Non Medical Independent Supplementary Prescribers Nursing Essay

Non Medical Independent Supplementary Prescribers Nursing Essay The purpose of this essay is to explore some of the processes involved in prescribing, from consideration of the patients pathophysiology, through consultation and decision-making to the provision of treatment. The authors rationale for choosing anticoagulation as the topic for discussion, is that although the authors field of practice is mainly with patients who have ischaemic heart disease, upon reviewing the practice log it became apparent that developments within the authors role were leading the author to participate more in the care of patients with atrial fibrillation. To highlight discussion and link theory to practice the author will use four case studies of patients admitted to a district general hospital, who subsequently were diagnosed with atrial fibrillation and due to the nature of the condition, were offered anticoagulation for the prevention of future thromboembolic events. The above processes will be discussed under the headings of the learning outcomes below. Evaluate effective history taking, assessment and consultation skills with patients/ clients, parents and carers to inform working/differential diagnoses. Integrate a shared approach to decision making taking account of patients/carers wishes, values, Religion or culture. Traditionally patient consultations have been performed with the doctors taking the more dominant role (Lloyd Bor 2009). These consultations have been doctor-centred, establishing a diagnosis and treatment plan without involving the patient in the decision making process. At this time this was accepted by the patient because the doctor knows best and the patient handed over responsibility for his well-being to the clinician. However this has now changed and patients are more interested in their illnesses, wanting to know more and be involved in their treatment plans. Increasing evidence suggests that a more patient-centred style of consultation results in happier patients who are more likely to adhere to their treatment plans (Stewart et al 2003). The author was able to observe her designated medical practitioner (DMP) in a variety of patient interactions but mainly during the process of consultation, for the purpose of establishing diagnosis and treatment plans, (see appendix for case studies). Consultations are made up of a number of elements such as establishing a rapport, gathering and interpreting information and physical examination, however the cornerstone of all patient interactions is effective communication. Prior to each consultation, the DMP prepared by reading through the medical records to obtain information regarding the patients past and present history, medications and allergies. At this stage consideration was given to potential treatment plans or required tests. The patients in case studies 1-4 were all admitted to hospital due to either new onset of symptoms or deteriorating clinical condition, thus each consultation was held at the bedside. Hastings (2006) highlighted the importance of recognising the different settings within which a consultation can occur and how these settings can affect the patient and practitioner. This is a view shared by White (2002) who felt that the environment can greatly influence the consultation process. Upon reviewing the literature the author has found that there are many different approaches that can be adopted and various consultation models that can be utilised, in order to produce the most effective consultation. The author felt that the DMPs methods of consultation spanned several models. It incorporated elements of the biomedical model described by Byrne Long (1976), in which they describe six phases which formed a logical structure, but take a very doctor-centred approach (see appendix). Charlton (2007) argues however, that whilst this model is simplistic and logical it has difficulty accommodating the feelings, beliefs and psychosocial issues which colour the meaning of health and illness. The consultations also incorporated elements of the more patient-centred models as described by Pendleton et al (2003) and Calgary-Cambridge (1996), see appendix **. These models aim to achieve a collaborative understanding of the patients problems. The authors DMP combined traditional m ethods of history taking with systematic physical enquiry and examination, to elicit information about the patients medical, social and family histories, together with drug and allergy information, and the patients perspective regarding their history and presentation of symptoms. Once the history was obtained the physical examination was performed to supplement the diagnostic process. In each case the examination was cardiovascular, paying particular attention to the auscultation of heart sounds, because in atrial fibrillation the exclusion of a valvular element is necessary prior to commencing anticoagulation. In accordance with the models used, diagnosis was established and discussed with the patient. The DMP used simple terminology to ensure understanding. The use of non-verbal communication was evident throughout each consultation, from the outset where introductions and shaking hands took place, to the use of empathy and touch when the patient showed fear and anxiety. The history taking process may have involved a doctor-centred approach but the discussion surrounding treatment choices was certainly patient-centred. In each consultation the plan between the patient and the DMP was