Development and Importance of Solar Electricity

Improvement and Importance of Solar Electricity Toxic gasses, harsh exhaust, scarred scenes, a gigantic carbon impression, and a warming air. These are the outcomes of acquiring vitality from nonrenewable assets, for example, coal, flammable gas, and oil. These are the sources we use to deliver power, imperiling the very planet we live on through their unsafe effects on the earth. These damaging impacts incorporate, yet are not restricted to, the making of a cover of carbon dioxide which traps heat in the environment and subsequently warms it, water and ground tainting from spills and different accidents, and air contamination. There is a superior response to getting power, one which diminishes ozone harming substance emanations and has an a whole lot littler effect on nature: the photovoltaic (PV) cell, otherwise called the sun oriented cell. Since the sunlight based cell has these fantastic advantages, our country ought to put significantly more cash into innovative work of sun powered capacity to create power. On account of impressive open interest in efficient power vitality that originated from the US, Germany, and China during the Great Recession, late American and European guidelines that have de-boosted coal power plants [,] rivalry among producers, and mechanical expertise (R. Meyer How Solar and Wind Got So Cheap, So Fast 1), sun oriented vitality has gotten a lot less expensive, and in this way, financially practical. While costs do change among locales and kinds of sun oriented boards, the normal expense is around 60 pennies for every watt (R. Meyer How Solar and Wind Got So Cheap, So Fast 1). Sun based cell innovation has been around since 1839 when French physicist Alexandre Edmond Becquerellar first showed the photovoltaic impact, or the capacity of a sun based cell to change over daylight into power (R. Meyer History of Solar Power 1). Forty after four years, in 1883, the American creator Charles Fritts made the universes first housetop sun based exhibit in New York (R. Meyer History of Solar Power 1). As yet, notwithstanding, the procedure behind the photovoltaic impact (otherwise called the photoelectric impact) was not comprehended. The procedure kept on escaping researchers until 1905 when Albert Einstein composed a paper clarifying the photoelectric impact (R. Meyer History of Solar Power 1). Together, Becquerellar and Einstein made ready for the advancement of photovoltaic innovation. During the 1950s, the U.S. military supported examination on PV technologys potential to control satellites (R. Meyer History of Solar Power 1), and in 1964 the National Aeronautics and Space Administration (NASA) propelled its first satellite furnished with sun based boards. In any case, it wasnt until the Arab oil ban of 1973 and the resulting vitality emergency that the United States began to genuinely create sun powered vitality. The U.S. governments initial step was passing the Solar Heating and Cooling Demonstration Act of 1974 (R. Meyer History of Solar Power 1), which made the Solar Energy Coordination and Management Project, an association intended to coordinate offices like NASA, the National Science Foundation, and the Department of Housing and Urban Development to improve sunlight based vitality innovation (R. Meyer History of Solar Power 1). At the point when Jimmy Carter became President in 1977, he named the vitality emergency as what might be compared to war and focused on vitality strategy of his organization (R. Meyer History of Solar Power 2). That equivalent year, he made the Department of Energy and pushed through Congress a few demonstrat ions identifying with sustainable power source use. The objective of Carters endeavors and those of Congress was to make sun powered practical and reasonable and showcase it to general society (R. Meyer History of Solar Power 2). In encouraging this objective, Congress made the business venture charge credit (ITC) and the private vitality credit (or private ITC) to give monetary motivators to people in general to buy sun based properties (R. Meyer History of Solar Power 2). Shockingly, the duty credit neglected to build Americas utilization of sun based force, as sun powered contained a unimportant measure of power age (R. Meyer History of Solar Power 2). Notwithstanding, declining residential oil creation and rising oil imports all through the mid 2000s (R. Meyer History of Solar Power 2) prompted the Energy Policy Act of 2005 (EPAct). This demonstration raised the business ITC to an impermanent 30 percent rate and restored the private ITC [which had terminated in 1985] (R. Meyer H istory of Solar Power 2). Today, notwithstanding charge credits and awards, the administration proceeds to intensely sponsor the business with innovative work, commercialization, and administrative help (R. Meyer History of Solar Power 3). In 1985, absolute sustainable power source creation and utilization added up to 6084 trillion Btu. Out of that sum, not exactly half trillion Btu originated from sunlight based force, under 0.0008 percent of all out sustainable power source. In correlation in 2015, all out sustainable power source creation and utilization added up to 9466 trillion Btu. Out of that sum, 427 trillion Btu originated from sunlight based force, about 4.5 percent of absolute sustainable power source. This implies from 1985 to 2015 complete sustainable power source creation and utilization expanded by 3382 trillion Btu, while in a similar timeframe, sun oriented vitality utilization and creation has expanded by around. 426.5 trillion Btu (US EIA Monthly Energy Review January 2017 151). Power is a critical factor of our regular day to day existences, however we ought to get this fundamental asset significantly more capably through sun oriented force. Sun oriented force creates essentially less ozone depleting substance outflows (all the more explicitly carbon dioxide) and has an exceptionally high specialized potential. As indicated by the United States Environmental Protection Agency (EPA), ozone depleting substances are gases that trap heat in the climate (EPA 1). In 2014, 81% of every single nursery ga emanations in the United States originated from carbon dioxide, which added up to 556,470,000 metric tons (EPA 1). This carbon dioxide enters the air through consuming petroleum derivatives, (for example, coal, flammable gas, and oil), just as strong waste, trees and wood items, and furthermore because of certain synthetic responses (EPA 1). As indicated by the EPA, 37% of carbon dioxide created originates from age of power (EPA 1). In the event that our country utilized sun powered capacity to create power, the measure of carbon dioxide we produce would radically diminish, as the carbon impression of the sun powered industry is a whole lot littler than that of the oil or gas business (R. Meyers The Solar Industry Has Paid Off Its Carbon Debts 2). This is made conceivable in light of the fact that the vitality put into making sun based boards, for example, quart and copper be[ing] mined. The crude materials be[ing] changed over into wafers, at that point [being] encased in defensive material Has the sun based industry truly spared any vitality whatsoever? (R. Meyers The Solar Industry Has Paid Off Its Carbon Debts). Specialists at the University of Utrecht and the University of Groningen have confirmed that the appropriate response is truly, utilizing a kind of exploration called lifecycle examination, which researches the all out natural effect of an item after some time (R. Meyer The Solar Industry Has Paid Off Its Carbon Debts 2). As per Meyers, this sort of exploration is dubious: scientists must discover and align long stretches of monetary and vitality information, gathered across 40 years, in a wide range of nations, considering various objectives (R. Meyers The Solar Energy Has Paid Off Its Carbon Debts 2). Scott Hershey, an educator of concoction and natural designin g at Olin College, expressed in an email that their [the researchers] techniques are strong, however this kind of investigation is full of suppositions (R. Meyer The Solar Energy Has Paid Off Its Carbon Debts 2). While precise numbers are not known identifying with how much carbon dioxide sun oriented force produces, it is realized that it is substantially less than