Pizza Hut, Yum! Essay

The operations standards are the key path defining elements in any business. Without set procedures optimal results cannot be obtained. The operations standards at pizza hut have multifaceted challenges and opportunities. The standards and procedures for doing business are well defined but some of the possible factors can cause to the deviations and variances. Those possible factors can be eradicated through extra efforts into the process. However the small chances of variance will remain the same because the real business scenarios may vary sometimes than the forecasted one. This report is an attempt to investigate the operational standards and the possible causes of variance in standards and how does it affect customer satisfaction. Introduction Operations management Traditionally it is believed that the operations management is as a transformation process that takes set of inputs and transforms them into the out put. The output can be the goods or services. This includes the effective planning, scheduling and control of the activities that produce the required outcomes. (Cecil C. Bozarth, Robert B. Handfield, 2008). Operations management plays a key role in determining the success or failure of an organization. To carry forwards the inputs of each unit all together and getting turned it into the outputs is the real synergy, which helps organization to set the directions towards climbing the heights of success. According to the William J. Stevenson as he state in his operations management book ‘Operations management is the management of the system or process that create goods and/or provide services’ this involves various inputs, he add, ‘ the creation of goods or services involves the transformation or conversion of inputs into outputs. Such as capital, labour and information are used to create goods or services using one or more transformation processes’. Although the goods and services go hand in hand, there are some very basic differences between the two. This can be determined through its nature of the business. Some organizations can have higher degree of tangibility or intangibility. This can be determined through its nature of business. For instance, if the organization is selling goods, it can be determined high level of tangibility and otherwise if its selling services then level of intangibility will be high. (William J.Stevenson 2005). Operation standards at Pizza Hut Functional Units The activities of business organizations are mostly divided according to the functionality, the management of the personnel and the responsibilities. (Joseph S. Martinich, 1997) The operations at Pizza hut can not be highlighted for any of the single functional unit. Rather it is the collection of several set of the activities that take place with in the unit and make things possible by turning customer expectations into the reality. The success or the failure of the product depends on the performance of several functional units. Those functional units operate separately but connected with each other through the job activities. The unit’s operation standards are discussed further down. The taste and the quality highly determine on the freshness of the ingredients, and the resultant the happiness of the customers. According to the Deputy Manager of Pizza hut, ‘If, there is variance observed in the product quality that will overall affect productivity and finally the customer satisfaction level. This is not acceptable at all’. He added, ‘if company is spending a huge amount of money on the product promotions and marketing activities that is for the business. And also company provides the training to the employee to how to maintain the product quality. So every single person should have to ensure the quality of the product and happy customer makes more return in the future’. In this regard, company has got set procedures and guideline to maintain the standards for the specified interactions between the employees and customers. If the deviations occur that will likely to lead to the unhappy customers. Food temperatures To keep products safe storage the temperature of freezers should be in between -18 to + or – 5 degree centigrade. The seals must be intact so that the temperature can be maintained. Quality Assurance The quality throughout the supply chain rests with the overall team. This is done by setting rigorous standards during product development. In order to ensure the standards, there is regular auditing and monitoring system in place. The one of the regular system to check quality is CHAMPS Excellence Review. Quality assurance is achieved through the complaints monitoring system and their corrections through available remedial methods. Core Competence. Organizational strength or abilities, developed over a long period, that customers find valuable and competitors find difficult or even impossible to copy. (Cecil C. Bozarth, Robert B. Handfield, 2008) The pizza hut has got high degree of core competence in the basic product. The pizza hut’s dough is treated as core competence of the business. This makes pizza hut different then the competitors. Cost & variance The cost of sales and the sales revenue are the actual things that support the managers to run the business on track. If the numbers seems going out of the track they need be highlighted and called as variance. The variance is the difference between the Actual cost and Theoretical Cost. Head office set forecast and provide targets to the business stores. The targets are set with the help of previous year business performance and the expected events. That is called as theoretical cost. On the other hand the cost occurred in the business dates is the actual cost. So if there is any difference occurs that will be treate as variance. The cost of sales of the store for the current period shows the variance of 36. 38. * The theoretical cost set by management was ? 2203. 22 and in percentage 22.46% where as the actual cost for the period occurred was ? 2239. 60 in percentage 22. 83%. The results indicate the variance remained ? 36. 38. The variance in costing is the actual indicator of the performance. Higher the variance depicts higher the concerns persist with in the business unit. In present case in hand, the above depicted variance treated to be normal. The business operations can not work on the absolute set tracks because the forecasted things can not happen on the absolute behaviours as predicted. Reasons of variances * Miscount The chance of miscounting always prevails during the operations. In the case of miscount the chances of wrong order increase and finally will increase the variance. * Wastage The several reasons for wastage may occur during the operations. However if forecast made is not effective then the chances of unexpected results may increase. That applies with the product forecast as well. If product is defrosted without realizing the demand for the product then this may cause to one of potential wastage. In other case the wastage can increase if no proper product forecast is being made and or staff make mistakes while making orders or at the time of dispatching orders. In any case if wrong delivered to customer the customer will complaint against it and in order to make customer happy the order is to be resent. This will certainly increase the cost. Higher the number of complaints more is the cost. These two factors are directly proportional. * Shrink The shrink may occur if inventory reduced without record. The variance shows the real picture of the business operations. Happy customers return back to business and become repeat customers and cause to increases in the sales revenue of the business. However, If sales revenue is running on the increasing trend or above of the forecasted track then it clearly indicates the successful operations of the business activities. And this will likely to decrease the percentage of variance as overall. Forecasting Forecasting the estimated demand is the real start of every single operational activity in the business unit. This involves every thing from human resource planning to the product planning. In this every single factor get into the touch of planning, organizing, and leading and control of the operational activities. This ultimately leads to the overall productivity of the unit. Forecasting product and customers demand is the most important activity for the b business organizations. (Derek L Waller 2003) Forecasting is very important element to carry forwards the business on the set line successfully up to the mark in efficient manners. (Joseph S. Martinich, 1997) The same goes true for the pizza hut business. According to the RGM ‘forecasting at pizza hut plays critical part for the success of the business’. The manager, prior to develop any plans for HR deployment or the food ordering, they observes the forecast of sales and expected upcoming events in the calendar. As per say, the usual shift requires two to three drivers and plus kitchen staff and the shift manager. Where as the number of drivers can increase on weekends, as high as 7 to 10 and 4 to 5 in store staff plus shift manager and support manager. This works fine when every thing works according to plans. However, if any of the external factors come into play then that can potentially affect the service delivery and the speed. This happens when for example the whether conditions. The road hazards in shape of blockades, accidents. All of these factors can slow down the serviceability. The unexpected orders can cause more demand of the product where as the availability of the ready to use product may be limited according to the expected demand for the shift. Therefore the variance in expected demand and actual demand can cause the shortage of the products and ultimately this can play around the one of the possible factors of the unhappy customer and can cause the variance in the productivity of the unit as over all. The demand can also increase because of the good weather, special occasions like sports, rituals, festivals, and purchasing power. According to the RGM of the unit, the demand for the food is high in the start of the month but that usually slow down in the end of the month due to the less availability of the funds with customers. Employee performance/training The training data base available at store and the views gathered from management team reveals the fact that the importance of the training in store is directly linked with the operations standards and productivity. The team member working on make table should have to be trained according to the specified requirements of the make table. The lack of training will cause the variances in operations activities. This directly results the variances in the customer satisfaction. Importance of Customer Experience Customer care is the core point of concentration behind the business. The business treats customers as king. The most important fact is to find out the ways through the customer want can be fulfilled effectively. Therefore there are some procedures and standards set by top management in order to interact with customer. Customers don’t really want relationships. At least not in the same way the brand does. They want to be treated well, respected, understood and to get what they want, when they want it. In other words, they simply want a good experience and the reassurance of knowing that they will have the same good experience every time they come into contact with the brand. So, if we the team get to the experience right, the opportunity to build meaningful relationships should follow. (Asbjorn Rolstadas, 1995 & Alan Mitchell Issue 5, Summer 1999) Pizza hut is selling pizzas but this is what other competitors have been doing. So what makes it really special about it? Who recognise that product alone? The product alone is nothing but the service is also important. That is the factor which make customers as ‘repeat customers’ The attitudes, values make key differentiations. The operational standards, the quality of food all of them are key factors. (Mary Say et all 2003, Issue 440) In order to achieve desired results the team members at Pizza hut are provided with set guidelines for the interaction with customers. The guide line called ‘moment of truth’ or ‘customer mania plus’. Moment of Truth The most important key elements to are set in this guidelines. (See Appendix 8) * Order taker The order taker is the key person who works as a bridge between the company and the customer. If he/she makes customer happy, the business will likely to repeat other wise can drain to the competitors. This results not only the loss of customer but also the loss of several networks of the lost customer. CHAMPS Excellence The order delivered to the customer should followed by the set procedures. The delivery person has provided particular guideline that he/she will have to follow when interacting with customers. This results in increase customer satisfaction. The other most important factors that the management follows are; * Delivered on time * Delivered completely. * Invoiced correctly. * Undamaged However, If any of the above factors missing from the cycle process of order making, then it start again from the make table. This * Response. (repeat customer/happy customer) * Complaints Resolving complaint * Offering service delivery * Offering hot food delivery * Beat the phone capture in busy times. * Beat the web orders There should be every reason for the return of the customer. Without fulfilment of the expectation that will not be possible. However the team at Pizza hut follows the guidelines and makes customers happy, but there may be several factors that may cause to the dissatisfaction. In general, the possible factors may be for instance, rush of customers and not enough staff available to take orders or to pick up a phone, bad quality, late delivery or the rude attitude. According to the pizza hut manual almost 2/3 of unhappy customers never return because of poor service. The RGM at store revealed the fact as ‘Customers don’t come pizza hut just for the food, they can get food anywhere. What most customers want when they visit or call us is a good time’. He adds, ‘when they order on phone they expect order takers to treat them well and make their time great. How do you do this? By having a service attitude and making customers feel welcome and important’. Marketing The Marketing plays very important role for the business. The customers actually receive message through marketing, thus it become very critical that the company should highlight the customer expectations in the marketing message. There are several set standards that are to be followed for the marketing purposes. (Francis J.Mulhern, 2004). The company invest considerable resources to find out the exact wishes of customers. For the Pizza hut’s delivery branches the segment of customers includes from families, to the teens. According to the Pizza hut database the primary customer are teens and young adults. Product Development The pizza hut success is not the matter of isolated activities. But it is the company’s restless efforts to put innovations into the realities by turning needs and wants in to the shape of products. Product development team run focus group to study the consumer behaviours towards product choices. Some time products are launched after having selected study of the chosen sample, but it does not survive for long time. This may cause occurrence of cost or the wastages to the stores. For instance the four for all, cheesy bread, Bombay wings, Indian pizza are all the examples of failed products. However the company has launched successful products as well. For instance cheesy bite pizza, which has cause around 24% increases in pizza sales over all. Company Profile Pizza hut started on 1958. The dream of Frank and Dan Carney turned into the reality when he opened the first Hut in Wichita, Kansas. The website of pizza hut states that in very beginning the restaurant was as too small. It had just 25 seats available for customers. The inspirations for the name as ‘Hut’ came into thoughts through the design of the building. It looked like a hut. Therefore it geared the idea to carry on with name as ‘Pizza Hut’. The Pizza has superior place in the market, particularly for the Pizza business. Through the time it has scattered in to the markets of the world. The numbers of the growth depicts that it Pizza hut has more than 600 outlets in the UK only. The Pizza hut is a part of Yum, which is another big company. The Yum own several big companies like KFC, Long John Silver’s, A & W Taco Bell The Pizza hut was formerly owned by Whitbread and Yum as a joint venture. But in the year 2006 Whitbread sold out their shares to Yum. Presently the Pizza Hut UK Ltd is now 100% owned by Yum! Conclusion The operations management depicts the performance of each and individual unit that is participating in over all acceleration of the engine of business. The business may have some times low speed and high speeds. It highly depends on the strategies that the top management set for the business and the way the strategies are followed by the key components that run the actual business. The operations at Pizza hut have multifaceted situations. The each component working in the process cycle of business plays equally important role to win the customer. However, if any one of the units deviating from the set standards will cause a variance in the performances as overall. Thus it is concluded that the success of the business is possible through collections of inputs from all the units participating in the conversion process.

