tanner Chapters 12

“Tonight you get a taste of what our world wil be like when our competition is out of the picture. Fol ow me!”

Riley bounded away; Raoul and his team were right on his heels. Kristie’s group started shoving and clawing right through the middle of them to get to the front.

“Don’t make me change my mind!” Riley bel owed from the trees ahead. “You can al go thirsty. I don’t care!”

Kristie barked an order and her group sul enly fel behind Raoul’s. Fred and I waited until the last of them was out of sight. Then Fred did one of those little ladies first sweeps with his arm. It didn’t feel like he was afraid to have me at his back, just that he was being polite. I started running after the army. The others were already long gone, but it was nothing to fol ow their smel . Fred and I ran in companionable silence. I wondered what he was thinking. Maybe he was only thirsty. I was burning, so he probably was, too.

We caught up to the others after about five minutes, but kept our distance. The army was moving in amazing quiet. They were focused, and more… disciplined. I kind of wished that Riley had started the training sooner. It was easier to be around this group.

We crossed over an empty two-lane freeway, another strip of forest, and then we were on a beach. The water was smooth, and we’d gone almost due north, so this must have been the strait. We hadn’t passed near any residences, and I was sure that was on purpose. Thirsty and on edge, it wouldn’t take too much to dissolve this smal measure of organization into a screaming free-for-al .

We’d never hunted al together before, and I was pretty sure that it was not a good idea now. I remembered Kevin and the Spider-Man kid fighting over the woman in the car that first night I’d talked to Diego. Riley had better have a whole lot of bodies for us or people were going to start tearing each other up to get the most blood.

Riley paused at the water’s edge.

“Don’t hold back,” he told us. “I want you wel fed and strong – at your peak. Now… let’s go have some fun.”

He dove smoothly into the surf. The others were growling excitedly as they submerged, too. Fred and I fol owed more closely than before because we couldn’t fol ow their scent under water. But I could feel that Fred was hesitant – ready to bolt if this was something other than an al -you-can-eat smorgasbord. It seemed like he didn’t trust Riley any more than I did. We didn’t swim long, and then we saw the others kicking upward. Fred and I surfaced last, and Riley started talking as soon as our heads were out of the water, like he’d been waiting for us. He must have been more aware of Fred than the others were.

“There she is,” he said, waving toward a large ferry chugging south, probably making the last commuter run of the night down from Canada. “Give me a minute. When the power goes out, she’s al yours.”

There was an excited murmur. Someone giggled. Riley was off like a shot, and seconds later we saw him fly up the side of the big boat. He headed straight for the control tower on top of the ship. Silencing the radio was my bet. He could say al he wanted about these enemies being our reason for caution, but I was sure there was more to it than that. Humans weren’t supposed to know about vampires. At least, not for very long. Just long enough for us to kil them.

Riley kicked a big plate-glass window out of his way and disappeared into the tower. Five seconds later, the lights went out.

I realized Raoul was already gone. He must have submerged so we wouldn’t hear him swimming after Riley. Everyone else took off, and the water churned as if an enormous school of barracuda were attacking.

Fred and I swam at a relatively leisurely pace behind them. In a funny way, it was like we were some old married couple. We never talked, but we stil did things at exactly the same time. We got to the boat about three seconds later, and already the air was ful of shrieks and the warm scent of blood. The smel made me realize exactly how thirsty I was, but that was the last thing I realized. My brain shut down completely. There was nothing but fiery pain in my throat and the delicious blood – blood everywhere – promising to put that fire out. When it was over and there wasn’t a heart left beating on the whole ship, I wasn’t sure how many people I’d personal y kil ed. More than triple the number I’d ever had on a hunting trip before, easy. I felt hot and flushed. I’d drunk long past the point at which my thirst was total y slaked, just for the taste of the blood. Most of the blood on the ferry was clean and luscious – these passengers had not been dregs. Though I hadn’t held back, I was probably at the low end of the kil count. Raoul was so surrounded by mangled bodies that they actual y made a little hil . He sat on top of his pile of the dead and laughed loudly to himself.

He wasn’t the only one laughing. The dark boat was ful of sounds of delight. I heard Kristie say, “That was amazing – three cheers for Riley!” Some of her crowd put up a raucous chorus of hurrahs like a bunch of happy drunks.

Jen and Kevin swung onto the view deck, dripping wet. “Got

’em al, boss,” Jen cal ed to Riley. So some people must have tried to swim for it. I hadn’t noticed.

I looked around for Fred. It took me a while to find him. I final y realized that I couldn’t look directly at the back corner by the vending machines, and I headed that way. At first I felt like the rocking ferry was making me seasick, but then I got close enough that the feeling faded and I could see Fred standing by the window. He smiled at me quickly, and then looked over my head. I fol owed his gaze and saw that he was watching Riley. I got the feeling that he’d been doing this for some time.

“Okay, kids,” Riley said. “You’ve had a taste of the sweet life, but now we’ve got work to do!”

They al roared enthusiastical y.

“I’ve got three last things to tel you – and one of those things involves a little dessert – so let’s sink this scow and get home!”