sums from nonrenewable sources. Notwithstanding, this carbon dioxide can be expelled from the air by being consumed by plants as a feature of the organic carbon cycle. Tragically, all plants have a cutoff to how much carbon dioxide they can ingest, and all the plants on the planet can't ingest all the carbon dioxide simply the U.S. produces (EPA 1). Sun based force delivers significantly less carbon dioxide than power plants consuming non-renewable energy sources, and there is high specialized potential. Specialized possible alludes to the reachable vitality age of a specific innovation given framework execution, geographical restrictions, natural, and land-use imperatives (Lopez, Roberts, Heimiller, Blair, Porro 1). At the end of the day, it is the measure of vitality an innovation can deliver inside severe boundaries. The procedure for creating these specialized potential assessments is precise, requiring complex computations and looking over of the land. Be that as it may, there are three distinct kinds of sun oriented innovations, and the specialized potential for each radically changes. The three distinct kinds of sun based advancements are utility-scale PV, housetop PV, and concentrating sun based force (CSP). As indicated by NREL, utility-scale PV is age of power through huge scope PV (NREL 3). Notwithstanding, NREL has a ssessed that 3,212,324 km2 of land is accessible for utility-scale sun based creation in the U.S. (Anthony Lopez, Billy Roberts, Donna Heimiller, Nate Blair, and Gian Porro 10,11), out of 9,833,517 km2, which is the all out land territory of the United States (The World Factbook 1). This implies 32.66% of U.S. land is appropriate for creation of power, which could deliver up to 282,844,911 gigawatt hours (GWh) of power (Anthony Lopez, Billy Roberts, Donna Heimiller, Nate Blair, and Gian Porro 10, 11). In 2015, the United States created 4.103 trillion (4,103,000,000) kilowatt hours (KWh) of power, which is equivalent to 4,103,000 gigawatt hours (GWh) of power (Philipp Beiter, and Tian 7)[i]. At the end of the day, utilizing simply utility-scale sun oriented force plants, we could deliver very nearly 68 percent of all the energ

Bullying in schools Research Paper Example | Topics and Well Written Essays - 1000 words

Tormenting in schools - Research Paper Example Some good natured ‘experts’ think harassing is an ordinary piece of social turn of events and really helps youngsters in adapting to tyrannical, ruling sorts for the duration of their lives. I accept that harassing is a significant issue and not one to be endured. The results of harassing can be extremely serious; from sorrow to self destruction paying little heed to which job was played. Fortunately, in light of the fact that harassing conduct regularly happens on a repetitive premise, it can likewise frequently be distinguished and forestalled simpler and sooner than increasingly degenerate conduct in later years, maybe with the aftereffect of a decrease in criminal conduct among grown-ups. Studies investigating the naturalistic conduct of kids on the play area show that those kids who experience low acknowledgment levels among their friends will in general become menaces. Along these lines, it gets significant for instructors to perceive the social structures creating in their study hall to be in better situation to take off any perilous conduct before it turns crazy. Intercession procedures would then be able to be utilized to help in danger kids in figuring out how best to deal with troublesome social circumstances. Field examines have distinguished a few gatherings with higher danger of tormenting conduct as either the attacker or the person in question, which can help educators in deciding when and what type of intercession is fitting. Barbarin, Oscar A. (November-December 1999). â€Å"Social Risks and Psychological Adjustment: A Comparison of African American and South African Children.† Child Development. Vol. 70, N. 6, pp. 1348-1359. Oscar A. Barbarin, PhD earned his degree in clinical brain research at Rutgers University and completed post-doctoral work in social brain science at Stanford. He is President of the American Orthopsychiatric Association, a Fellow in the American Psychological Association, a Senior Investigator for the Frank Porter Graham Child Development Center at the University of North Carolina and was named the L. Richardson and Emily Preyer

Industrial Relations at Telstra Corporation †MyAssignmenthelp.com

Question: Talk about the Industrial Relations at Telstra Corporation. Answer: Presentation: Mechanical connection is considered as multidisciplinary territory which essentially examined the business relationship. By and large, modern connections are additionally called as business relations or representative relations. Ordinarily specialists thought about this intention as expansive change of human asset the executives. At the end of the day, specialists consider the worker connection term as equivalent of representative relations. Some different creators are likewise there who think representative connection is the term which just arrangements with the non-unionized specialists, and work connection is the term which manages the unionized laborers. Studies identified with modern relations analyzed various circumstances of business, not only once with an approved workforce. Ultimately, paper is finished up with brief end which sums up the key realities of every one of these expressions. Change theory of mechanical relations: Extraordinary, discusses has directed in setting of mechanical relations change in various nations. On one side, there are number of specialists who contended for the presence of the change happened in this specific situation. It must be noticed that these changes reflected over the most recent 2 decades over the globe. This can be comprehended through model; there are number of focal changes in this idea in various OECD nations (Locke, Kochan, and Piore, 1995; Katz, 1993; Swenson, 1989). Some different creators are additionally there who noticed that changes are likewise happened in creating countries. Nonetheless, a few specialists differing this reality, and express that there is no change in the mechanical relations. Writing assessment in setting of new development of IR thinks about absence of amicability what brings about the modification or focal change in modern relations. With the end goal of this discussion, premise is framed by the book The Transformation of American Industrial Relations (Kochan, Katz and McKersie, 1986). These creators consider where dealing is reflected and who settles on the most significant choice identified with system. They further contended for decentralization, increment in self-governance by the administration, changes happened in the practices led at work environment, unexpected compensation; support of representatives, preparing and business protections, and every one of these ideas brought about change in mechanical relations in the United States. As of late, one more assessment is led in setting of changes happened in the mechanical relations, and according to this investigation distinctive normal attributes of modern relations change in Sweden, Australia, the previous West Germany, Italy, the United Kingdom, and the United State and these progressions are significant for the business started decentralization of haggling. As expressed by Locke, Kochan, and Piore (1995), there are right around four normal factors in the changes of the United States, United Kingdom, Australia, Spain, Italy, France, Germany, Sweden, Norway, Japan, and Canada, and these four components are focal point of the association, increment in adaptability, developing significance of aptitude and improvement, and decrease in the enrollment of association. Past decade witness change of the universal work rights, and this happen due to the essential reception of the 1998 ILO Declaration on Fundamental Principles and Rights at Work and furthermore as a result of the across the board utilization of the idea of center work norms. Notwithstanding, it is contended by various gatherings that this system has significant potential defects, for example, it chiefly relies upon the standards rather than the privileges of works. ILO statement likewise give the base to the work arrangements in the delicate law