negotiated, with the DMP explaining the risks associated with atrial fibrillation, and being honest with the patient about the risks versus benefits of anticoagulation. Charlton (2007) believes that it is important to elicit a patients concerns and expectations in order to ensure that both the patient and the doctors agendas are the same. This is supported by Neighbour (2005) who stated that, Patients differ widely in their factual knowledge, in their beliefs, their attitudes, their habits, their opinions, their values, their self-images, their myths, taboos and traditions. Some of these are relatively labile and easy to change on a day to day basis, others are more firmly held and difficult to alter. Each patient we encounter will have come from a different background and some from different cultural systems whereby their values, beliefs and behaviours may not be the same as the practitioners (Lloyd Bor 2009). Each patient within the sphere of their culture or religion will have a different view about what treatments or care is acceptable (Helman 2000). This was the case in respect of patient * who was a Jehovahs Witness. Patients who share this religion do not accept blood transfusions or blood related products based upon their interpretation of Acts, a book in the New Testament Bible (Wikipedia 2012). Although the authors DMP and the patient were from different cultural and religious backgrounds, effective communication was still maintained. The DMP took time with the patient to explore the implications that the patients beliefs would have upon the form of treatment that was indicated. In this case it was not taking the drug that posed the problem but the increased risk of bleeding that could occur, which potentially may require a blood transfusion if the bleeding were to be severe. In the case of patient * they initially were not keen to start warfarin. When it was first mentioned the patient grimaced and said oh, isnt that rat poison. Indeed the patient was correct, Warfarin has previously been used to kill rodents but its safety and efficacy as a medication has also been proven. Patients often have misconceptions about medication which can influence their decision making. Their decisions regarding treatments are based upon their understandings and these can often by influenced by external factors such as the media. However, with regard to the consultations observed by the author, it seems that the intrinsic factors were more influencial. Patient * and * were both concerned about potential lifestyle changes. How often would i need to come for tests? What about going on holiday? Will I bruise easily? What happens if I cut myself? Will it affect my other medicines. For patient * the answers were acceptable and warfarin was prescribed. However patient * felt that the change would be too much and declined. Respecting a patients right to refuse treatment is part of the consultation and prescribing process. In its guidance on consent, the GMC (2008) discusses the importance of accepting that a competent patient has the right to make decisions about their healthcare and that doctors must respect these decisions, even if they do not agree with them. This view is supported by NICE (2009) who state that patients if they chose to, should be involved in the decision m aking process, and as long as they have mental capacity, as defined in the Mental Capacity Act (2005), to be able to make informed choices, as professionals we must understand that patients have different views to us about risks and benefits and we must accept their right to refuse. For patients ***and *, the recommended treatment was anticoagulation. Patient * and * once their initials concerns were addressed, were happy to proceed with the treatment. Patients * and * were not. The author noted that this did not change the DMPs treatment of the patient, who respected their decision and agreed an alternative plan. Although each consultation was different in the patient specifics, there were still common elements. Each interaction was structured and was systematic in establishing the required elements. A good rapport was established with each patient, resulting in effective communication. Communication problems between the doctor and patient can lead to dissatisfaction (Simpson et al 1991), causing misunderstandings and lack of agreement or concordance with treatment plans (Barry et al 2000). This was not the case however in patient * and *. Each patient was given a full explanation of the treatment options and each made an informed choice regarding their treatment, choosing to pursue a path not recommended by the authors DMP. A review by Cox (2004) summarised that patients and health care professionals need to have a two way discussion in order to share their views and concerns regarding treatment. 