With laughter mixed in with the snarls, the army went to work dismantling the boat. Fred and I bailed out the window and watched the demo from a short distance. It didn’t take long for the ferry to crumple in the middle with a loud groan of metal. The midsection went down first, with both the bow and the stern twisting up to point to the sky. They sank one at a time, the stern beating the bow by a few seconds. The school of barracuda headed toward us. Fred and I started swimming for shore. We ran home with the others – though keeping our distance. A couple of times Fred looked at me like he had something he wanted to say, but each time he seemed to change his mind. Back at the house, Riley let the celebratory mood wind down. Even after a few hours had passed, he stil had his hands ful trying to get everyone serious again. For once it wasn’t a fight he was trying to defuse, just high spirits. If Riley’s promises were false, as I thought, he was going to have an issue when the ambush was over. Now that al these vampires had real y feasted, they weren’t going to go back to any measure of restraint very easily. For tonight, though, Riley was a hero. Final y – a while after I would have guessed that the sun was up outside – everyone was quiet and paying attention. From their faces, it seemed they were ready to hear just about anything he had to say.

Riley stood halfway up the stairs, his face serious.

“Three things,” he began. “First, we want to be sure we get the right coven. If we accidental y run across another clan and slaughter them, we’l tip our hand. We want our enemies overconfident and unprepared. There are two things that mark this coven, and they’re pretty hard to miss. One, they look different – they have yel ow eyes.”

There was a murmur of confusion.

“Yel ow?” Raoul repeated in a disgusted tone.

“There’s a lot of the vampire world out there that you haven’t encountered yet. I told you these vampires were old. Their eyes are weaker than ours – yel owed with age. Another advantage to our side.” He nodded to himself as if to say, one down. “But other old vampires exist, so there is another way that we’l know them for sure… and this is where the dessert I mentioned comes into play.” Riley smiled slyly and waited a beat. “This is going to be hard to process,” he warned. “I don’t understand it, but I’ve seen it for myself. These old vampires have gone so soft that they actual y keep – as a member of their coven – a pet human.”

His revelation was met by blank silence. Total disbelief.

“I know – hard to swal ow. But it’s true. We’l know it’s definitely them because a human girl wil be with them.”

“Like… how?” Kristie asked. “You mean they carry meals around with them or something?”

“No, it’s always the same girl, just the one, and they don’t plan to kil her. I don’t know how they manage it, or why. Maybe they just like to be different. Maybe they want to show off their self-control. Maybe they think it makes them look stronger. It makes no sense to me. But I’ve seen her. More than that, I’ve smel ed her.”

Slow and dramatic, Riley reached into his jacket and pul ed out a smal ziplock bag with red fabric wadded up inside.

“I’ve done some recon in the past few weeks, checking the yel ow-eyes out as soon as they got near the area.” He paused to throw us a paternal look. “I watch out for my kids. Anyway, when I could tel that they were moving on us, I grabbed this” – he brandished the bag – “to help us track them. I want you al to get a lock on this scent.”

He handed the bag to Raoul, who opened the plastic zipper and inhaled deeply. He glanced up at Riley with a startled look.

“I know,” Riley said. “Amazing, right?”

Raoul handed the bag to Kevin, his eyes narrowing in thought.

One by one, each vampire sniffed the bag, and everyone reacted with wide eyes but little else. I was curious enough that I sidled away from Fred until I could feel a hint of the nausea and knew I was outside his circle. I crept forward until I was next to the Spider-Man kid, who seemed to be at the tail end of the line. He sniffed inside the bag when it was his turn and then seemed about to hand it back to the kid who had given it to him, but I held my hand out and hissed quietly. He did a double take – almost like he’d never see me before – and handed me the bag.

It looked like the red fabric was a shirt. I stuck my nose in the opening, keeping my eyes on the vampires near me, just in case, and inhaled.

Ah. I understood the expressions now and felt a similar one on my face. Because the human who had worn this shirt had seriously sweet blood. When Riley said dessert, he was dead right. On the other hand, I was less thirsty than I’d ever been. So while my eyes widened in appreciation, I didn’t feel enough pain in my throat to make me grimace. It would be awesome to taste this blood, but in that exact moment, it didn’t hurt me that I couldn’t.

I wondered how long it would take for me to get thirsty again. Usual y, a few hours after feeding, the pain would start to come back, and then it would just get worse and worse until – after a couple of days – it was impossible to ignore it even for a second. Would the excessive amount of blood I’d just drunk delay that? I guessed I’d see pretty soon.

I glanced around to make sure no one was waiting for the bag, because I thought Fred would probably be curious, too. Riley caught my eye, smiled the tiniest bit, and jerked his chin slightly toward the corner where Fred was. Which made me want to do the exact opposite of what I’d just been planning, but whatever. I didn’t want Riley to be suspicious of me. I walked back to Fred, ignoring the nausea until it faded and I was right next to him. I handed him the bag. He seemed pleased I’d thought to include him; he smiled and then sniffed the shirt. After a second he nodded thoughtful y to himself. He gave me the bag back with a significant look. The next time we were alone, I thought he would say aloud whatever it was he had seemed to want to share before.