instruments, for example, UNs Global Compact, the OECD Guidelines, and the ILO MNE Declaration, and furthermore in the approaches of the World Bank, and so forth. Every one of these progressions happened at the global level additionally sway the modern relations in the Australia (Alston, 2004). Change of modern relations in Australia: during the previous decade, Australia observes the sensational changes in the nature and job of the work advertise organizations. The most essential purpose for these progressions is the move towards progressively decentralized framework for the conventional courses of action in modern relations. Prior to the time of 1980s, business conditions for most extreme representatives in Australia are by and large rely upon the exceptionally inflexible multi-boss honors, and on this benefit they decided the outsiders who were disconnected from the work environment. Today these honors just express the base principles and the wages and other business conditions which are commonly embraced by and by are the aftereffect of the immediate exchanges happened between the laborers or their agent and the businesses (Rice, n.d.). Connections in the work the board are molded by the court based frameworks of pacification and assertion, and this framework assume significant job in the assurance of wages and conditions. It must be noticed that, arrangement of grants is certifiably not a focal methodology for deciding the wages and conditions. It very well may be said that more prominent degree exists for the two bosses and representatives to thrive their mechanical relations by satisfying the necessities of the business. In the twentieth Century, premise of authoritative methodology for province modern relations are denied by the Conciliation and Arbitration Act 1904. His Act direct the tasks led by the Australian Industrial Relations Commission till the time of 1988, and after that this Act is supplanted by the Industrial Relations Act 1988. It very well may be said that this procedure is developmental in nature and not the progressive. At the point when changes happened, these progressions are considered as the gradual in nature (Hawke Wooden, 1998). Advancement of Labor law transformations in Australia: Presentation of the worker's organization Acts in the nineteenth Century bring about different open doors for laborers. For example, just because laborers can legitimately haggle with the representatives for deciding their pay rates and conditions. Worker's guilds Initiated in the time of 1860 and 1870 in Australia, and they were productive for passing on the terms in the kindness of their individuals, particularly at the hour of dash for unheard of wealth when work was frightened. Right off the bat over the globe, stonemasons in the Melbourne become the main gathering of mechanical specialists who win the issue identified with the eight-hour day (Phillips, 2015). In any case, there are number of pioneer government officials, particularly Charles Kingston, and after that head of South Australian who began to appearance at the required and intervention. The fundamental thought behind this idea is that on the off chance that businesses denied haggling with the worker's organizations then law set up the structure for giving access of free council to the worker's guild and their individuals. In the event that supervisors and laborers of the association can't arrange and arrive at a concurred outcome, at that point autonomous court as a free gathering have capacity to force settlement on both the sides. Prior to the league, there are various provinces who embraced this methodology. It must be noticed that model of the provincial enactment was utilized, and it named as Conciliation and Arbitration Act of 1904, under which governing body make the Commonwealth Court of Conciliation and Arbitration. Adhering to are the work laws zones in which reorgani zation occur: The lowest pay permitted by law presentation Above expressed Act in setting of mollification and assertion was quickly confirm with achievement case which built up the primary Australian the lowest pay permitted by law triumph. For this situation Court expressed that an untalented work need compensation to help himself and a family in economical solace. As expressed by Breen Creighton, this idea in setting of universal terms was very interesting on the grounds that it ensures the idea that essential or the lowest pay permitted by law must be a bearable age, and this is the fundamental thought of the Australia. Over-grant installments it must be noticed that mechanical honor arrangement of Australia guarantees not just the base wages for every single activity yet additionally guarantee tough abatement in the quantity of working hours in seven days. During the time of post-war, framework feel weight and this prompts escapes in pay rates in the early time of 70s and 80s. In this amazing association arranged the ascent in the compensation over the honor rates (Phillips, 2015). Systems of IR: Institutional structures in setting of aggregate bartering by laborers, particularly worker's guilds, assume significant job in the work showcase entertainers. Every one of these foundations, for example, government offices, partnerships, and worker's organizations manage the issue identified with the enthusiasm of their laborers or enthusiasm of their business. Specialists call this issue as the rule operator issue. Following are a few procedures encircled by lawmaking bodies and experts in setting of modern relations, and sufficient reaction of worker's organizations to these systems (Allan, Brosnan, Walsh, 1999): Associations and the more extensive society-these methodologies set up and underwrite the estimations of Australian associations, for example, job of association in the work and general society. Worker's organizations likewise guarantee that association exercises should coordinate in such way as it accomplishes the outcome that contributes in utilized relations. Distinctive discussion gives the foundation of privileges of specialist and association must be considered as issues identified with the work environment. It likewise improve access to the association and considered various alternatives, for example, advancing a typical national call place number and building up a speakers program to present the job and work of the associations to the understudies. Association and the working environment in this association assemble the aggregate limit of dealing by putting resources into those projects which improve association delegate numbers, structures, instruction and rights. It builds the association interest as far as instruction appointment and bolster the legislature for advancing open financing for the training of association. Associations r

Mental illness and stigma - Free Essay Example

1. Introduction 1.1 Mental illness and stigma Inequalities in health services delivery and utilization for people with mental illness has been widely documented.1 Subsequently this results in poorer outcomes for this population in regard to general health, such as circulatory diseases, mortality from natural causes, and access to interventions .2-4 Several issues have been identified as contributing to these disparities in health service access and delivery, including stigma.5-6Stigma associated with mental illness has been defined as negative attitudes formed on the basis of prejudice or misinformation that are triggered by markers of illness.1-5Illness markers include atypical behaviours, the types of medication prescribed and noticeable medication related adverse effects.5-7These markers allow for the continuation of stigma concerning people with mental illness, but they also allow community pharmacists to identify patients with a broad range of what are often unaddressed health related needs.1 Behavioural and mental disord ers are estimated to account for 12% of the global burden of diseases. Mental health related medications account for 10% of all medications prescribed by general medical practitioners8, therefore, it is an inescapable fact that community pharmacists must interact with patients suffering from mental health problems.9 Mental illness is relevant to practising pharmacists who can play vital roles in the treatment of patients with mental illness.10 Throughout the latter half