6. Integrate and apply knowledge of drug actions in relation to pathophysiology of the condition being treated. With the advent of independent and supplementary prescribing, and the ever changing role of the nurse, it is considered imperative that nurses have a greater knowledge and understanding of drug pharmacology (Thomas Young 2008). Pharmacokinetics studies how our bodies process drugs and Pharmacodynamics studies how these drugs exert their effect (Greenstein Gould 2009). When the heart beats normally, a regular electrical impulse causes the muscular heart walls to contract and force blood out and around the body. This impulse originates in the top chambers of the heart (atria) and is conducted to the bottom chambers (ventricles). In atrial fibrillation this impulse is initiated and conducted in a random uncoordinated manner causing the heart to function less efficiently. The risk of a pooling or stasis of blood remaining in the heart, increases the risk for a thromboembolic event. Atrial fibrillation is the most commonly sustained cardiac arrhythmia affecting 10% of men over 75 years (NHS Choices 2013) and if left untreated is a significant risk factor for stroke (NICE 2006). The patients identified in the case studies were all given a diagnosis of non-valvular atrial fibrillation. Their individual risk for thromboembolic event was assessed using the CHAD scoring systems and the outcome was that each patient required treatment with anticoagulation. Anticoagulants were discovered in the 1920s by a Canadian vet who found that cattle eating mouldy silage made from sweet clover were dying of haemorrhagic disease, and it wasnt until the 1950s that anticoagulants were found to be effective for preventing thrombosis and emboli by reducing clot formation, and were finally licenced for use as medicines. (Wikipedia 2012). Warfarin is the anticoagulant most commonly used in the treatment of atrial fibrillation. To understand the pharmacodynamics of warfarin, one must first understand the basic clotting cascade. Blood contains clotting factors (inactive proteins) which activate sequentially following vascular damage. These factors form two pathways (Intrinsic and Extrinsic) which lead to the formation of a fibrin clot. The extrinsic pathway is triggered by tissue damage from outside of the blood vessel. It acts to clot blood that has escaped from the vessel into the tissues. Damage to the tissues activates tissue thromboplastin which is an enzyme that activates Factor X. The intrinsic pathway is triggered by elements that lie within the blood itself. Damage to the vessel wall stimulates the cascade of individual clotting factors which also activate Factor X. Once activated Factor X converts Prothrombin to Thrombin which in turn converts Fibrinogen to Fibrin. Fibrin fibres then form a meshwork which traps red blood cells and platelets and so stems the flow of blood (Doohan 1999). Vitamin K is essential for the maturation of clotting factors such as Factor X and prothrombin and it is on Vitami n K that anticoagulants such as Warfarin take effect. Warfarin reduces coagulation by inhibiting the processing of Vitamin K. This reduces the amount of matured clotting factors available for the clotting cascade, causing clotting time to be prolonged (Melnikova 2009). This time frame can be measured by testing a patients INR (International Normalised Ratio), which is simply a recording of the amount of time it takes for a blood sample to clot. Using Warfarin in the treatment of Atrial Fibrillation, reduces the risk of clot formation and the risk of potential clots being ejected from the heart into the general circulation. This process however is dependent upon how the body initially processes the drug (pharmacokinetics). Warfarin is readily absorbed from the GI tract, however this can be affected by age related changes such as reduced gastric emptying and slowed motility affecting intestinal transit time. This phase determines a drugs bioavailability. The extent of drug distribution depends on the amount of plasma proteins and whether a drug is bound or unbound. Warfarin is 99% bound to plasma proteins and therefore takes longer to reach the site of action, thus the distribution phase lasts approximately 6-12 hours (Holford 1986). The patient in case * was noted to be on aspirin. Patients on drugs which bind at the same site can cause problems when administered together, as one displaces the other causing elevated levels o f the drug to be circulating, leading to toxicity (Sunalim 2011). Whilst the benefits of warfarin are apparent the side effects and precautions for use are numbered. Warfarin has a narrow therapeutic window making control difficult and increases the risk of bleeding and haemorrhage. It interacts with other prescribed, over the counter and herbal medicines and is contraindicated in pregnancy. Despite its use in clinical practice for over 50 years, the MHRA still receive a substantial number of adverse reaction case reports through the Yellow Card system. The majority of these reports were as a result of over anticoagulation with the majority of fatal cases being attributed to haemorrhage. It was concluded that in some cases interaction with other medications was the cause (MHRA 2009). It is therefore essential that a full drug history including allergies is taken prior to commencing any new medication. Critically appraise sources of information/advice and decision support systems in prescribing practice and apply the principles of evidence based practice to decision making. 