Training Plan

TEACHING/FACILITATION PLAN (Please remember to maintain anonymity of the area of work and the persons involved). Date on which the teaching occurred: | |Learning environment: | | | |Number/s and learning style/s of learner/s ( if known) : | | | |Learner’s previous knowledge, skills and attitude : | | | |Title of Session /Aim : | | | | | | | |Learning outcomes: | | | |Time frame: |Content: |Teaching methods used :(e. g. |Resources used: | | | |explanation, | | | | |Lecture, demonstration, | | | | |practice, questioning). | | | | | | | | | | | | | | | | | | | | | | | | | | |Do not evaluate within in this plan, evaluate the assessment within your 1000 word reflection include: | |What would you do if you were to undertake this again? Would you alter anything with reference to your learning environment, timing, aim, learning | |outcomes, resources used etc? | | | | | | | | | | | | | | | | | | Essay 1 1. Discuss in detail the effectiveness of your teaching plan ie y ou may include discussion regarding the learning environment and the teaching methods used. 2. How did you establish the aim and learning outcomes discuss and reflect upon why these are important and useful in practice? The aim of the teaching plan was decided upon following a discussion with the student, when it was highlighted by the student that she felt under confident with taking manual blood pressure readings. The learning outcomes were formulated during a one to one session using Nicklin and Kenworthy (2003) who state that learning outcomes should be: SMART Specific †¢ Measureable †¢ Achievable †¢ Realistic †¢ Time framed Mager (1997) conjectures that without objectives you won’t be able to decide which content and procedures will get you to your aim. The formulation of learning outcomes communicates the assessor’s intent and are not open to interpretation. They give the student a clear understanding of what is expected of them. Clinical plac ements can be daunting for the student and having clear learning aims can help students focus on one aspect at a time thus helping to increase confidence. 3. Discuss learning styles and how knowledge of these may have influenced your choice of teaching methodsIt is generally acknowledged that learning styles indicate an individual’s preferred way of learning or how the individual acquires information (Fedder and Brent, 2005). Learning styles also influence the way in which learners master the goals and objectives of an educational programme (Rassool and Rawaf, 2008). (Word count for essay 1 =†¦.. words (NB: Please do not   include your words from the teaching plan) ASSESSMENT PLAN (Please remember to maintain the anonymity of the area of work and the persons involved). |Date on which the assessment occurred: | |Learning environment: | | | | | | |Number/s and learning style(s) of learner(s) being assessed: ( if known) | | | | | | | | | |Learner’s previous k nowledge, skills and attitude : | | | |Title of assessment /Aim: | | | | | |Learning outcomes: | | | | | |Preparation of the learner/s for the assessment :(please include the context of assessment e. g. ormative/summative): | | | | | | | | | | | | | |Consider any Issues to be considered by the Assessor with the learner/s: (such as maintaining dignity, confidentiality, maintenance of safety. please | |include the standard/level to be achieved, and relate to knowledge/skills/attitudes/safety). | | | | | | | | | | | | | | | | |Assessment Criteria to be used for this assessment? Trust policy/Standard etc. |Do not evaluate in this plan, evaluate the assessment within your 1000 word reflection include: | |What would you alter if you were to undertake this again? Would you alter anything with reference to your learning environment, timing, aim, learning | |outcomes, resources used etc? | |What methods would you use to collate information regarding the assessment for e. g. utilise observation? Patient narrative or questioning techniques? Would| |you prepare the learner more satisfactorily for the assessment? Would you alter the aim/ learning outcomes? Did you assess knowledge, skills and attitude? | | | | | | | | | | | | | | | | Essay 2 1. Explore in detail why it is necessary to assess your learner The NMC sets out standards of education of pre-registration students. These set out what nursing students must demonstrate to be fit for practice at the point of registration with the NMC. All nurses are required to share their knowledge, skills and expertise and must assist students in the development of competence (Nursing and Midwifery Council (NMC) 2008a).Recent changes highlighted in the Standards to Support Learning and Assessment in Practice (NMC 2008b) have raised the profile of mentoring in practice. These standards provide a clear framework to enhance the quality, principles and accountability of mentorship. Practical knowledge and per sonal experience are cornerstones for integrating theoretical knowledge and developing nursing skills and are a major reason for clinical placements during nurse education (Midgley,2006) A context of learning is created when learning is acknowledged as a legitimate aspect of the nursing situation e. g. when an experienced nurse accompanies the student either to observe or teach in the situation. The role of the mentor in clinical practice settings is an important aspect of nurse education.Through mentorship, qualified nurses get the opportunity to pass on professional values, knowledge and skills to the trainee nurse. 2. What were your aim and learning outcomes? Where did the assessment criteria come from? Was the assessment valid and reliable? The aim of the assessment session was that the student would demonstrate the ability to perform a manual blood pressure recording. That she would have an understanding of the relevance of the readings and that the recordings would be document ed accurately. The assessment criteria were compiled from policies and guidelines set out by the NMC, Royal Marsden Manual of Clinical Procedures and employers policies. Thus ensuring that the procedure adheres to NMC and local guidelines.The assessment was both valid and reliable as the learning outcomes were specific to policy and procedure. 3. Discuss the importance of constructive feedback and how it was given to your learner Feedback is an important part of the process in improving skills, knowledge and confidence. Students in all professions require feedback in order to stay motivated in their learning. The importance of thoughtfully and appropriately delivering feedback becomes clear when the deleterious consequences of poorly given or misunderstood feedback are considered. For example when learners view feedback purely negatively, they can become anxious or resentful and less receptive to further learning and evaluation (King, 1999).The feedback given to my student following the assessment was undertaken in a quiet private area, where time was taken to discuss together how we both felt the assessment had gone. I gave positive feedback on the assessment, pausing to allow the student to comment, the student herself highlighted the area of the assessment she felt under confident about. We had a further discussion on this and together compiled an action plan and scheduled regular one to one session to facilitate practice sessions. The session ended on a very positive note with the student thanking me for my guidance. 4. Reflect on your strengths and weaknesses of the assessment sessionOn reflecting my own strengths and weaknesses during the assessment session it has become apparent to me that I should have given the student the opportunity to postpone the assessment due to the unexpected noisy environment . I felt the student’s concentration was compromised. This indeed could be identified as a weakness, not enabling the student to have an ideal lea rning environment. My strength during the assessment would have been my delivery of feedback following the session. I was able to use my positive mentor student relationship in order to allow the student to self-reflect and become aware of the area of the assessment in which she was weak. By allowing the student to 5. (Word count for essay 2 =†¦.. words ( NB: Please do not   include your words from the assessment plan) References