of the previous century, the diagnosis and pharmacological treatment of mental illness improved radically.9 1990-2000 was proclaimed the à ¯Ã‚ ¿Ã‚ ½Decade of the Brain. to promote the study of disorders of the brain, including mental illnesses.11 Despite these advances, the stigma associated with mental illness remains a compelling negative feature in society.10 Unfortunately health care professionals, including pharmacists are not invulnerable to such harmful attitudes.9 Pharmacists attitudes toward mental illness and the mentally ill are extremely important because they can affect their professional interactions and clinical decisions.12-13 In addition, they could ultimately affect the delivery of pharmaceutical care which has been defined as the pharmacist assuming the responsibility for positive patient outcomes.14 Activities like medication counselling and monitoring of therapy have been documented to improve both satisfaction and adherence to drug therapy in patients with mental illness.15 It has been pointed out that pharmacists must become more involved in such activities for patients with mental illness.9 1.2 Optimising the use of medications for mental illness Community care offers many advantages over institutional care; however, it can place extra demands on family, friends and primary health care practitioners.16 Health professionals have identified people with mental illness as the most challenging patients to manage.8 The quality and accessibility of community care for people with mental illness needs to be improved.17 The appropriate use of medicines plays an imperative role in the effective management of mental illness, nonetheless, there is evidence that psychotropic medicines are often used inappropriately.18-19 Elderly people are especially susceptible to the effects of psychotropic medicines, and may experience adverse effects such as cardio toxicity, confusion and unwanted sedation .8 Contributing factors to the high rates of non-compliance to psychotropic medicines include, psychosocial problems, the emergence of side effects, and the delayed onset of action of anti-depressant medication.20-21 Medical co-morbidity is also co mmon, and polypharmacy increases the risk of medication misuse and drug-drug interactions.22 The World Health Organisation (WHO) has indicated that the inclusion of pharmacists as active members of the health care team can improve psychotropic medication use.23 The benefits of dynamically engaging mental health service users in their own management is supported by both clinical experience and research evidence.24 A systemic review of the role of pharmacists in mental health care, published in 2003, concluded that pharmacists can bring about improvements in the safe and effective use of psychiatric medicines.23 The wide range of pharmaceutical services provided by community pharmacists are potentially well suited to assisting patients and prescribers optimise the use of medications for mental illness.8 2. Method 2.1 Literature search strategy Pubmed (1965-March 2010), International Pharmaceutical Abstracts (1970-March 2010), Embase (1974-March 2010), Cinahl (1981-March 2010) and Psychinfo (1972-March 2010) were searched using text words and MeSH headings including: community pharmacist.s, pharmacist.s, pharmaceutical care, pharmaceutical services, mental illness, mental disorders, stigma and mental illness, mentally ill persons, depression, schizophrenia, bipolar disorder, psychotic disorders, psychotropic drugs, antidepressive agents, benzodiazepines, anxiety agents and antipsychotic agents. ~550 abstracts were read. Reference lists of retrieved articles were checked for any additional relevant published material. Exclusion criteria included articles not published in English, no service provided by pharmacists, not relevant to mental illness, and studies and surveys that were carried out to evaluate pharmacist.s services in hospital inpatient or acute care settings. The literature search identified 88 papers that repor ted or discussed community pharmacist.s involvement in the care of patients with mental illness. 2.2 Inclusion criteria and review procedure For section 3.1 of the discussion, studies and surveys conducted into the attitudes of community pharmacists toward mental illness and the impact of stigma were considered. The literature review procedure for section 3.2 of the discussion, which deals with optimising the use of medication for mental illness, differed from that of 3.1, as studies without control groups, results of postal surveys and qualitative interviews were excluded. Studies with a parallel control group that reported the provision of services by community pharmacists in community and residential aged care facilities were considered. This included trials specifically conducted for individuals with a mental illness, and studies of medication reviews and education initiatives to optimise the use of medication for mental illness. Papers that reported pharmacist.s interventions in nursing homes were included, because community pharmacists frequently provide services to nursing homes. Studies of pharmacist.s activitie s as part of multi-disciplinary teams were also included. The literature search identified 57 papers that reported or discussed community pharmacy services to optimise the use of medications for mental illness. 3. Discussion 3.1 Mental illness and stigma While the views of the public9 and of certain health care professionals25 and health care students26-28 toward mental illness have been well documented over the years, there are limited numbers of investigations accessing community pharmacists and pharmacy student.s attitudes. Crimson et al.12 examined the attitudes of 250 baccalaureate pharmacy students toward mental illness, Phokeo et al.29 studied the outlook of 283 community pharmacists toward users of psychiatric medication, Cates et al.9 detailed the attitudes of community pharmacists toward both mental illness and the provision of pharmaceutical care to patients with mental illness, and Black et al.1 studied the satisfaction that patients with mental illness have with services provided by community pharmacists. 3.1.1 Community pharmacist.s attitudes toward patients with mental illness In general, pharmacists express positive, unprejudiced attitudes toward mental illness,1, 9, 29, 30 and overall they show encouraging attitudes toward the provision of pharmaceutical care.9 Phokeo et al.29 reported that pharmacists feel uncomfortable inquiring about a patient.s use of psychiatric medication and discussing symptoms of mental illness compared to the medication and symptoms associated with cardiovascular problems. Pharmacists also monitor patients with mental disorders for compliance and adverse effects less frequently than patients with cardiovascular problems. Crimson et al.12 found an association between a personal or family history of mental illness and attitudes of pharmacists toward mental illness. Age and years in practice are also connected with attitudes toward providing pharmaceutical care to patients with mental illness. The older and more experienced pharmacists have more encouraging responses than their counterparts.9Pharmacists are of the opinion, howeve r, that patients with mental illness do not receive adequate information about their medication from their physicians. These patients may also receive less attention from pharmacists compared to medically ill patients, which raises concerns that their drug-related needs are not being met.29 3.1.2 Patient.s attitudes toward community pharmacists Consumers of mental health services generally have a positive perception of community pharmacists and their services, however, expectations are limited to standard pharmacy services, like providing patients with information about their medication and resolving prescription issues when dispensing medications.29 The majority of patients feel at ease while discussing their psychotropic medication and related illnesses with pharmacists.31 Clinically orientated services like working collaboratively with other health care providers, making dosing or treatment recommendations, monitoring response to treatment, and addressing the individuals physical and mental health needs have been found to be unavailable to patients.32 Patients with mental health problems, expectations of community pharmacists are low, and do not match the services that they can provide.33 Although stigma has been perceived to be similar with other health care professional, Black et al.1 revealed that 25% of patients wi th mental illness have experienced stigma at community pharmacies. 