9. Demonstrate an expert understanding of prescribing decisions made within an ethical framework with due consideration for equality and diversity. The decision to prescribe an anticoagulant such as warfarin is not a decision taken lightly. Due to the potential side effects, mainly the increased risk of bleeding, the risks versus benefits discussion must be explored. The benefit of warfarin is the reduction in risk of thromboembolic events such as a stroke or pulmonary embolism, the risks areà ¢Ã¢â€š ¬Ã‚ ¦however before this discussion can take place, it must first be established whether anticoagulation with warfarin is needed or whether an alternative treatment is possible. In 1994 the Atrial Fibrillation Investigators (AFL), conducted randomised clinical trials whose participants had untreated atrial fibrillation. Data from these trials showed that patients with previous stroke, hypertension or diabetes were at increased risk of stroke. This data was confirmed by the Stroke Prevention Atrial Fibrillation Investigators (SPAF 1995) who looked at thromboembolic risk for AF patients on aspirin. The amalgamation of these two bodies in 2001 led to the development of the CHAD2 scheme (see appendix), which is a clinical prediction tool used for estimating the risk of stroke in patients with AF and to determine whether or not treatment is required with anticoagulant or antiplatelet therapy. Risk stratification schemes that accurately and reliably stratify stroke risk could influence the management of those who have AF and spare those low-risk patients the risks, inconvenience and costs associated with anticoagulation therapy (Gage et al 2004). The use of the C HAD2 and CHAD2VASc score is advocated in the European Society of Cardiology (ESC) guidelines (2010), which recommends that if the patient has a CHAD score of 2 or above anticoagulation therapy such as warfarin or one of the newer drugs, such as dabigatran, should be prescribed. This view is supported by NICE guidance (2006) which analysed respective trials and concluded that warfarin significantly reduced the incidence of stroke and other vascular events in people with AF. NICE also discusses stroke risk stratification models, of which the CHAD2 score is one. It does not however make recommendations as to the best choice of tool. Patient * was the only one out of the case studies that had their stroke risk calculated using the CHAD scoring system and had it recorded in the notes. The reasons for this are unknown however the author hypothesises that perhaps as the other patients had greater apparent risk due to their existing co-morbidities, it was deemed unnecessary to actually perf orm the calculation as anticoagulation would ultimately be indicated. The author could argue here that if this was the case this generalisation goes against the concept of diversity. Warfarin has been widely accepted as the drug of choice for oral anticoagulant therapy, however newer drugs on the market such as dabigatran and rivaroxban have also been recommended as alternatives to warfarin , yet it is the authors experience that these are very rarely discussed with patients as alternative treatment and only seem to be prescribed when warfarin is not an option. The author believes the reason for this may be partly due to economic and geographical inequalities in health, a view shared by Abraham Marcy (2012) Wartak Bartholomew (2011). They concluded that compared to warfarin dabigatran was disadvantaged by the lack of knowledge about its use, its poor gastrointestinal tolerability and ultimately the cost which resulted in its limited use. Treatment decisions made for these patients were in keeping with National and European guidelines promoting access to treatment for all. Local guidelines however are under current review and were not available for scrutiny. As prescribers we must use all available information to ensure that we make the best evidence based prescribing decisions with our patients. Guidelines facilitate best practice but resources such as the British National Formulary (BNF) and the Electronic Medicines Compendium (EMC) are invaluable reference tools in facilitating best prescribing practice. In everyday practice healthcare professionals are expected to make judgements about what is best for their patients. The NMC (nnn) advocate that to practice in an ethically sound manner it is necessary to balance ethical considerations with professional values and relevant legislation. The ethical theory of principlism described by Beauchamp Childress (2008) considers the principles of beneficence, non-maleficence, autonomy and justice as the elements of ethical theory that are the most compatible in supporting decision-making within the healthcare system. Making ethical prescribing decisions is not a solitary activity, especially when the decision will impact upon another person. The ethos of quality patient care relies upon a team approach that supports the decision making of the patient, in partnership with the professionals, ensuring that the values and beliefs of the patient have been respected and acknowledged. 5. Demonstrate critical awareness of the roles and relationships of others involved in prescribing, supplying and administering medicines. Earlier discussion highlighted the importance of communication in developing the doctor-patient relationship and how consultations are either doctor or patient-centred. This is also true with regard to other professional relationships the patient may have with members of the multidisciplinary team, who are also involved in prescribing, supplying and administering their medications. A review of the supply, prescribing and administration of medicines by the DOH (1999), recommended that there should be two types of prescriber; independent and supplementary. An independent prescriber is responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management requiredà ¢Ã¢â€š ¬Ã‚ ¦.supplementary prescribing is a voluntary partnership between a doctor or dentist and a supplementary prescriber to prescribe within an agreed patient specific clinical management plan, with the patients agreement NPC (2012). As a potential non-medical prescriber the author recognises the importance in understanding and applying the principles of good prescribing practice, in order to become an