Birth Defects Essay Example | Topics and Well Written Essays - 1500 words

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Media Audiences Essay Example | Topics and Well Written Essays - 2000 words

Media Audiences - Essay Example Also, as with other qualitative approaches, in any one study, ethnography relies on a range of data collection methods and data sources to increase the validity of findings. A distinct feature of ethnography, however, is its reliance on participant observation – the researcher as a participant of the context being observed. The researcher is at one and the same time a researcher and participant. It is through the extensive and total immersion in a context that a participant observer is able to build a rich descriptive picture of those studied as a backdrop against which explanations can be explored (Arnould & Price 1993, pp. 24-45) When comparing all three different qualitative methodologies, each quite distinct in their procedures for data collection, interpretation and theoretical development. For example, grounded theory is ?exible in terms of data, but insists on theoretical sampling and saturation of both data and theory before theory development can be claimed. It is als o a methodology particularly suited to situations that have a symbolic and, or, an interactional element to them. Consequently, it has potential for a number of research directions and contexts that go beyond consumer behavior, for example relationship marketing or even the sales situation (Brownlie, 1997, pp. 263-82). Ethnography is generally concerned with culture and power with the main forms of data generally participatory observation and interviews. Again, research agendas that focus on, for example, inter-departmental dynamics, gender issues, ethical marketing or green consumption may well bene?t from the application of an ethnographic approach. Finally phenomenology has its own unique characteristics and philosophy, which... This study looks into ethnography as a branch of anthropology which provides scientific descriptions and interpretations of human social behavior. It is a systematic study of people that observes, through extensive fieldwork, how humans act and interact in a specific and defined culture. Ethnography is an approach to research dedicated to collecting in-depth information on social behavior in a specific context. Traditionally, culture was understood in geographic or ethnic terms. Now culture or context (the word used in this paper), can refer to a range of settings/environments where people interact. Each context will be different and complex as a result of differences in history and cultural practices, for example. A context may be a school or workplace setting, a housing estate in an inner city or a hospital and will be selected based on the purpose of the research. The complexity of each context underpins and helps to explain behavior. Audience plays a key role in determining the s uccess of any media, program or channel. Undeniably audience stands as the backbone of any mass media. But this term has been exploited and manipulated by many researchers and theorists when they relate the actual meaning of audience in relation to define mass media and other broadcasting services. It is easily understandable that no program, channel or a media can excel without having a proper viewership or a large number of audiences.

In your 17 or 18 years of life, in what do you place your highest Essay

In your 17 or 18 years of life, in what do you place your highest value, what is your passion and what do you have a commitment towards. Explain why - Essay Example More particularly, this essay will discuss education as my most important value, learning in different settings as my passion, and my commitment is a desire to develop personal learning habits which will contribute to and enhance my education values. As an initial matter, the concept upon which I place the greatest value is education. Without an education, without knowledge and experience, I am what my father refers to as an empty house. Education, as my personal value, is not intended to be defined too narrowly; quite the contrary, I envision education as encompassing facts and experiences. It is learning how to socialize with different kinds of people as well as learning about facts. It is as much about learning about my limitations, whether physical or emotional, as well as learning about philosophies and the hard sciences. Curiosity is one of my motivations and a desire to live my life purposefully is another. We learn every day, if we are aware of the opportunities, and in this way education is something which permeates our lives. I can’t think of a greater value to be passionate about. Related to my choice of education as my greatest value is my continuing passion to learn in different settings. To be sure, most people associate education with formal educational settings. They think of desks, and classrooms, and exams. This is certainly one type of learning setting, but is hardly the only setting of which I am passionate about. My passion is to visit lakes and ponds, to examine artifacts and relics in museums, and to meet people both young and old. Each experience furnishes the house to which my father alluded, making it more beautiful and complete, and I view broad experiences as a passion to be pursued and indulged in with passion. Given my greatest value, and my passion for broad experiences, my commitment is to develop learning habits that help me to fulfill my goals.

Mathematical Logics Essay Example | Topics and Well Written Essays - 500 words

Mathematical Logics - Essay Example It does not only promote proper reasoning but it also enhances a proper use of common sense. The sum of numbers available for Andy are Belle’s; 3+4+7=14 or Carol’s 4+6+8=18 or the sum on my cards=?Let the sum of Andy’s cards be A, Sum of Belles cards is B and some of Carol's cards be C and the sum of my cards is M. So M=B or M=C. This is because we are told that there are at least two card sums which are equal. The sum of Carol's cards and Belle’s cards are not equal(B ≠  C).This means that the sum of my cards is either equal to Carol’s or Belle.This reasoning is derived from the fact that Andy admitted that there are two people with an equal sum of cards. The union of odd numbers is 1,3,5,7 and 9.Also, Belle admits that he can see all the five odd numbers, what does this imply? Firstly Belle cannot see 3 and 7 since he is the one possessing these subsets. Secondly, it means that the odd numbers Belle sees are 1, 5 and 9.It is obvious that Andy possesses the card with 1 on it. Who has 9 and 5? Since there is no one else in the game, it is obvious that I possess cards with 9 and 5. From above, the sum of my cards so far is 9+5=14.I still have another card to add to this which means the sum of my cards can never be 14.That is M>14.Therefore it is obvious that the sum of my cards is 18 since it is the only remaining (M=18).14+X=M=18.X=18-14=4.This means my third card is 4.Therefore my cards are 9, 5 and 4. In conclusion from the above calculations and reasoning, it is evident beyond reasonable doubt that I have a 4, a 9 and a five. These answers have arrived after a rigorous process of extensive logical reasoning and application of a little bit of Boolean algebra. The fact that there were three sets of cards visible to Andy, that is mine, Carol and Belle enable me to come down to the situation that the actual cards available to Andy are two sets.  

The evaluation of the social value of fossil and alternative fuels Essay

The evaluation of the social value of fossil and alternative fuels (hybrid) and the use of unleaded petrol - Essay Example ans in discovering alternative forms of energy, such as solar energy, hydrogen energy, etc that seem to affect the social value of fossil fuels adversely (Foster & Witcher, pp. 39-51, 2009). However, fossil fuels continue to enjoy their economic importance despite of such adverse effects. In particular, this paper will focus on social value of the fossil fuels, as well as alternative fuels along with some light on the unleaded petrol that has becoming common in various countries around the globe due to its associated benefits. In order to evaluate social value of fuels, it is very important to understand the meaning of this notion. According to experts (OECD, pp. 10-13, 2006), social value is an entity that indicates a product or service’s benefit in line with the well-being of citizens of the society. In addition, social capital is one of the major aspects of social value that relates to the goodwill and trust that an organization or a product acquired during a period of various years. From this understanding, it will now be easier to evaluate social value of the fuels that seem evident from results of the different researches. In specific, fossil fuels are playing an imperative role in the human society; however, at the same time, its social value seems to diminish every day and every year due to a number of factors. According to the social value theory, that is the basic premise of evaluating social value, ‘everything is connected to everything else’ (Kramer & Bazerman, pp. 55-63, 2009), and these connections allow the organisms to identify some patterns that create the social value. From this principle, fossil fuels seem to be focusing on the necessity aspect of the human society; however, at the same time, they have been affecting the citizens with their increased costs and prospective adverse impacts associated with them that indicate lower social value of fossil fuels in the human society. One of the basic ways of evaluating social value of fossil