I tossed the bag toward Spider-Man, who reacted like it had fal en out of the sky but stil caught it before it hit the ground. Everyone was buzzing about the scent. Riley clapped his hands together twice.

“Okay, so there’s the dessert I was talking about. The girl wil be with the yel ow-eyes. And whoever gets to her first gets dessert. Simple as that.”

Appreciative growls, competitive growls.

Simple, yes, but… wrong. Weren’t we supposed to be destroying the yel ow-eyed coven? Unity was supposed to be the key, not a first-come, first-served prize that only one vampire could win. The only guaranteed outcome from this plan was one dead human. I could think of half a dozen more productive ways to motivate this army. The one who kil s the most yel ow-eyes wins the girl. The one who shows the best team cooperation gets the girl. The one who sticks to the plan best. The one who fol ows orders best. MVP, etc. The focus should be on the danger, which was definitely not the human.

I looked around at the others and decided that none of them were fol owing the same train of thought. Raoul and Kristie were glaring at each other. I heard Sara and Jen arguing in whispers about the possibility of sharing the prize.

Wel, maybe Fred got it. He was frowning, too.

“And the last thing,” Riley said. For the first time there was some reluctance in his voice. “This wil probably be even harder to accept, so I’l show you. I won’t ask you to do anything I won’t do. Remember that – I’m with you guys every step of the way.”

The vampires got real stil again. I noticed that Raoul had the ziplock back and was gripping it possessively.

“There are so many things you have yet to learn about being a vampire,” Riley said. “Some of them make more sense than others. This is one of those things that won’t sound right at first, but I’ve experienced it myself, and I’l show you.” He deliberated for a long second. “Four times a year, the sun shines at a certain indirect angle. During that one day, four times a year, it is safe… for us to be outside in the daylight.”

Every tiny movement stopped. There was no breathing. Riley was talking to a bunch of statues.

“One of those special days is beginning now. The sun that is rising outside today won’t hurt any of us. And we are going to use this rare exception to surprise our enemies.”

My thoughts spun around and turned upside down. So Riley knew it was safe for us to go out in the sun. Or he didn’t, and our creator had told him this “four days a year” story. Or… this was true and Diego and I had lucked into one of those days. Except that Diego had been out in the shade before. And Riley was making this into some kind of solstice-y seasonal thing, while Diego and I had been safe in the daylight just four days ago. I could understand that Riley and our creator would want to control us with the fear of the sun. It made sense. But why tel the truth – in a very limited way – now?

I would bet it had to do with those scary dark-cloaks. She probably wanted to get a jump on her deadline. The cloaked ones had not promised to let her live when we kil ed al the yel ow-eyes. I guessed she would be off like a shot the second she’d accomplished her objective here. Kil the yel ow-eyes and then take an extended vacation in Australia or somewhere else on the other side of the world. And I’d bet she wasn’t going to send us engraved invitations. I would have to get to Diego quick so we could bail, too. In the opposite direction from Riley and our creator. And I ought to tip Fred off. I decided I would as soon as we had a moment alone.

There was so much manipulation going on in this one little speech, and I wasn’t sure I was catching it al . I wished Diego were here so we could analyze it together.

If Riley was just making up this four-days story on the spot, I guess I could understand why. It’s not like he could have just said, Hey, so I’ve lied to you for your whole lives, but now I’m telling the truth. He wanted us to fol ow him into battle today; he couldn’t undermine whatever trust he’d earned.

“It’s right for you to be terrified at the thought,” Riley told the statues. “The reason you are al stil alive is that you paid attention when I told you to be careful. You got home on time, you didn’t make mistakes. You let that fear make you smart and cautious. I don’t expect you to put that intel igent fear aside easily. I don’t expect you to run out that door on my word. But…”

He looked around the room once. “I do expect you to follow me out.”

His eyes slid away from the audience for just the teensiest fraction of a second, touching very briefly on something over my head.

“Watch me,” he told us. “Listen to me. Trust me. When you see that I’m okay, believe your eyes. The sun on this one day does have some interesting effects on our skin. You’l see. It won’t hurt you in any way. I wouldn’t do anything to put you guys in unnecessary danger. You know that.”

He started up the stairs.

“Riley, can’t we just wait – ,” Kristie began.

“Just pay attention,” Riley cut her off, stil moving up at a measured pace. “This gives us a big advantage. The yel oweyes know al about this day, but they don’t know that we know.”

As he was talking, he opened the door and walked out of the basement into the kitchen. There was no light in the wel -shaded kitchen, but everyone stil shied away from the open doorway. Everyone but me. His voice continued, moving toward the front door. “It takes most young vampires a while to embrace this exception – for good reason. Those who aren’t cautious about the daylight don’t last long.”

I felt Fred’s eyes on me. I glanced over at him. He was staring at me urgently, as if he wanted to take off but had nowhere to go.

“It’s okay,” I whispered almost silently. “The sun’s not going to hurt us.”

You trust him? he mouthed back at me.

No way.