independent/supplementary prescriber. Doctors undertake training in prescribing as part of their undergraduate programme and are required to demonstrate this activity in order to obtain their registration. Their practice is guided and governed by the General Medical Council (GMC). Likewise nurses and midwives who are independent/supplementary prescribers, are governed by the Nursing and Midwifery Council (NMC), whose regulatory standards and legislation require practitioners to be experienced before they undertake such training and in safeguarding the best interests of the patient, ensure that nurses and midwives remain up to date with the knowledge and skills that enable them to prescribe and administer drugs safely and effectively (NMC 2004, NPC 2012). Pharmacists whose governing body, the General Pharmaceutical Council (GPC 2010), allow that a pharmacist independent prescriber may, after successful completion of an accredited course, prescribe autonomously for any condition within their clinical competence. Current legislation however only allows other multidisciplinary members such as radiographers and physiotherapists to be supplementary prescribers. During a patients stay in hospital, it is most likely they will enter into a medication consultation with at least one or two of the multidisciplinary members mentioned above. All the patients in the case studies had contact with a doctor, nurse and pharmacist. The doctors performed the initial consult at the patients admission and it is here that the initial drug history was taken. The nurse then administered the medication prescribed on the drug chart, giving the patients information about the drugs they were taking and potential side effects. This information was limited to their individual knowledge base. If the drug was unavailable then it was requested from the pharmacy department. The author observed the practice that occurred when an unavailable drug was requested. The initial process was simple, the doctor prescribed it and the ward nurse sent the drug chart and request slip to pharmacy. Once in pharmacy the process became more complex requiring the request to pass through s everal stations before being dispensed. Prior to this course the author had very little understanding as to how important the role of the pharmacist was. Pharmacists play an important role in improving a patients medication management during admission and through transitions of care from hospital to home. Weiss (2013) agreed that patients are often discharged from hospital with changes from their previous medication regimes, causing discrepancies and lack of understanding, which lead to non-adherence and adverse drug effects. The pharmacists spoken with by the author agreed that providing medication counselling in preparation for discharge is a large part of their role. Patient * and * who were commenced on warfarin, received counselling prior to discharge. The author was able to observe this practice. The session took place at the bedside which, upon reflection, was not conducive to this information exchange. Noise and interruptions from a confused patient in the next bed meant that the passage of information was often disrupted and had to be repeated. The pharmacist provided the patient with an information pack and discussed the drug, side effects, anticoagulant monitoring and lifestyle changes such as travel, diet, recreational activities and dental visits. NICE medicines adherence guidance (2009) advocate the importance of providing patients with both written and verbal information in order to make an informed choice. For patient * and *, verbal information was given prior to prescription, but the written information was only provided after the patient had agreed to treatment. Providing all the information beforehand could increase patient conse nt to treatment (Elwyn et al 2006). Considering the role of others within the prescribing team has led the author to examine and reflect upon her own role. The author entered this course with knowledge and competence in diagnosing a patient with an acute coronary syndrome and questioned why such a broad prescribing knowledge was necessary. It is the view of Lymn et al (2010) that non-medical prescribers within a narrow specialist field often ask this question. Taylor Field (2007) believe the answer to be because advancements in medicine have meant that patients are often able to live with chronic disease and multiple co-morbidities. Becoming a prescribing student has given the author insight into what she did not know and what she never realised she needed to know. Conclusion. At the beginning the author posed the question, Anticoagulate or not to anticoagulate? In order to answer this, the author explored some of the processes involved in prescribing and through the use of case histories, linked theory to practice with analytical discussion. The answer to the question is clear, there is no one true answer. It is the authors conclusion that each case for anticoagulation must be viewed separately. Each patient is different, their understanding, their views and their pathophysiology all are unique. As practitioners it is our duty to provide our patients with the information and support they need in order to make informed choices. As prescribing practitioners these responsibilities are increased. Using the process of accountable practice as described by Lymn et al (2010), it is essential that we analyse our responsibilities as accountable prescribers and in doing so consider each prescribing situation on its own merits.