The Child Essay Example for Free

The Child Essay The Social Model of disability came about through the disability movement and other organisation campaigning for equal rights, opportunities and choices for disabled people. The social model of disability recognises that any problem of disability are created by society and its institution and that The Discrimination Acts are tools to help to improve the response of society to disability, also a wheel chair user is not hampered by their disability but by lack of adequate access to buildings. The social model may impact upon our practise as we would provide inclusive environments as a starting point for all children. The Scope website stated ‘The social model of disability says that disability is caused by the way society is organised, rather than by a person’s impairment or difference’. The medical model of disability views a disability as the problem also that disability is a tragic incurable fact that leaves the suffer with little chance of a normal life, people should be cared for in institutions and may not be able to be independent. If practitioners follow the medical model of disability this might impact upon our practise by viewing children with a disability as not being able to do anything the other children can do. The medical approach stresses the importance of curing and nowadays preventing disability as though disability is in some ways a tragedy. This has now resulted in screening in pregnancy so that parents can find out if their child is going to have a disability. E2). The legal requirements that support the actions to be taken when it is considered a child may have special needs. The government want to reform the Special Educational Needs (SEN) system to address problems which include parents having to battle to get the support their child needs also children falling between the gaps in services or having to undergo multiple tests, the government are going to by 2014 they are going to include parents in the assessments and give the parents control of funding for the support their child needs. With parents getting the money they might not know where to spend it as they might not have had the money before to spend, with the parents getting the money they have a greater choice of schools that they can send their child to and gives parents and the community groups the power to set up special free schools. The guardian states ‘More than one in five children in England are identified as having SEN – 21% of the school population in January 2010. Only 2. 7% have statements. More than half of the pupils, 11. 4%, are in the school action category. ’ To help children that have learning needs but not necessarily a special educational need we will work with SEN specialists as we develop the reading progress check for six years old to help identify children who require additional support. E3 + C ). The different types of provision available to support children with special needs and their families a voluntary organisation like Barnardo’s where staff just volunteer to work there to help children and their families, they have to find their own way to get money because the government don’t help with any money, they have charities and donations of people to run the business they might also ask for a pound or two for some groups they do to help with the funding. We believe we can bring out the best in every child whether the issue is child poverty, sexual exploitation, disability and domestic violence. † Barnardo’s set up groups for children and parents to go to, so they can talk and so the children can play with each other. Staffs help and support the children and their families. A statuary would be a school this is where children can have one to one support often a special needs or learning support assistant, theses only work alongside the children in the early years settings, through mainstream school parents and families will get support from social services and also get help with respite care, so the children can go for the weekend and have fun and play there this is gives the parents and families a rest as with some children it can be 24 hour every day. By the children going to respite care the children go there so the parents no their child is safe as it can be hard and distressing leaving their child somewhere else. Adults working with SEN children spend the majority of their time supporting that child however sometimes it’s the practitioners that needs the support. The role of the practitioners can be hard work and isn’t taken lightly, the practitioner needs support from other people around them to help promote their confidence and provide the correct provision for the children. A helpful support to practitioners could be the charity Mencap. Mencap work in partnership with people with a learning disability and all our services support people to live life as they choose. E5). One common condition is Dyslexia. It may be possible to detect symptoms of dyslexia before a child starts school. Possible symptoms include: * delayed speech development in comparison with other children of the same age * speech problems, such as not being able to pronounce long words properly and jumbling up phrases – for example, saying helicopter instead of helicopter, or beddy tear instead of teddy bear * problems expressing themselves using spoken language, such as being unable to remember the right word to use, or putting together sentences together incorrectly * little understanding or appreciation of rhyming words, such as the cat sat on the mat, or nursery rhymes * difficulty with, or little interest in, learning letters of the alphabet You can get Dyslexia from family history and genetics, children can get one to one support with spelling and writing and vocabulary, Dyslexia has effects on development with verbal memory, language and concentration. Dyslexic pupils benefit from early intervention to prevent slipping behind their peers. Where specialist support is offered at a lat e age, learning is less effective and self-esteem and emotional well-being may be considerably undermined. Dyslexic pupils will need individual support which is differentiated from that offered to low achieving pupils, addressing the very different learning style of the dyslexic brain, if pupils are to make significant progress. Ideally this should be offered by staff with some training in supporting dyslexic children. In some cases, one-to-one tuition from a specialist dyslexia teacher may be necessary. Practitioners support children within the setting the Class teachers need to have an understanding of the problems that the dyslexic child may have within the classroom situation. Hopefully, with this knowledge, a great deal of misunderstanding of a childs behaviour can be prevented. In a positive and encouraging environment, a dyslexic child will experience the feeling of success and self-value. Another professional that will help children with dyslexia is a one to one tuition from a specialist dyslexia teacher. E6). Ways to overcome barriers to achievement for children with special needs by having adapting the environment and the building this might mean putting a ramp down so the children can get in to the building it might also mean moving the classroom around so children with a walker or a wheelchair can get round the class room, it is also important to adapt activities in order to provide children with the opportunities to learn and feel successful. All children need to experience success in order to maintain motivation and promote a positive self-esteem. This means practitioners need to think about planned activities and consider their suitability for each individual. As practitioners we need to consider how best to adapt the activity in order for the child to have opportunities to learn and feel successful, this may mean changing the format to make it more or less challenging or using a different approach or media. Sometimes equipment and resources need to be modified in order that children can successfully use them, in some cases it is possible to make simple adaptations for example buttons on dressing up clothes may be substituted for Velcro. We also need to get parents involved in planning so we know how we can meet the child’s needs and also so the parents know how the child is getting on in school. An invisible barrier is teachers saying the child can’t do and activity because of their disability and the teachers not changing the lessons for the children, really practitioners should change the activity for each child’s learning needs so that all children are included in each activity and no one is left out of any activities done in the setting, each setting should have an inclusion policy in the setting which means practitioners have to follow the policy to include all the children in the activity, if they don’t they aren’t giving all the children the same chances as everyone else. All practitioners should encourage all children to join in activities together; an example of this could be getting other children to read to a child that has a visual impairment. E7). The role of the practitioner in maintaining the privacy and dignity of children in situations where intimate personal care such as toileting, practitioners would take the child out the room away from the other children and have another member of staff with us, also so making sure practitioners are following policies and procedures like telling other practitioners that you are toileting. As practitioners we need to make sure that we are getting the right training to support the children when toileting. It is important for practitioners to ask parents how we can meet the child’s needs are best met, and maintain privacy and respect of the child, one of the keys for practitioners is to be organised with pads, underwear and toiletries are ready, self-esteem is linked to independence this means that even in tiny ways it is important to support the children to help the child do as much as they can. Children with SEN often take medication. Practitioners will need to uphold knowledge pm the medication so they should research what they are providing to the child, if there could be any side effects what could happen? Communication should take place with the parent or carer to make sure when they should be taking it and if the practitioners will need appropriate training in order to safe guard the child and practitioner. Parents will need to give written consent as to what the practitioner is giving to the child. E8). One professional who supports the needs of children with special needs and their families is a Speech Therapist they are concerned with all aspects of communication, they assess children’s hearing, speech, language, check the mouth and tongue movement, they prepare individual programmes and exercises for children to help them acquire language. Speech therapists either work in the community, hospital clinics or schools; they also help children with cleft lip/palate, cerebral palsy, hearing impairment and stammer. Terms used is assessing speech impairment are fluency, Dysfluency, stutter/stammer, Avoidance behaviour. Signs to watch for and seek advice on birth to 3 months is mother not communicating with the baby or if the child is seriously ill, or having feeding problems. A child 3 to 6 months is silent most of the time and eye contact is not developing. A child 6 to 9 months does not respond to play, vocal and non-vocal and no consistent response to noise, a child 9 to 12 months not trying to communicate and not responding to single words and simple commands, a child 12 to 15 months unable to give a toy to a adult on request. Exercises that may help the children develop could be tongue exercises, blowing bubbles, different lip shapes, making noises with toys and adapting songs. Another professional who supports the eeds of children with special needs and their families is a Community Nurse in some areas community nurses visit schools and settings to help provide advice and support, they may undertake general health and work with parents or they may work with particular children and their famil ies. The Every Child Matters programme is a major focus on early year’s centres. The community nurse may assess the children with epilepsy, mental health and behavioural problems. The http://dera. ioe. ac. uk stated ‘Currently, few local community children’s nursing (CCN) services are able to meet the needs of all ill and disabled children and young people, who have been divided into four groups. These are: †¢ Children with acute and short-term conditions; †¢ Children with long-term conditions; Children with disabilities and complex conditions, including those requiring Continuing care and neonates; and †¢ Children with life-limiting and life-threatening illness, including those requiring Palliative and end-of-life care. ’ D). The importance of a sensitive, non-judgemental approach when working with children with special needs and their families, this is linked right through my assignment talking about that no two children are the same, each child have their own personality and interests and this requires that practitioners are sensitive and reflective. Observing children and thinking about their responses is therefore useful especially where a child’s communications skills are limited. As practitioners we see it as it’s important that many children with special needs are educated alongside their peers, many parents and families have a fight to get equal access to education for the child. As not all schools might have the support that the child may need and to government funding they may not be able to afford it. B). The benefits of an inclusive approach for the child with special needs, the concepts of inclusive education emphasis on schools and settings to adapt and be flexible enough to accommodate each and every child. Organisations seeking inclusive practice also point out the importance of significant funding as poor resources, both physical and human are often barriers to inclusive education. Inclusive education enables all students to participate fully in any mainstream schools, colleges or university it also has training and resources aimed at fostering every student’s equality and participation in all aspects of the life of the learning community, inclusive education aims to equip all people with the skills needed to build inclusive communities. Inclusive education is based on principles: * A person’s worth is independent of their abilities or achievements * Every human being able to feel and think * Every human being has a right to communicate and be heard * All humans beings need each other * Diversity brings strengths to all living system. If children with special needs are to take their place in society after school then, it is important for a school to be truly inclusive, and ending discrimination, removing barriers as talked about in E6, and welcoming and valuing all children. Local education authorities are required to educate children with special needs subject to parents’ wishes, I think it is important that if parents want their child to go in mainstream school they have the chance to go, and learn with other children. A). It is important that different professionals work together to help children and their families as they are there to help and support the child and the family. Multi-agency teams work together to provide benefits for children, young people and families because they receive tailor-made support in the most efficient way. The Education. gov website stated† Multi-agency working brings together practitioners from different sectors and professions to provide an integrated way of working to support children, young people and families†. The benefits of this include early identification and intervention, easier or quicker access to services or expertise, improved achievement in education and better engagement in education, better support for parents, children, young people and family’s needs addressed more appropriately, better quality services, reduced need for more specialist services. The teams work together to help the child meet their needs. A multi-professional approach is important because all the professionals need to work together to help the child and their family for example a child might have a speech impairment the professionals like the practitioner, health visitor and the speech therapist will all work together to help and support the child and the family all the professionals will have a meeting once a month if not more often. t is important for all the professionals to work together for the safety of the child and their family, if they dont work together a situation could end up like baby p, baby p died because professionals didnt work together and have regular meetings and communication. All the professionals need to work together so they know everything about the child and their family and the child and family are getting on and what professionals are working with the family. A multi-agency team helps a team of professionals that work together to support children and their families. A multi-agency team use the Common Assessment Framework (CAF) this supports children and young people who have a low level of additional needs. A multi-agency team will help professionals from relevant agencies to work together to assess the child or young person and therefore support development and learning appropriately. A multi-agency team need to have regular meetings to keep up with all the information; they also need to respect everyone’s views in the team as some people might have different views and opinions. The team of professionals need to have patience as there will be a lot of people in the team with questions to ask. They also need good communication with other members of the team, the children, the parents and the teacher. Good communications mean having emails, letters and information passed on correctly and on time. It also helps being well organised, also making sure they have a right date and time for a meeting.