3.1.3 Substance misuse The prevalence of coexisting substance misuse and mental illness (dual diagnosis) has increased over the past decade, and the indications are that it will continue to do so.15 A patient with both a mental illness and a substance misuse problem can face prejudice and stigma from health care professionals, who might question the capacity of dually diagnosed individuals to respond to care.34 A Canadian survey into the attitudes of community pharmacist.s toward mental illness showed that only 55% of respondents agreed that substance misuse is a mental health problem. This finding reflects the perception that addiction represents poor self control or is a self inflicted problem.29 Over recent years, the capacity to intervene pharmacologically in substance misuse has increased greatly, pharmacotherapy is now available for opiate, alcohol and nicotine misuse.19 Some psychiatric patients with comorbid substance abuse achieve stabilisation rapidly, furthermore, severe mental illness does no t necessarily predict worse outcomes.35 Socio-economic and emotional aspects are the main challenges to recovery, and case management in the context of integrated community and residential services has been shown to increase medication compliance over time.36 The contribution that community pharmacists have in the management of substance abuse has been well documented.37 Most general psychiatrists are only in the position to give patients 5-10 minutes of brief advise or intervention regarding a substance misuse problem,38 whereas community pharmacist.s are easily accessible to the public and are in a central position to provide specific advice about substance misuse.37 Community pharmacists currently provide dispensing services to drug addicts,38 and they are also the first point of contact for people misusing substances who are not in touch with the substance misuse services.39 3.1.4 Overcoming the barriers created by stigma Studies have indicated that patients prefer to go to the same pharmacy for their medication and other pharmacy needs and a significant number of patients favour to interact with the same pharmacist, which suggests that the relationship they have with their pharmacist plays an imperative role in their health and well being.1 A lack of privacy from failure to use an available private counselling room in the pharmacy contributes to patients feelings of discomfort regarding talking about their medication and their illness.31 Pharmacists are trained to educate and support patients regarding psychotropic medications, including how a drug works, monitoring for treatment response and adverse effects, and guiding patients through the process of stopping treatment, however, there are inconsistencies in the provision of these services.29 The potential for discrimination and stigma in community pharmacies has been well documented and initiatives to improve exposure of pharmacists to persons wi th mental illnesses in practice and in training has been suggested.23, 29 Pharmacists experience an increased level of discomfort in this therapeutic area as they receive inadequate undergraduate training in mental health.9 Adequate training in mental health is needed to improve the professional interactions of community pharmacists toward users of psychiatric medication.1 3.2 Optimising the use of medications for mental illness Community pharmacists are one of the primary health care providers in the community and have the opportunity to influence patient.s perception of their mental illness. Patients are far less likely to adhere to medications for mental health problems outside the hospital setting. Community pharmacists can significantly contribute to optimising medication use in mental illness through counselling, 40-42 patient education and treatment monitoring, 43-36 medication review services, 30, 47-49 pharmacotherapy meetings with general medical practitioners, 50-54 delivering services to community mental health centres and outpatient clinics,55-57 improving the transfer of information between health care settings,58-60 and being active members of community mental health teams.61-63 3.2.1 Counselling services In the Netherlands, three studies were carried out to highlight the impact of community pharmacist.s medication counselling sessions for people commencing non-tricyclic antidepressant therapy.40, 42 Intervention patients participated in three consecutive counselling sessions which lasted between 10 and 20 minutes each. They also received a take-home video that reiterated the importance of adherence. Throughout the counselling session, pharmacists informed patients about the appropriate use of their medications, which included, providing information about the benefits of taking the medication, informing patients about potential side effects, informing patients about the onset of action for antidepressant medication and explaining the crucial importance of taking their medication on a daily basis. Medication compliance was measured using an electronic pill container that recorded the time and frequency that the cover was opened.41 At the three month follow up the intervention patient s had significantly more positive attitudes compared to the controls.40 At six months greater medication compliance was observed with the intervention patients that remained in the study25 55, also apparent improvements in symptoms were noted.41 Research on adherence shows that the patient.s knowledge and beliefs about the benefits of adhering to their medication regime plays a critical role in compliance.64 Non-adherence is not an irrational act but rather a product of poor communication.65 Patient compliance to health care recommendations is more likely when communication is optimal.66 The results of these studies indicated improvements in depressive symptoms,41 more positive attitudes,40 and better compliance to their medication.42 A limitation of this method was that the same pharmacist provided counselling services to both the intervention and the control group. As the intervention studied was multifactorial, it is inconclusive whether the three face-to-face counselling sess ions or the take home video were primarily responsible for changes in drug attitude, adherence and the symptom scores.40-42 3.2.2 Patient education and treatment monitoring Four studies have reported results from pharmacist conducted patient education and treatment monitoring services for people prescribed antidepressant medications in the United States.43-46 These services involved the pharmacist taking a medication history, providing information about the prescribed antidepressant medications, and conducting telephone and face-to-face follow-ups. In two of the investigations, one of which was controled43 and the other randomised controlled, 62 medication adherence was calculated by reviewing prescription dispensing data, and reported using an intention-to-treat analysis. Both studies also demonstrated that involvement of the pharmacist was associated with a decrease in the number of visits to other primary health care providers; however, statistical significance was only achieved in one of the studies. Improved adherence to antidepressant medication was reported in both studies, 43-44 although patient satisfaction was only evident in one.44 The othe r two studies were randomised controlled.45-46 One of the studies was conducted using a self administered health survey,45 while in the other study antidepressant adherence was measured by asking patients how many times a day they took their medication in the past month. The results obtained from these investigations45-46 showed that patients who were taking their medication at the six month follow-up exhibited better antidepressant compliance and improved symptoms. However, antidepressant adherence and depression symptoms scores were similar for both the intervention and control group.46 Given the high rates of antidepressant discontinuation during the first three months of treatment, pharmacists have a potentially crucial role