The Hunters: Phantom Chapter 1

Elena Gilbert stepped onto a smooth expanse of grass, the spongy blades col apsing beneath her feet. Clusters of scarlet roses and violet delphiniums pushed up from the ground, while a giant canopy hung above her, twinkling with glowing lanterns. On the terrace in front of her stood two curving white marble fountains that shot sprays of water high into the air. Everything was beautiful, elegant, and somehow familiar. This is Bloddeuwedd's palace, a voice in her head said. But when she had been here last, the field had been crowded with laughing, dancing partygoers. They were gone now, although signs of their presence remained: empty glasses littered the tables set around the edges of the lawn; a silken shawl was tossed over a chair; a lone high-heeled shoe perched on the edge of a fountain. Something else was odd, too. Before, the scene had been lit by the hel ish red light that il uminated everything in the Dark Dimension, turning blues to purples, whites to pinks, and pinks to the velvety color of blood. Now a clear light shone over everything, and a ful white moon sailed calmly overhead. A whisper of movement came from behind her, and Elena realized with a start that she wasn't alone after al . A dark figure was suddenly there, approaching her. Damon. Of course it was Damon, Elena thought with a smile. If anyone was going to appear unexpectedly before her here, at what felt like the end of the world – or at least the hour after a good party had ended – it would be Damon. God, he was so beautiful. Black on black: soft black hair, eyes black as midnight, black jeans, and a smooth leather jacket. As their eyes met, she was so glad to see him that she could hardly breathe. She threw herself into his embrace, clasping him around the neck, feeling the lithe, hard muscles in his arms and chest. â€Å"Damon,† she said, her voice trembling for some reason. Her body was trembling, too, and Damon stroked her arms and shoulders, calming her. â€Å"What is it, princess? Don't tel me you're afraid.† He smirked lazily at her, his hands strong and steady. â€Å"I am afraid,† she answered. â€Å"But what are you afraid of?† That left her puzzled for a moment. Then, slowly, putting her cheek against his, she said, â€Å"I'm afraid that this is just a dream.† â€Å"I'l tel you a secret, princess,† he said into her ear. â€Å"You and I are the only real things here. It's everything else that's the dream.† â€Å"Just you and me?† Elena echoed, an uneasy thought nagging at her, as though she were forgetting something – or someone. A fleck of ash landed on her dress, and she absently brushed it away. â€Å"It's just the two of us, Elena,† Damon said sharply. â€Å"You're mine. I'm yours. We've loved each other since the beginning of time.† Of course. That must be why she was trembling – it was joy. He was hers. She was his. They belonged together. She whispered one word: â€Å"Yes.† Then he kissed her. His lips were soft as silk, and when the kiss deepened, she tilted her head back, exposing her throat, anticipating the double wasp sting he'd delivered so many times. When it didn't come, she opened her eyes questioningly. The moon was as bright as ever, and the scent of roses hung heavy in the air. But Damon's chiseled features were pale under his dark hair, and more ash had landed on the shoulders of his jacket. Al at once, the little doubts that had been niggling at her came together. Oh, no. Oh, no. â€Å"Damon.† She gasped, looking into his eyes despairingly as tears fil ed her own. â€Å"You can't be here, Damon. You're†¦ dead.† â€Å"For more than five hundred years, princess.† Damon flashed his blinding smile at her. More ash was fal ing around them, like a fine gray rain, the same gray ash Damon's body was buried beneath, worlds and dimensions away. â€Å"Damon, you're†¦ dead now. Not undead, but†¦ gone.† â€Å"No, Elena†¦Ã¢â‚¬  He began to flicker and fade, like a dying lightbulb. â€Å"Yes. Yes! I held you as you died†¦Ã¢â‚¬  Elena was sobbing helplessly. She couldn't feel Damon's arms at al now. He was disappearing into shimmering light. â€Å"Listen to me, Elena†¦Ã¢â‚¬  She was holding moonlight. Anguish caught at her heart. â€Å"Al you need to do is cal for me,† Damon's voice said. â€Å"Al you need†¦Ã¢â‚¬  His voice faded into the sound of wind rustling through the trees. Elena's eyes snapped open. Through a fog she registered that she was in a room fil ed with sunlight, and a huge crow was perched on the sil of an open window. The bird tilted its head to one side and gave a croak, watching her with bright eyes. A cold chil ran down her spine. â€Å"Damon?† she whispered. But the crow just spread its wings and flew away.