Changing Trends in Indian Marriages

Changing Trends in Indian Marriages INTRODUCTION: Marriages are divine alliance between the two individuals and have to be maintained for the entire life. They portray a bond which unlike business should not be dissolved if any problem arises. Marriages on the other hand make it important to maintain heavenly relationships among the humans and promote peace and love. In this modern world, meaning of marriages has changed all throughout the people making more intense problems to maintain a good relationship among individuals. Even though there are some countries which still follow the traditional ways to make this heavenly bond, there are influences from the western societies and the minds of the people which cause the break-up in relationship and some problems which affect the entire society. In this essay, let us see the trends which have made some huge changes to the cultural marriages in India. The rich customs and cultural heritage in India make marriages a special occasion for the friends and relatives. The marriages in India have different varieties owing to the different religions that prevail in India. Every different religion has different wedding rituals, methods and way of celebrations. The common feature of Indian marriages is fun and excitement due to the gathering of friends and relatives. The developing India, has liked the changes that were brought to marriages from the recent past. In the olden days, there used to be many rituals and customs that take place in the marriages and the marriages were considered as a heavenly bond between the individuals and the families as whole. Traditionally, the approval by the elders of the families was considered more important than of the individuals. The trend that was prevalent among these Indian marriages is that of the dowry system. Main reasons for the plummeting trend of arranged marriages are that of the problems that are created by the dowry system which affects the entire society. This system demands material gifts from the family of brides for the exchange of the bridegrooms. This trend in this modern India has caused some deaths of the entire family or the bride because of the rising of the demands even after the marriages. Other trends which had caused some unrest in the society were that of the practice of Sati by the widow women and child marriages. According to the laws, practice of Sati is illegal in modern India but some cases have been reported. This practice of Sati resembled and was followed by the acts performed by Gods and Goddess depicted in the epic writings of Mahabharata. On the other hand, child marriages portray the suppression of choice of the individuals in the field of marriages. This was done in the early days to maintain the status of the upper caste families in marrying peoples from other castes or of religion. The existence of a society mainly depends on the customs and traditions of the people. These customs remains as a strong pillars in identifying a particular society. Without a tradition or a culture, the man will represent the primitive man from the jungle. This thought urges us to follow a tradition and culture to be respected and make a path of life for the people. The practice of arranged marriages was performed since the fourth century and it primarily was done to pass on the family tradition and culture from one generation to another. The concept of arranged marriages is liked by the majority of the people in India because the love marriages are not penetrated throughout India. The unlikeliness of love marriages is because it is considered against the Indian culture. Nowadays, both love marriages and arranged marriages are accepted in India. The Indian way of marriages is entirely different from the western way of a marriage where the main difference is the matter of choice of b ride or bridegrooms. In the western countries, the couples tend to live together before their marriage which will help them to understand each other in every aspect. But, In India, marriages are planned according to the factors of dowry, caste, age, order of birth among their siblings and the needs of the family to showcase their pride. This tradition which is followed in India causes in inequality to the communities and is also mistreating women in this modern world. About 90% of the Indian marriages are arranged and follow the old tradition of social rituals. Making the individuals in India marry within their caste system bounds them of choices for their likes and also oppresses the ability of women because of the dominant character of men. Marriages are a divine relationship between man and a woman which depends on love, trust and faith between each other. Marriages are celebrated as a festival by the both families to make the couples understand the tradition and value behind the relationship. Problems of Dowry System Treatment of women in India has been on a rise since 1920s before which the women were treated poorly and badly making the life tougher to lead. The change mainly occurred due to the modernisation and because of the laws introduced by the Indian government. Even nowadays, the countries in Middle East have restrictions for women to own land, or to come out of the houses. Even the modernisation of the life of people has not changed the aspects of the oppression of women in the world. In India, â€Å"dowry deaths†, different form of assault on women and â€Å"stove burnings† have become common in India. In India, even the family of a girl tend to show hatred owing to the financial struggle because of the dowry that the girl will bring to the family in the future. This also causes many families to choose unsuitable man for the girl who might have some problems in his health. In India, there are many factors which play an important part in requesting of dowry from the girls family. One of the factors is that of the age of the woman, which should be less if the dowry needs to be less and vice versa. Taking this into account, many families tend to marry the girls just after the girl reached 21 or 23. The gifts or the dowries that are requested from the bridegrooms perspective also depends on the boys study i.e. higher studies is equal to higher bribes(dowry). In India, dowries range from as little as $2000 to as high as $200,000 with some material gifts and jewels. If the girls family cannot stick on to the demands of the boys family, the bridegrooms family might not respect the girl and may exploit and treat her as a maid in the future or may result in dowry deaths. Dowry deaths in India are common and not taken serious by the governments or not bought in to notice. These dowry deaths may make way for the bridegroom to remarry requesting for a better dowry from the other family. The newlyweds in India are the ones who are subject to the â€Å"Dowry Dea ths†. This aspect of violence is skyrocketing due to the living costs and other rise in costs. According to an investigation, there were about 7000 deaths due to the dowry demanded from the brides family. Many deaths go un-noticed or reported due to the status of their family and because of the dominant nature of the bridegrooms family. Other common death prevalent among the Indian marriages due to the dowry systems is that of the â€Å"Stove-burnings†. These incidents occur due to the dowry issue or that of the hatred or misconduct with their wife. These are also classified as kitchen accidents but it is false in the real sense. The husbands who commit crime by killing their wife easily get away from law by bribing the police, judges and other people who serve as an evidence for that case. Most of these crimes go un-noticed in India because of the inequality for women. Taking into account the evil deeds of dowry system in India, government has proposed the dowry prohibition act in 1961 which punishes the person taking dowry for imprisonment and fine. If the demand of a particular person is proved in the court of justice, such person is subject to imprisonment for six months and a fine of $500. A Joint Family System Until the twelfth century, the Indian couples liked the principle of joint family structure and the concept was a main feature of Indian society. But, nowadays due to the urban influence, this principle started to fade out in many families. This system represents the main feature of the Indian society and had a good reputation for the society as whole. Even in many rural villages, this trend of joint family has been reduced to a great extent. The males in families are subject to leave their native to pursue higher education or for a lucrative job in the metros. The main reason that can be blamed for is that of the industrial growth in many countries which has led to this decline. Other reasons for this decline can also be stated to the increase in divorce rates and urban migration. The people who are financially sound, career oriented and who has the freedom to make their independent decision mainly contributed for this change in the joint family system. This decline in joint familie s has improved the bond between the couples in many cases and vice versa in some cases. In case of any misunderstanding between the couples have been easily solved if they were in a joint family or the situation could become worse and lead to deaths in other cases. Other important issue that arise in the Indian marriages is the age of women, where the concept of two people uniting together is side-lined. According to the marriage act of 1986, the idle age for marriages is below 18 for female and below 23 for males. This rule by the government has caused infertility and population growth in India. The population growth in the recent years has called the people of India to go in for a one-child per family policy. This is also a main cause for the gender equality prevailing in the country. Another reason for this gender gap can be pointed out to the act that made abortions legal but, illegal to sex selective abortions. The trend of Indian marriages are changing because of the immigrants who get to foreign countries for work and living. In the past, there were many cultural limitations as women getting separated from the own family system and moving to another system. This system allows the tradition of Indian marriages intact and keeps balance of the shift from immigrants in culture these days. Although there are some laws passed in the past to protect women from oppression or ill-treatment, these customs will still prevail as they are deeply rooted in the minds of people from India. Nowadays, the trend of marrying a person who is of other caste or other religion is getting common. These changes were mainly due to the social awareness and advancement of the society. These changes arose due to the approval of the love marriage decision which brings happiness to their sons or daughters life. Although, love marriages are accepted, the final result of the marriage turns out to be an arranged marriage by the approval of the elders in the family. The people of the orthodox family background still follow the tradition of marrying within the caste and religion. The love marriages which are not performed by the approval of the family members may lead to hatred of the each community and may turn in to a riot between the communities or families. Change of Surnames after marriage Another important aspect of marriages in India is that of the tradition of changing the surnames of the brides after the marriage. Even though this concept of changing the surnames portrays a male dominated India, it creates a strong feeling of love and togetherness among the couples and the family members. In Hindu mythology, it says that the unique family name brings a feeling of secure and love. It also says that the women are epitome of familys pride and respect and the replacement of the surname depicts the responsibility taken by her in sustaining and improving the familys name in the society. This change also expresses the sacrifice and obedience to the elders in the family. Its main aim is to show the status of the women and show that she belongs to that particular family. Man in the other hand secures his wife and children and leads a happy life in the society. This change helps in securing the family tradition for many generations to come. The women regain her maiden family name if she plans for a divorce from the husband which is the common system around the world. Due to the advancements in the society and the empowerment of women, this wonderful tradition is vanishing in many metros in India. This portrays the women values are on the rise and there are getting more secure in the society by being independent to make their decisions. Dissolution of marriage Divorce or dissolution of marriages has been a rare case in the Indian family history. The respect, values and public opinion have made this decision unfeasible in the past. Indian marriages are a sacred bond between the couples of two families and not just an agreement to stay together as liked by the elders in the family. Even in case of torture, pressure and stress from the husbands family or the husband himself have not caused any dissolution keeping in mind the difficulties that the woman has to face in the future. In Hindu culture, virginity of a woman is an important aspect of a marriage and guarded as a respectability of a woman. This makes it difficult for the women for a remarriage after her divorce. Owing to this entire problem a woman can face in the future, marriages nowadays are just a transfer of a female from one community to another. The sacred moments between the couples are missing and are just a relationship to share some aspects of life. Even though there is a change in shift of the culture, the Indian marriages are strong in every aspect and unlike that in western countries which are very fragile and break for silly reasons. The divorce rates are very rare in Indian society where only one in fifty couples apply for it when compared to four out of ten couples who go in for separation. The divorce rates in the urban India are on a rise owing to the advancements in the society. Government has also made the divorce and remarriage legal by law and have to apply for their separation before the court. The higher rate of divorce in the cities cannot say that the concept of life long marriages are in trouble, it only gives them the freedom to keep away from the unlike that pre vious generations accepted. The increases in rate of divorces only mean that people are ready to sacrifice their marriage for unsatisfactory relationships. The Muslim law of Sheriat says that it is legal for a Muslim to have multiple wives in India. The government has also recently approved the concept of homosexual marriages in India Conclusion Even though India is emerging in all the fields for improvement, its culture of showing inequality for women is still not changed in form of marriages. The dowry system, stove burnings, female foetus abortion ratio all state and remain as an evidence for the issue. Even though these factors are a hindrance to the emerging society, this tradition is important in every means to lead a decent life in India. The empowerment of women has given a new dimension for them to show their talents in many fields. The government has allotted 33% for the women to encourage their ability and prove that women in India are living in a modern era and not that of the times when they were not given permission to study or come out of their houses. This initiative from the government in the past has made India accept the first president after the regime of A.P.J.Abdul Kalam. Even though government has been giving many percentages for women, the tradition of arranged marriages wont change in the coming year s. The deed of arranged marriages is also related to the respect and pride got from the close family relatives and friends on regarding the marriage system. In India, almost 90% of the marriages are arranged and successful owing to these positive outcomes, people go by the traditional way of arranging the marriages. The practice of arranged marriages in India cannot be judged as a false idea because of the divorce rates in India are less than 5% of the total marriages and the society is optimistic about these outcomes.