in providing medicines information and conducting treatment monitoring for those patients at high risk of non-compliance. Studies need to be conducted to compare outcomes of pharmacist.s treatment monitoring of people commencing antidepressant medication and other health professionals monitoring.8 An investigation into the impact of nurses treatment monitoring, also demonstrated improved medication adherence.67 3.2.3 Medication management reviews Pharmacist conducted medication management reviews are crucial in identifying potential medication related problems among people taking medications for mental illness.8 Medication review services provided by pharmacists comprise of comprehensive medication history taking, patient home interviews, medication regimen reviews, and patient education.68 A randomised controlled study of pharmacist conducted domiciliary medication reviews was carried out in the United States. The patients involved in the study were individuals living independently in the community that were identified to be at high risk of medication misadventure. The results showed a significant decline in the in the overall numbers and monthly costs of medication, however, there was no major difference in cognitive or affective functioning between the intervention and control group. The majority of patients were unwilling to follow the pharmacist.s recommendations to discontinue benzodiazepines and narcotic analgesics.4 7 The great potential of pharmacist conducted medication reviews for people with mental illness may not be limited to optimising the use of mental health medication.8 Physical health care for people with mental illness is generally less than adequate. This is caused by the tendency among health professionals to focus solely on the management of the mental illness among people with both mental and physical illnesses. Pharmacist conducted medication reviews may be a comprehensive strategy to improve medication use for both mental and physical illness.68 3.2.4 Medication management reviews in nursing homes Older people who are cared for in nursing homes are arguably the most vulnerable patient group, and the useful contribution that pharmacists can make to the care of these patients has been documented.30 Older people are particularly sensitive to the effects of medication,69 regular use of psychotropic medication is associated with an increased risk of recurrent falls,70 and also long term usage is linked with tardive dyskinesia.71 Psychotropic medication use may also be connected with an increased rate of cognitive decline in dementia.72 The beneficial effects of psychotropic medication must be balanced against extrapyramidal and other side effects.73 In 1995 it was reported that psychotropic drug use in Australian nursing homes was 59%, although this figure has fallen in recent years.74 In Ireland, 19% of older people in nursing homes were reported to be taking phenothiazines,75 however, this figure is lower now following a tightening of the licensing indications of thiordazine . In the England, a study showed that 30% of residents in nursing homes were taking antipsychotics.76 Two studies have looked at the appropriateness of psychotropic medication prescribing in the United Kingdom. In Scotland antipsychotic medication use in nursing homes is 24%, it was found that 88% of these prescriptions were inappropriate if the United States criteria for use were applied. In England, 54% of prescriptions were found to be inappropriate according to the United States criteria.77 A study conducted in Denmark suggested that behavioural problems were a determinant for the use of antipsychotics and benzodiazepines, irrespective of the psychiatric diagnosis of the resident.78 A randomised controlled study of pharmacist-led multidisciplinary initiative to optimise prescribing in 15 Swedish nursing homes was carried out. The study involved pharmacists participating in multidisciplinary team meetings with nurses and physicians at regular intervals within a 12 month period . A significant decline in the use of antipsychotics, benzodiazepines and antidepressants by 19%, 37% and 59%, respectively was observed in the intervention facilities.79 A follow-up investigation of the same intervention and control facilities three years later indicated that the intervention facilities maintained a significantly higher quality of drug use, with far fewer residents being prescribed more than three drugs that could lead to confusion, not-recommended hypnotics and combinations of interacting drugs.48 An additional randomised controlled study showed that pharmacist.s medication reviews in residential care facilities demonstrated significant reductions in the number and cost of medications prescribed. 10.2% fewer residents were administered psychoactive medications and 21.3% fewer hypnotic medications. The impact of medication reviews on mortality was also measured and a noteworthy reduction was observed.49 One study indicated that one hour per week of a pharmacist.s t ime can make a significant contribution to patient care in nursing homes. It was found that this input was well received by nursing staff and prescribers and that general medical practitioners accepted the pharmacist.s advice in 78% of cases.30 Physician.s recognition was 91% in south Manchester, where 55% of interventions resulted in treatment modifications. Community pharmacist.s in Northamptonshire analysed prescriptions of nursing home residents and provided prescribing advice to general medical practitioners. The advice was accepted in 73% of cases and it was estimated that pharmacist involvement could give a 14% reduction in the cost of prescribing.69 A randomised controlled trial in 14 nursing homes in England showed that a brief medication review reduced the quantity of medication overall with no detriment to the mental and physical functioning of the patients.58 A reduction in the use of primary and secondary care resources by pharmacist medication review services has also been shown.80 The recommendations provided by pharmacists included stopping and starting medicines, generic substitution, switching to another medicine, dose modification, changes in administration frequency, formulation change and requests for laboratory tests or nurse monitoring.30 Almost 50% of the recommendations were to stop medication and 66% of these were due to the fact that there was no indication for the drug prescribed. This suggested that medication regimes were not reviewed. Conversely, initiation of a new drug made up 8% of recommendations, which implied that indications were present but not always treated76. Pharmacists have an important part to play in multi-disciplinary health teams and they must be integrated into any proposed models of care. Nursing home residents are a vulnerable group of patients who deserve the same high-quality clinical care as people of any age living at home.30 3.2.4 Pharmacotherapy interventions to optimise prescribing Pharmacist.s educational visits to general medical practitioners have been shown to modify prescribing behaviour.54 Four studies have evaluated the impact of pharmacists educational visits to general medical practitioners to optimise the prescribing of benzodiazepines and other psychotropic medications prescribed for mental illness,50-53 two of which showed positive results.52-53 A cluster randomised controlled study carried out in the United States found that pharmacists educational visits to general medical practitioners were associated with a significant decline in the prescribing of potentially inappropriate psychotropic medications in intervention facilities.53 An Australian study of educational visits to general medical practitioners, conducted by three physicians and one pharmacist resulted in a noteworthy decline in the prescribing of benzodiazepines.52 In the Netherlands, groups of local pharmacists and general medical practitioners conduct inter-professional meetings t o optimise prescribing. These pharmacotherapy meetings are undertaken as part of routine clinical practice. A cluster randomised study of pharmacotherapy meetings to discuss prescribing of antidepressant medications resulted in a 40% reduction in the prescribing of highly anticholinergic antidepressants, compared to a control group of practitioners that did not partake in these