Information Technology Essay

A technologically enabled organization is a technologically capable company. Data and information will be at the heart and information re-use shall be constant. In other word, everything is integrated, finance, services, customer files, support database, helpdesk, quality management, customer satisfaction, email, attachments†¦ The information both flow in and out where you can get an holistic view of every information, communication, exchange concerning a specific project that might affect multiple customers, or every bits and pieces of information that pertain to a specific customer. It is a an organization where you have a symbiosis between the customer, who request and the customer who contribute, again, idea bounce in and out and might potentially be shared among interest group, much like a social network, the organization being the enabler between various customers with similar issue, reason why they are the customer of organization XYZ. The information is on the ecommerce site, in the corporate portal, in the intranet, on the mobile phone, the communications are interactive and customers share whiteboard, desktop, files, document management with the organization. Every relation the organization have with its customer contact is managed through a unique ID assigned to each of those contact, nothing complex, maybe an OpenID since so many people already have them or a simple challenge response via SMS, Text Message, Email to login your customer/employee experience center†¦ I hope this will help you understand my perspective of a technologically enabled enterprise, it is a only a vision for now, but it might be the future, who knows 🙂 For now, to me, any subset of those features with integration within a specific business workflow would classify has a technology enabled organization. 2. How does an Organization acquire & disseminal knowledge? First respondent meant from technical perspective . data 1s and 0s .knowledge can be acquired by working in a domain . no other legitimate shortcut. both for a business and anindividual. it is the collective experience that resides in a non physical plane of existence.it can be imparted/propogated to others in the form of a processor documentation( paper or electronic ) or it will be ingrained in the team members even without documentation.this process or documentation should not be dependent on a single person. ie nobody should be indispensableincluding top leadership. many business entities thrive as leaders even without proper documentation of theirworking knowledge . it is ingrained in their employees& stakeholders.There are a number of ways, but all are connected with a common link-experienced workers need to share bestpractices. Formal Mentor programs encourage face to face meeting where mentors can monitor and validate theirprotege’s progress. Another method that we are implementing is wikis where we ask very specific questions andmonitor the responses. This has been a good way for the organization to share the collective knowledge anddefines our corporate culture. 3. Why do you suppose inquiry – only applications were developed instead of fully on lines system? Participation constraint – a participation constraint determines whether relationships must involve certain entities. An example is if every department entity has a manager entity. Participation constraints can either be total or partial. A total participation constraint says that every department has a manager. A partial participation constraint says that every employee does not have to be a manager. Overlap constraint – within an ISA hierarchy, an overlap constraint determines whether or not two subclasses can contain the same entity. Covering constraint – within an ISA hierarchy, a covering constraint determines where the entities in the subclasses collectively include all entities in the super class. For example, with an Employees entity set with subclasses Hourly Employee and Salary Employee, does every Employee entity necessarily have to be within either Hourly Employee or Salary Employee? Weak entity set – an entity that cannot be identified uniquely without considering some primary key attributes of another identifying owner entity. An example is including Dependent information for employees for insurance purposes. Aggregation – a feature of the entity relationship model that allows a relationship set to participate in another relationship set. This is indicated on an ER diagram by drawing a dashed box around the aggregation. Role indicator – If an entity set plays more than one role, role indicators describe the different purpose in the relationship. An example is a single Employ ee entity set with a relation Reports-To that relates supervisors and subordinates. 