Recovery Programme For Patients Undergoing An Anterior Resection

Recovery Programme For Patients Undergoing An Anterior Resection The topic I have chosen for my project is the Enhanced Recovery Programme (ERP) for patients undergoing elective colorectal surgery, and whether this aids with early discharge from hospital. I shall discuss traditional pre and post operative assessments alongside the one used for ERP. I will also discuss each of the seventeen modals used within ERP and how when it is used collaboratively can aid with early discharge. I will also discuss any complications that arise from ERP and traditional surgery and if there is any difference to the patient. Within the conclusion, I will discuss the findings and any way of gaining additional knowledge and skills. I will undertake a comprehensive search of literature using the cinhal, pubmed databases and reading literature that is available within the university library. I will use quantitative research to analyse my data and incorporate this and any further learning into my conclusion. During the last four years of my training, I have developed a keen interest in colorectal surgery and this is something I would like to expand on when I become a qualified nurse. I have nursed a lot of patients on the Enhanced Recovery Programme, but I have never looked into this at any great length and I wanted to see if this had any benefit to the patient or even whether it truly did mean early discharge from hospital. In the early part of the 1990s, surgery underwent a drastic change it went from using long lasting anaesthetics to shorter fast acting ones. Combining the new anaesthetics and analgesic methods together with new surgical techniques, a new surgical pathway was created and this seems to have shortened the post operative recovery period. This means that patients could be taken out of main operating theatres as they didnt need as much recovery time. Minor surgical cases were moved to smaller day stay units (Apfelbaum 2002). The term for this new pathway was called fast tracking. Recovery times for patients on the fast track programme were considerably shorter in comparison to those patients that were not. Arguments were bought up to justify the use of fast track surgery such as reduce the nurses workload, reduce hospital costs and improve patient care by getting them back to their preoperative condition more quickly (Watkins 2001). The expansion of fast track meant that more surgical pro cedures were being performed as day cases. The expansion of the fast track concept to colonic surgery was pioneered by Henrik Kehlet, a surgeon of the Hvidovre University Hospital in Denmark. He stated that of 60 patients who underwent a colostomy on the fast track programme, 59 required a hospital stay of two days. In 2001 Enhanced Recovery after surgery (ERAS) group was formed, it was their job to look into the case mix, clinical management and clinical out comes of colorectal patients. What they found was that in Denmark, the length of stay was considerably shorter than Edinburgh, Sweden and Norway who were practicing care that is more traditional. The length of stay within Denmark was 2 days and the other 4 had an average stay of between 7-9 days (Nygren 2005). With the experiences of Denmark in mind, ERAS group developed a new evidence based concept that was holistic in its approach. There are 17 key elements to the Enhanced Recovery Programme (ERP) (appendix1). The 17 elements can be divided into 3 facets Preoperative, Intraoperative and Post operative. Each one of these facets is evidence based and only when they are used collaboratively in elective surgery do they produce a paradigm shift on how we manage our patients. The concept of ERP is to increase patient satisfaction and decrease patient complications. A patient preparing for traditional open bowel surgery used to be prepared in pre-operative assessment for a stay in hospital of around 14 days (Rickard et al 2004); Enhanced recovery patients are being prepared for a stay in hospital of 5 days (Elwood 2008). What ERAS did was to discover that there is a gap between evidence and practice, one of the consistent findings in health service research was what should be done according to scientific evidence and best clinical practice (Bodenheimer 1999). Improving the quality of care increases the amount of patients that are seen each year. This is because the right things are being done in a timely and organised fashion. Preoperative The effectiveness of the Enhanced Recovery Programme (ERP) depends on changing the patients outlook on their hospital stay. Encourage patients to believe that a shorter stay in hospital is a viable option. Department of Health (2009) states that the enhanced recovery uses evidence based interventions both pre and post operative. It is well established that stress levels rise when faced with the prospect of surgery but this concept has recently been challenged by Fearon K (2005a) in which he suggests that elements of the stress response can be reduced or even eliminated with the application of modern anaesthetic, analgesic and metabolic support. The ERP relies heavily on a multi professional approach involving all members equally. Tradition was that doctors gave the pre assessment teaching. But due to time constraints on the consultants, this was often rushed due to the amount of other patients that needed to be seen and not all patients questions were answered. The introduction of nurse specialist pre assessment clinics helped alleviate some of the pressure, and the atmosphere was more relaxed and the nurses understanding of the programme made it easier for patients to follow (Crenshaw, Winslow 2002). It is essential that all patients are well prepared for the operation, not just for a check on their physical condition but also their psychological needs. Looking after the patients psychological needs is an important part of the enhanced recovery programme as it helps reduce the stress of surgery. Patients are counselled on the important parts of the enhanced recovery programme such as early mobilisation and diet resumption. Screening for malnutrition will also take place at this appointment it should include weight, height and the body mass index should be calculated and any unintentional weight loss should be calculated use of the malnutrition universal screening tool (MUST) should be used (appendix 2). It is also reasonable to discuss discharge at this point. A patient being diagnosed with any disease is hard enough to deal with but then to be told you need an operation. Obtaining consent is a vital component to the success of the programme. Gaining consent is more than signing a bit of paper (Department of health 2009). Consent must be given freely and without coercion. All the facts must be given about the treatment and any risks should be discussed. The core ethical principle according to royal college of nursing (2004) is respect for the individuals rights. Gaining consent is a legal requirement. As a nurse the NMC (2008) states that, we are accountable for our own actions so we must ensure consent is obtained before any procedure is carried out. Some patients may not wish to know all the facts if this is the case the consultant in charge of the patients care should document this in the patients medical records, and all healthcare professionals should adhere to this. Patients are encouraged to bring in their own clothes so they are not sitting around in bed all day. Patients with disabilities or who may require more help are also identified at this visit. It is explained in the pre assessment what is expected of the patient after surgery. Clarke (2005) suggest that only forty two per cent of day surgery patients in the UK are currently offered a pre-assessment visit, within my own personal experience a pre assessment appointment is well advised, as this gives the patient time to ask any questions and alleviate any last minute fears. This part of the ERP has not changed from the preoperative counselling for traditional surgery. The preoperative assessment is a critical component of ERP as it gives patients autonomy over their own care. One of the main principles of the enhanced recovery care is that bowel preparation is avoided as this can cause dehydration and electrolyte imbalance particularly in the older patient (Burch, J.2009) a point that is also raised by Holte (2004a) he also goes on to state that bowel prep can also be very stressful. The trust that I am placed only one of the consultants uses bowel preparation usually in the form of an enema as these help prevent post operative constipation and contamination of the surgical area by faeces and is only ever used if a stoma formation is not required. Bowel preparation is still used for traditional surgery with oral sodium phosphate being the most convenient method. However concerns were raised that by not giving bowel preparation this could cause problems post operatively, but these fears have not surfaced (Holte et al 2004b). A recent study by Guenaga (2005) suggested that giving oral bowel preparation can cause anastomotic leaks, and may cause wound infect ions and possibly death. Nil by mouth after midnight originated in 1946 when reports suggested that a higher risk of pulmonary aspiration existed among patients that had general anaesthesia that had not fasted. Reassessment of this tradition began in the 1980s where numerous studies failed to demonstrate that fasting ensured that the stomach would be empty (Crenshaw, Winslow 2002). Also noted was patients that had prolonged fasting would complain of headaches, dehydration, hypovalemia and hypoglycaemia. As a result, in 1999 American Society of Anaesthesiology developed guidelines that support a more liberal preoperative fasting protocol. The original belief of nil by mouth (NBM) from midnight before surgery is still widely adopted for some surgical procedures and is still applied to some elective cases (Maltby 2006).Consumption of oral fluids up to 2 hours prior to surgery is known to reduce post operative vomiting without any adverse effects, contrasting with patients that are starved normally prior to surgery (Khoyratty, Bhavik, Ravichandran 2010).There are several elements of the programme that are important, one element is the careful use of fluids, traditional surgery uses too much (Burch 2009). It is documented that hyperglycaemia increases diabetic complications, in a study by Nygren et al (1999) also found that patients that werent Diabetic had the same amount of glucose within their blood work as