meetings39. The possible awareness of prescribing related issues generated by asking general medical practitioners to conduct a self-audit of their prescribing caused this overall reduction.52-53 Additionally, pharmacist.s initiatives to improve prescribing are most effective when both pharmacists and general medical practitioners have an opportunity to build rapport.39 3.2.5 Community mental health centres and outpatients clinics Two studies were carried out to investigate the effect of pharmacist delivered services to community mental health centres and outpatient.s clinics.56-57 In a controlled trial, pharmacists managed patient cases in a community mental health centre in the United States. Significantly better personal adjustment scores were observed from patients receiving case management from a pharmacist in comparison to those receiving it from a nurse, social worker or psychologist.56The patients also rated themselves as healthier and were considerably less likely to seek help from other health care providers. The medication service provided allowed the pharmacist to adjust medication doses and dose timing, and prescribe or discontinue medications under supervision. The cost effectiveness of incorporating a pharmacist as part of the health care team was also measured. It was estimated that a 60% cost reduction can be achieved when medication monitoring is conducted by a pharmacists instead of a clin ic psychiatrist. The pharmacist also performed more medication monitoring of patients per month than the clinic psychiatrist and had more contact with each individual patient .56 In Malaysia, a study of patients discharged from hospital after admission for relapse of schizophrenia, who were identified as having poor medication adherence were allocated to receive pharmacist medication counselling or standard care.57 The importance of compliance to medication was also reinforced by the patient.s psychiatrists at follow up visits. At the 12 month follow-up, patients receiving counselling from a pharmacist and who were exposed to daily or twice daily medication treatments, had significantly fewer relapses that required hospitalisation than patients receiving standard care.57 3.2.6 Integrated mental health services The needs of people with recurrent, severe mental illness fluctuate over time and services must be coordinated, and be able to anticipate, prevent and respond to crisis. Integrated mental health services across primary and specialist services should promote early interaction and allow the provision of continuous care to meet patients needs.58 Prescribed medication is an important component in the successful management of mental illness. Accurate information should be transferred seamlessly between primary and secondary sectors to ensure the optimum care of these patients.59 The simple delivery of information to community pharmacists regarding drugs prescribed at discharge enables comparison with general medical practitioners prescriptions and any discrepancies can be followed up and resolved.82 Discrepancies that may occur can be described as any changes observed between supplies of prescribed drugs, including a wide spectrum of observed events.83 These can range from simple cha nges between supplies of prescribed drugs to more complex errors that might result in adverse reactions.60 This information transfer enables a cost-effective reduction in all unintentional discrepancies, including those judged to have significant adverse effects on patient care.58 An investigation that evaluated the impact of providing mental health patients with a pharmacist generated medication care plan at the time of discharge found that patients with care plans were less likely to be readmitted to hospital than those without. Information contained in the care plan included lists of discharge medications, a summary of the patient education that was provided, and the potential adverse effects that need to be assessed. Community pharmacists who received copies of the care plan were also more likely to identify medication related problems for the discharged mental health patients than those pharmacists who were not provided with copies of the care plan, however, the results from th is study are not significantly significant.57Other methods of transferring information such as electronic transfer have the potential to be of value in this patient population.84 People with mental illness have complex needs which are not recognised by organised boundaries.58When discussing discharge and after-care in the community, medication management must be prioritised.85Mentally ill patients are vulnerable and medication is a vital part of their well being. It is therefore essential that an accurate transfer of information between care settings minimises the potentially harmful discrepancies that can occur. Community pharmacist.s interaction in this area could prevent such incidents.58 3.2.7 Community mental health teams Most people with bipolar mood disorders and psychotic illnesses in the United Kingdom and Australia are managed by interdisciplinary community mental health teams (CMHTs).86 The potential benefits of greater involvement by pharmacists in CMHTs have been documented and debated for over 30 years.87-90 The majority of clinical team meetings conducted by CMHTs do not involve a pharmacist. A review of CMHTs in New South Wales found that just 1 in 5 had a designated pharmacist.91 Pharmaceutical care programs provided by pharmacists working as members of CMHTs can fulfil an important public need.32 Psychotropic medications are frequently used for unapproved indications,92-94 outside recommended dosages,95-96 and are prescribed concurrently.97-99 Adverse drug reactions to psychiatric medications include extrapyramidal side effects, weight gain, sedation, orthostatic hypotension and antcholinergic effects.32 Patients taking psychotropic medications may have higher rates of mortality, hospit alisation, and experience more adverse drug reactions.100-101 Routine monitoring for potential metabolic and cardiovascular complications of antipsychotic treatment is suboptimal.102-103 In addition, patients with mental illnesses have reported their dissatisfaction with the quantity and quality of drug information provided by their health professionals.104 Potential roles for community pharmacist.s in CMHTs in the United Kingdom have been investigated, with 7 possible pharmaceutical care roles being identified, they included, patient facilitating, instalment dispensing, domiciliary visiting, provision of medication education and advice, adherence monitoring, medication reviews, and inter-professional liaison.61 A survey of pharmacist.s interventions at 12 mental health trusts in the United Kingdom reported the detection of 579 cases of less than ideal prescribing of which 60% were clinical in nature.105 Between 35% and 81% of pharmacists recommendations for patients of CMHTs hav e been judged clinically significant by expert panels.62-63 Pharmacists participation in CMHTs could be facilitated by the formation of collaborative working relationships with community pharmacists working in the same locality as CMHTs. An Australian study into the impact of community pharmacists being active members of CMHTs was carried out, in one case the study pharmacist was also the local community pharmacist, this was perceived as a factor that contributed to the success of the collaboration. New models of pharmaceutical care proposed from focus groups comprising of psychiatrists, indicated the new level of awareness and recognition of the potential of community pharmacy services. Most of the studies conducted in this area raised the important issue of whether pharmacists should be considered as essential and legitimate members of interdisciplinary CMHTs.32 4. Conclusion Herein, I have discussed the contribution that community pharmacist.s can make to the care of patients with mental illness. The provision of community pharmacist.s services are limited by a lack of specific training to counsel this patient population, and pharmacist.s attitudes toward people with mental illness. Community pharmacist.s need to examine an address factors that can predispose, enable, and reinforce activities and behaviours associated with stigma toward people with mental illnesses in their practice setting. I believe that the wide range of pharmaceutical services provided by community pharmacist.s are potentially well suited to assisting patients and prescribers optimise the use of medications for mental illness. The review of the international literature highlights that medication counselling and treatment monitoring conducted by community pharmacist.s can improve medication adherence. Community pharmacist.s performed medication reviews and resulting recommendations to optimise medication regimens may reduce the numbers of potentially inappropriate medications for mental illness prescribed to elderly people. This review of the available published evidence supports the continued expansion of pharmaceutical service delivery to people with mental illness. 