4. What kind of technology is least flexible? Most flexible? I would say that it is dependent on the licensing. The most flexible being that which comes from the Open Source family. At the root of it all, Open Source software allows any to read edit and redistribute any technology they encounter(based on the licensing). The closed source model, is exactly that closed, you can not even view the code usuallywithout first signing a non-disclosure agreement, if you can even see it at all. This means you can not audit thecode that may be entering your environment, nor can you make any real modifications or taylor it to your own specific needs. In the Software Industry an example of this is the adoption of Unix (Free BSD) by Apple to develop their Softwareon. The BSD licensing has been a favorite of big business due to its flexibility. However it would seem Apple hasshot themselves in the foot by alienating the open source community, the lack of support from Apple for theOpenDarwin project resulted in its end of life. This was a community who was actively contributing to the core of their Operating System for free. There is still a wealth of portable code that is available to anyone looking todevelop on their platform, however the closed source elements within due definitely inhibit growth. Linux is often deemed the champion of Open Source Software, however since its inception it has been a mixed bagof software licenses. This has been brought to light by the influx of lawsuits over the years, its licensing GPL may beless favorable for the corporate developer. 5. How does strategic planning differ between a firm that offers services & one that manufacturers a product? Is there a difference in the impact of technology on strategy in any two types of firms? The Strategic Planning Process So let’s step back and take a look at what an end-to-end product planning cycle might look like when integrated with the company’s strategic planning cycle. Assuming that a company resets its corporate strategy, financial plans, and product plans once per year, the planning process would ideally occur during the 3rd and 4th quarters of the fiscal year in preparation for the upcoming year. The five basic steps in the planning process (as depicted in figure 1) are: 1. Market review.  2. Financial review. 3. Corporate strategy. 4. Product strategy. 5. Product Roadmap and Release schedules. During the first step, product management presents a market review to executive management sharing facts on market trends and opportunities, key customer needs, and competitor moves and positions. Though product management will keep tabs throughout the year on many of these items, this is the opportunity to update the information to make sure it is complete and current. Other functions may be invited to provide their perspectives on the market and customers as well. During the financial review phase, the finance organization presents results on the financial performance for the company overall, for its sales channels and for its products. Providing revenue and profitability by product is critical to making good product decisions and developing effective strategies. The next step is where the company’s executive team outlines its corporate strategy in terms of its vision, financial goals and its plan for achieving those goals. The corporate strategy should be explicitly presented to the product management team to facilitate development of a product strategy. For some smaller businesses, steps 3 and 4 may be combined into a single step. During step 4, product management develops its product strategy considering market dynamics, customer needs, financial goals, and corporate strategy. It specifies what changes to the products are needed and indicates the financial plan for each product area. The product strategy should be reviewed by the executive team to ensure alignment with the corporate strategy before proceeding to the next step. The final step involves the development of a product roadmap and more detailed release plans for the coming quarters consistent with the product strategy. This roadmap becomes the official â€Å"product plan of record† and should be managed with formal change control procedures. This step is executed at the conclusion of the annual planning cycle and is repeated every 3 or 4 months to allow responses to changing market conditions and deployment schedules and should be re-approved by executive management.

The First Child Of Her Parents, Henry Viii Of England

Mary Tudor was the first child of her parents, Henry VIII of England and Catherine of Aragon, to survive until adulthood. Politically motivated, Henry was unsatisfied that his wife had not birthed a healthy son, and since he desired a son to succeed him, he attempted to get a divorce. In order to do so, since divorce was not allowed in the Catholic religion, he broke from Rome and made himself head of the church. Henry was eventually successful in bearing a son, and when he died in 1547, Edward, age nine at the time, took over the throne. King Henry and Edward both lead England with the influence of Protestantism, but there were still a lot of people who practiced Catholicism. Mary Tudor, Henry’s daughter, was dedicated to Catholicism; and when Edward passed away in 1553, she was next in line for the throne. From 1552 to 1558, Mary Tudor was the Queen of England. These years were the most prominent in regards to the conflict within the church between the Catholics and Protesta nts. 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