patients with type2 diabetes. Patients on the enhanced recovery programme are given two clear carbohydrate drinks to take: 800mls is taken the night before surgery, 400mls is to take with breakfast (Grover 2010) this reduces the preoperative thirst and hunger but it also reduces post operative insulin resistance, therefore patients are in a better anabolic state to benefit from post operative nutrition, The Carbohydrate drink consists of 12.6g of complex carbohydrate in the form of Maltodextrin Nygren et-al (2006). Having these carbohydrate drinks is the equivalent of having 2 roast dinners. A patient on a morning list must not eat after midnight but can have clear fluids until 3am. In contrast, consumption of an appropriate mixture composed of water, minerals and carbohydrates offers some protection against surgical trauma in terms of metabolic status, cardiac function and psychosomatic status. Oral intake shortly before surgery does not increase gastric residual volume and was not associated with any risk of as piration. For normally nourished patients restoration of gastrointestinal (GI) function is one of the primary goals of post operative care. A recent study by Khoyratty, Bhavik, Ravichandran (2010) found that many of their patients voluntarily fasted longer than was given in the written instructions this is not advisable as this can cause post operative complications and can delay the healing process. This was also noted by others (Baril Portman 2007). Food and drink is a basic need and is needed to sustain life and aid with the healing process. A patient will routinely have a catheter inserted on the operating table and close monitoring of Urine output is vital, minimum output per hour is usually 35mls if it reduces then the team should be called because understanding fluid management is vital for the ERP to work. Intravenous fluid will have been prescribed avoiding normal saline and ideally stopping after 24hours (Billyard et al 2007). Fluid balance charts are vital as 60% of a males body weight and 55% of a females body weight is made up of water and electrolytes; one third of this fluid is extracellular (ECF) and two thirds intracellular (ICF). A reduction of 5% in total will result in thirst and thus considered to be mild dehydration (Welch 2010). Inadequate fluid intake or fluid loss can also cause dehydration. Patients who have had major abdominal surgery will have some fluid loss. With reference to preoperative and post operative patients Intravenous fluid on traditional surgical patients were given 3.5 to 5l of intravenous fluid on the day of surgery (Tambyraja et al 2004) however recent studies have found that providing no more fluid than is necessary to maintain fluid balance (for example a patients body weight), as this reduces post operative complications thus reducing a patients stay in hospital (Brandstrup et al 2006).For more traditional surgery the patient would normally be on restricted oral intake but this is not the case with ERP so monitoring intake is vitally important. Poor urine production can lead to renal failure and electrolyte imbalance. Monitoring fluid balance is important because as nurses we need to carefully monitor a patients input and output, as poor monitoring can lead to poor outcomes. The hourly catheter bag is changed to a leg bag on day 1 after the operation to make it easier for the patient to mobilise but strict fluid balance must be maintained (Burch J 2009). This should include stoma output if a patient has had a stoma. The catheter is usually removed on day 2 post operatively as long as there are no post operative complications and strict out put is still monitored. While fluid balance charts are a good and useful tool for monitoring fluid balance they are only as accurate as the data recorded on them, another good way of monitoring fluid loss or gain is to weigh a patient, as 1000mls is equivalent of 1kg any rapid weight gain can be directly related to a change in fluid status. The detrimental effects of fluid imbalance can be life threatening, therefore the importance of strict monitoring and accurate recording can not be stressed enough. Nursing staff of all levels should strive to complete fluid balance charts as fully and as accurately as possible. Traditional surgery required starving a patient the day before surgery. When a patient returned from theatre they were not allowed to eat until the Surgeon could hear normal bowel sounds and sometimes this may not happen for 4-5 days post operatively. So a patient could be starved of anything to eat and drink for as long as a week. A patient undergoing colorectal surgery may already be malnourished and the complications following surgery are greatly increased. Malnutrition can affect every tissue, muscle and organ within our bodies it can also have an affect on our psycho-social welfare (Todorovik 2003). National Institute for Clinical Excellence (2006) state in their nutritional support in adults that malnutrition is usually caused by physical factors. A recent study into nil by mouth versus early feeding found that of 837 patients that met with inclusion criteria found that early feeding reduced the risk of any type of infection although the risk of vomiting was increased (Lewis, e t al 2001). Patients on the programme are encouraged to drink and eat straightaway if they feel like it. Usually sips of water are offered and if tolerated they are offered nutritional supplements to drink, usually one about an hour after surgery, if this is tolerated then another will be given and left for the patient to drink at leisure (Fearon 2005b), Billyard (2007) contradicts this and states: the patient should drink at least 2L including three nutrition drinks on returning to the ward. Once a patient can tolerate fluids without vomiting or feeling nauseous, they can progress on to solid foods usually something light. A concern for surgeons was post operative ileus (POI). POI is a well recognised consequence of any abdominal surgery and is frequently experienced by patients, Leir (2007) states that it is not a life threatening complication but is a costly post operative complication. POI is defined as a transient impairment of intestinal motility after abdominal surgery (Han-Geurtz et al, 2007).There are many factors that have shown to increase its progression such as Local intestinal inflammation Anaesthetic Agents Over hydration Post operative analgesia(opiates) Reduced mobility. POI along with nausea and vomiting are the most common complication. POI can be minimised with the use of epidurals. Scoop et al (2006) stated: that mid-thoracic epidural is considered the pinnacle of the enhanced recovery programme. Although it is possible to use Patient Controlled Analgesia (PCA), Morphine can increase the risk of vomiting it can also cause the bowels normal peristaltic movement to temporarily paralyse. Recent research in to POI and the different approaches to treatment found by giving a patient chewing as a form of Sham feeding (making the body think it was eating) helped with gut motility. Schuster et al (2006) found that gum was an inexpensive and of some benefit after colostomy formation. Five randomised trials of chewing gum to restore the natural gut motility found that patients who were chewing gum passed flatus 24% earlier and had bowel movement 33% earlier, which shows a significant and positive conclusion of early discharge which on average 17.6% earlier than those that did not have the chewing gum (Chan and Law 2007). POI is usually diagnosed with symptoms of nausea and vomiting along with abdominal distension, pain and the failure to pass flatus or faeces. Parnaby et al (2009) found although flatus and faeces were passed earlier in patients who chewed gum it did not have any bearing on early discharge or post operative complications. If tachycardia is present then other causes should be excluded. The treatment for POI is inserting a nasogastric tube (NG) although one is inserted during the intubation process during surgery it is removed as soon as the surgeon has finished operating because there is good evidence to suggest that leaving a NGT in place can cause pneumonia (Cheatham et al 1995). Once a diagnosis of POI has been made, all oral intake should discontinue, and the patient should be removed from the programme and the traditional approach should commence. Patients are encouraged to take regular anti emetics to aid the patient with early return of oral intake the trust that I work cyclizine is the anti emetic of choice. Post operative pain is always a concern this is why Professor Kehlet designed the ERP because he believed every patient deserved to have a pain free recovery. For patients to understand pain nurses need to be able to educate the patient. Biggs (2009) states that less than 1% of university education is spent on pain and the effects of pain. It is vital that nurses have an understanding of pain physiology in order to educate our patients and in turn increase patients knowledge and reduce anxiety, increasing patient satisfaction. Regular pain assessments should be maintained at rest and on movement by a competent nurse (DH2009). It is stated by Vickers et al (2009) that pain should be classed as the Fifth Vital sign. In postoperative patients on ERP, it is vital that nurses monitor pain because pain can reduce a patients motivation for all the other parts of ERP. Concerns have arisen about the use of thoracic epidurals as the analgesia of choice due to immobility and urinary retention, but if inserted high enough in a thoracic position it is possible to mobilise safely and with fewer side effects such as constipation, this means that opiates which have an adverse effect on the bowel can be avoided and again this can facilitate to an earlier discharge. 1 gram of paracetamol is given 4 times a day and is given in conjunction with PCA or epidural, this is also part of multimodal approach. Also, the afferent nerves are blocked resulting in less stress response less gut paralysis and a decreased risk of pulmonary complications (Jorgenson et al 2000). The epidural dose is reduced 48 hours after surgery, and once epidural is running at 2mls per hour then a trial without epidural should commence and pain reassessed after 1 hour if minimal or no pain then commence co codomol 30/500 every 6 hours and oral Non Steroidal Anti Inflammatory Drug (NSAID) diclofenac 50mg every 8 hours (British National Formulary, 2009) with this in mind the consultant can prescribe a mild laxative for patents as this will avoid constipation although this is not the case where stoma formation occurs. Alternatively, at the anaesthetists request oral paracetamol 1g 6 hourly may be given also diclofenac 50mgs 8 hourly and 10-20 mgs of Oxynorm every 2-4 hourly. As a nurse I am aware of the importance of pain management within the ERP because psychologically a patient in pain will not feel like eating, or mobilising so keeping on top of pain by using trust pain charts and ensuring that pain relief is delivered on time helps reduce anxiety. In theory, there is not hing stopping nurses from giving paracetamol or co-codamol every 4 hours during the day as making the patient comfortable will aid sleep meaning that paracetamol or co-codamol will not be needed between midnight and six in the morning, it also means that extra pain relief may not be needed thus reducing post operative complications. On saying all of this post operative pain is believed to be at its worst directly after surgery and the intensity is expected to diminish over time (Buyukilmaz et-al 2010), the World Health Organisation analgesic ladder (2007) is used in reverse for surgical patients. on return from surgery patients, initial observations should be taken by the trained nurse so she has a baseline to work with. All further observations should be meticulously maintained as per any hospital policy. The use of Bair huggers during surgery has reduced the incidence if hypothermia during the operation it is important to maintain a constant core temperature as it was found that all of the anaesthetics used during operations caused hypothermia also there are several non pharmacological reasons that warrant the use of Bair huggers for example shaving the surgical site (Sessler and Akca 2002). Wound infection is a serious and costly complication. During colorectal surgery, the incidence of wound infections increases to 10%. Ikeda et al state that all incidences of wound infections occur during the first two hours of any surgical procedure. The primary connection between hypothermia and surgical site infection (SSI) is vasoconstriction because of a decrease in tissue oxygenation and if a patient is immunosuppressed which most colorectal patients are this can also cause SSI. Blood loss during surgery can increase the risk of SSI due to blood transfusions during surgery. On return to the ward from recovery the nurse in charge of the patient must ensure that the wound site is checked for bleeding and check the dressing for any sign of strike through the nurse would expect to see some excess on the dressing but it should be regularly monitored so any problems can be found early. Port sites where a patient has had laparoscopic surgery should be checked. When a stoma has been formed, the nurse should look at the site making sure it is pink/red in colour and it is warm and there is no excessive bleeding. Wound infections can delay discharge so any problems should be found early reported to the patients team and the correct antibiotics can be prescribed early and may only delay discharge by 2-3 days. Anti thrombotic prophylaxis is a must within colorectal surgery; treatment is usually commenced the evening following surgery and continued on a small maintenance dose of 40mg of enoxaprim (Dylan 2010) until the patient has regained full mobility. There are no further advantages in general surgery for extended use of enoxaprim but there are advantages for patients undergoing orthopaedic surgery. Associated use of low dose heparin and continuous use of epidural analgesia is open for discussion as there have been reported cases mainly in the United States of epidural haematomas (Tryba 1998). A patient undergoing stoma formation under ERP pathway can have their discharge delayed due to teaching, on how to care for the stoma. Although pre-operative teaching does occur, the reality often does not sink in until after the operation. The stoma nurse specialist will see the patient on the day after the operation. The patient returns with a clear see through bag so nursing staff can see when t he stoma becomes active. Teaching begins at the bedside where the patient may only want to observe the proceedings, but all of the time the stoma nurse actively encourages the patient to take note of the proceedings. Psychologically the patient may need lots of reassurance as to them this is not natural (Rust 2007). A patient with a stoma should plan for a stay in hospital between 5 -10 days and it usually takes this long for a patient to be able to manage their stoma. To become self caring with a stoma is the patients biggest psychological battle (Bekkers et-al1996). So on my understanding of the research available stoma formation does infact delay discharge by four days depending on the patient and his/her ability to manage. Patients are not always proactive recipients of care (Ellwood 2008). Early Mobilisation is important to reduce complications such as chest infections. Chest infection rates have dropped from 4% to less than 2% this is because patients are not laying in bed for days. Bed rest not only increases insulin resistance it also decreases muscle tone and in addition, there is an increased risk of thromboembolism. On the ward, the physiotherapist has a book which nurses can refer patients and patients should be seen on day 1 following surgery. Patients are encouraged to sit in the chair for two hours on the day of surgery to encourage deep breathing (Francis 2008). A care plan should be formulated with a specific mobilisation plan incorporated. It is essential that a patient should be nursed in an environment that encourages early mobilisation. Anti embolic stockings are also prescribed. The stockings facilitate venous return from the lower extremities. They also provide venous thrombosis. As nurses, we should make sure the patient is lying down as this allows the veins to relax. The stockings should be removed at least once a shift, so that the nurse can inspect the patients legs and feet for any signs of redness as the skin around the heel can break down very quickly. Encourage leg exercises every hour during the day. Muscle contractions compress the veins, preventing a clot. Contractions also promote arterial blood flow. The introduction of the enhanced recovery nurse has been invaluable not only for the patients but also for staff. The role of the ERP nurse (ERPN) is fundamental to the programme as she/he co-ordinates patient care from the beginning. The ERPN works freely within the colorectal team seeing patients in clinics. He/She helps the patient through their hospital admission reinforcing the goals and liaising with hospital ward staff. ERPN works closely within the surgical team, colorectal cancer team and stoma nurses. The biggest challenge for the ERPN was changing the practice of nursing staff on the wards repeated teaching sessions with all new nurses and doctors with regular feedback and all new updates to the programme (Elwood 2008). Unfortunately, within the trust I am placed the already busy colorectal cancer team initiate all of the teaching, ERP has become a large part of the daily schedule within the trust that a need for an ERP nurse is deemed necessary and funding for the post has become available. Although regular care pathways and protocols are in place, an integrated care pathway was drafted but due to increased pressure from our consultants the document was abandoned, and deemed unworkable but after reviewing the evidence it seems to be used within most other trusts that incorporate the ERP as part of their surgical planning. Nursing interventions within the ERP can influence the out come so it is important that the nurse looking after the patient has the most up to date knowledge and skills and able to detect when a patients condition deteriorates. Another useful tool is a patient diary so that the patient can keep a record of when they got up so the patient is aware of when they can get back into bed. On the first day of surgery, the Patient should aim for 2 hours and then 6 hours until discharge (Fearon et al 2005). Patients are encouraged to walk 60 meters from day one post operatively. To enable continuity of care nurses need to consider the clients needs for assistance within the home. Discharge planning begins even before the patient comes into hospital; the process is usually started at pre admission clinic. The nurse will take a full social history; this is obtained so nursing staff on the ward are aware of any social problems. Fearon et al (2005c) stated that patients are fit for discharge after the following criteria has been met Have good pain control with oral analgesia Are eating solid food and no Intravenous Fluids Are independent with all ADLs And willing to go home All patients should be discharged with an information leaflet including a telephone number of the ward in case they have any problems. In some of the trusts, an enhanced recovery nurse specialist post has been created and on discharge, the ERPN will telephone the patients on the programme at home to allay any fears and to check that there are no post operative complications. a telephone helpline has been set up at one London hospital so that patients can have direct contact with someone during out of hours and they are hoping that this will reduce the amount of AE admissions. The ward I worked on would refer all patients on the ERP to the district nurse with first visit being on the day of discharge, making sure that the referral form states that the patient is currently on ERP. Patients can telephone the ward if problems occur within the first 24 hours. Because patients on ERP are discharged earlier, this means that potentially serious complications can occur at home for example ana stomotic leaks (King et al 2006). Therefore, it is important that patients have a port of call once they are home and within the community setting. The need for support at discharge is also unlikely, compared to a patient who has traditional open surgery Readmission rates for patients on ERP shows that from 1998-2008 334 patients of which 99 (30%) were on ERP and 235 were not (Larsson et-al 2010). The 99 on ERP tolerated soft diet approximately 2.5 days earlier than those not on ERP and were discharged at least 2 days earlier from hospital. Recent research done by 2 Doctors searching the colorectal cancer data base for the trust found; ERP has reduced the length of stay by 3 to 5 with no change in mortality or readmission, the best results came from a gynaecology ward where the nursing staff followed the ERP care pathway in its entirety. Conclusion Traditional Perioperative procedures and prac