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Health Communication 6, (1994): 253-265 65. Donavan, J. L.; Blake, D. R. à ¯Ã‚ ¿Ã‚ ½Patient non-compliance: Deviance or reasoned decisioning?à ¯Ã‚ ¿Ã‚ ½ Social Science and Medicine 34, (1992): 507-513 66. Maguire, T. à ¯Ã‚ ¿Ã‚ ½Good communication à ¯Ã‚ ¿Ã‚ ½ How to get it rightà ¯Ã‚ ¿Ã‚ ½. The Pharmaceutical Journal 268, (2002): 214-216 67. Aubert, R. E.; Fulop, G.; Xia, F.; Thiel, M.; Maldonato, D.; Woo, C. à ¯Ã‚ ¿Ã‚ ½Evaluation of a depression health management program to improve outcomes in first or recurrent episode depressionà ¯Ã‚ ¿Ã‚ ½. American Journal of Managed Care 9, (2003): 374-380 68. Hocking, B. à ¯Ã‚ ¿Ã‚ ½Reducing a mental illness stigma and discrimination à ¯Ã‚ ¿Ã‚ ½ everybody.s businessà ¯Ã‚ ¿Ã‚ ½. Medical Journal of Australia 178, (2003): 47-48 69. Lindley, J.; McNair, P.; Lund, B. à ¯Ã‚ ¿Ã‚ ½Inappropriate medication is a major cause of adverse drug reactions in elderly patientsà ¯Ã‚ ¿Ã‚ ½. Age and Ageing 21, (1992): 294-300 70. Thapa, P. B.; Meador, K. G.; Gideon, P. à ¯Ã‚ ¿Ã‚ ½Effects of antipsychotic withdrawal in elderly nursing home residentsà ¯Ã‚ ¿Ã‚ ½. Journal of American Geriatric Society 42, (1994): 280-286 71. Nygaard, H. A.; Bakke, K. J.; Breivik, K. à ¯Ã‚ ¿Ã‚ ½Mental and physical capacity and consumption of neuroleptic drugs in residents of nursing homesà ¯Ã‚ ¿Ã‚ ½. International Journal of Geriatric Psychiatry 5, (1990): 303-308 72. McShane, R.; Keane, J.; Gedling, K. à ¯Ã‚ ¿Ã‚ ½Do neuroleptic drugs hasten cognitive decline in dementia? Prospective study with necropsy follow-upà ¯Ã‚ ¿Ã‚ ½. British Medical Journal 314, (1997): 266-270 73. Granek, E.; Baker, S. P.; Abbey, H. à ¯Ã‚ ¿Ã‚ ½Medications and diagnoses in relation to falls in a long-term care facilityà ¯Ã‚ ¿Ã‚ ½. Journal of the American Geriatric Society 35, (1987): 503- 511 74. Snowdon, J. à ¯Ã‚ ¿Ã‚ ½A follow-up survey of psychotropic drug use in Sydney nursing homesà ¯Ã‚ ¿Ã‚ ½. Medical journal of Australia 170, (1999): 299-301 75. Panmore, A. P.; Crawford, V. L. S.; Beringer, T. R. O. à ¯Ã‚ ¿Ã‚ ½Determinants of drug utilisation in an elderly population in north and west Belfastà ¯Ã‚ ¿Ã‚ ½. Pharmacoepidemiology and Drug Safety 4, (1995): 147-160 76. Furniss, L.; Burns, A.; Craig, S. K. L. à ƒ ¯Ã‚ ¿Ã‚ ½Effects of a pharmacist.s medication review in nursing homes. Randomised controlled trialà ¯Ã‚ ¿Ã‚ ½. British Journal of Psychiatry 176, (2000): 563-567 77. McGrath, A. M.; Jackson, G. A. à ¯Ã‚ ¿Ã‚ ½Survey of neuroleptic prescribing in residents of nursing homes in Glasgowà ¯Ã‚ ¿Ã‚ ½. British Medical Journal 312, (1996): 611-612 78. Sorensen, L.; Foldspang, A.; Gulmann, N. C. à ¯Ã‚ ¿Ã‚ ½Determinants for the use of psychotropics among nursing home residentsà ¯Ã‚ ¿Ã‚ ½. International journal of Geriatric Psychiatry 16, (2001): 147-154 79. Schmidt, I. K.; Fastborn, J. à ¯Ã‚ ¿Ã‚ ½Quality of drug use in Swedish nursing homes à ¯Ã‚ ¿Ã‚ ½ A follow-up studyà ¯Ã‚ ¿Ã‚ ½. Clinical Drug Investigation 20, (2000): 433-446 80. Hughes, C. M.; Lapane, K. L.; Mor, V. à ¯Ã‚ ¿Ã‚ ½Impact of the legislation on nursing home care in the United States: lessons for the United Kingdomà ¯Ã‚ ¿Ã‚ ½. British Medical Journal 319 (1999): 1060-1063 81. Esse x, B.; Doig, R.; Renshaw, J. à ¯Ã‚ ¿Ã‚ ½Pilot study of records of shared care for people with mental illnessesà ¯Ã‚ ¿Ã‚ ½. British Medical Journal 300, (1990): 1442-1446 82. Duggan, C.; Bates, I.; Hough, J. à ¯Ã‚ ¿Ã‚ ½Discrepancies in prescribing à ¯Ã‚ ¿Ã‚ ½ where do they occur?à ¯Ã‚ ¿Ã‚ ½ Pharmaceutical Journal 256, (1999): 65-67 83. Bates, D. W.; Cullen, D. J.; Laird, N.; à ¯Ã‚ ¿Ã‚ ½Incidence of adverse drug events and potential adverse drug events: implications for preventionà ¯Ã‚ ¿Ã‚ ½. Journal of the American Medical Association 274, (1995): 29-34 84. Young, A. à ¯Ã‚ ¿Ã‚ ½Improving information transfer from hospital to primary careà ¯Ã‚ ¿Ã‚ ½. Hospital Pharmacist 13, (2006): 312-314 85. Warner, J. P.; King, M.; Blizard, R. à ¯Ã‚ ¿Ã‚ ½Patient-held shared care records for individuals with mental illness: randomised controlled evaluationà ¯Ã‚ ¿Ã‚ ½. British Journal of Psychiatry 177, (2000): 319-324 86. Harvey, C. A.; Fielding, J. M. à ¯Ã‚ ¿Ã‚ ½The configuration of mental health services to facilitate care for people with schizophreniaà ¯Ã‚ ¿Ã‚ ½. Medical Journal of Australia 178, (2003): 49-52 87. Stimmel, G. L. à ¯Ã‚ ¿Ã‚ ½Clinical pharmacy practice in a community mental health centreà ¯Ã‚ ¿Ã‚ ½. Journal of the American Pharmaceutical Association 15, (1975): 400-401 88. Branford, D. à ¯Ã‚ ¿Ã‚ ½Is there a role for community pharmacists in community psychiatry?à ¯Ã‚ ¿Ã‚ ½ Pharmaceutical Journal 279, (2002): 842 89. Gray D. R.; Namikas, E. A.; Sax, M. J. à ¯Ã‚ ¿Ã‚ ½Clinical pharmacists as allied health care providers to psychiatric patientsà ¯Ã‚ ¿Ã‚ ½. Contemporary Pharmacy Practice 2, (1972): 108- 116 90. Watson, P. J. à ¯Ã‚ ¿Ã‚ ½Community pharmacists and mental health: an evaluation of two pharmaceutical care programmesà ¯Ã‚ ¿Ã‚ ½. Pharmaceutical Journal 258, (1997): 419-122 91. Buhrich, N.; Butchart, A.; Johnston, S. Lauchlaan, R. à ¯Ã‚ ¿Ã‚ ½Delivery of medication to psychiatric patients in community health services in New South Walesà ¯Ã‚ ¿Ã‚ ½. Australian and New Zealand Journal of Psychiatry 30, (1996): 523-530 92. Keks, N. A.; Alston, K.; Hope, J. à ¯Ã‚ ¿Ã‚ ½Use of antipsychotics and adjunctive medication by an inner urban community psychiatric serviceà ¯Ã‚ ¿Ã‚ ½. Australian and New Zealand Journal of Psychiatry 33, (1999): 896-901 93. Snowdon, J.; Days, S.; Baker, W. à ¯Ã‚ ¿Ã‚ ½Why and how antipsychotic drugs are used in 40 Sydney nursing homesà ¯Ã‚ ¿Ã‚ ½. International Journal of Geriatric Psychiatry 20, (2005): 1146-1152 94. Obourne, C. A.; Hooper, R.; Chi Li, K.; Swift, C. G.; Jackson, S. H. D. à ¯Ã‚ ¿Ã‚ ½An indicator of appropriate neuroleptic prescribing in nursing homesà ¯Ã‚ ¿Ã‚ ½. Age and Ageing 31, (2002): 435-439 95. Owen, P. R.; Thrush, C. R.; Kirchner, J. E.; Fischer, E. P.; Booth, B. M. à ¯Ã‚ ¿Ã‚ ½Performance measurement for schizophrenia: adherence to guidelines for antipsychoti c doseà ¯Ã‚ ¿Ã‚ ½. International journal of quality health care 12, (2000): 475-482 96. Meagher, D.; Moran, M. à ¯Ã‚ ¿Ã‚ ½Sub-optimal prescribing in an adult community mental health service: prevalence and determinantsà ¯Ã‚ ¿Ã‚ ½. Psychiatric Bulletin 27, (2003): 266- 270 97. Harrington, M.; Lelliott, P.; Patton, C.; Okocha, R.; Duffet, R.; Sensky, T. à ¯Ã‚ ¿Ã‚ ½The results of a multi-centre audit of prescribing of antipsychotic drugs for inpatients in the UKà ¯Ã‚ ¿Ã‚ ½. Psychiatric Bulletin 26, (2002): 414-418 98. Paton, C.; Lelliott, P. à ¯Ã‚ ¿Ã‚ ½The use of prescribing indicators to measure the quality of care in psychiatric inpatientsà ¯Ã‚ ¿Ã‚ ½. International journal of quality health care 13, (2004): 40- 45 99. Callaly, T.; Trauer, T. à ¯Ã‚ ¿Ã‚ ½Patterns of use of antipsychotic medication in a regional community mental health serviceà ¯Ã‚ ¿Ã‚ ½. Australia and New Zealandà ¯Ã‚ ¿Ã‚ ½s Journal of Psychiatry 8, (2000): 220-224 10 0. Centorrino, F.; Goren, J. L.; Hennen, J. Salvatore, P.; Kelleher, J. P.; Baldessarini, R. J. à ¯Ã‚ ¿Ã‚ ½Multiple versus single antipsychotic agents for hospitalized psychiatric patients: case-control study of risks versus benefitsà ¯Ã‚ ¿Ã‚ ½. American Journal of Psychiatry 161, (2004): 700-706 101. Centorrino, F.; Fogarty, K. V.; Sani, G. à ¯Ã‚ ¿Ã‚ ½Use of combinations of antipsychotics: McLean hospital inpatientsà ¯Ã‚ ¿Ã‚ ½. Human Psychopharmacology 20, (2005): 485-492 102. Taylor, D.; Young, C.; Esop, R.; Paton, C.; Walwyn, R. à ¯Ã‚ ¿Ã‚ ½Testing for diabetes in hospitalised patients prescribed antipsychotic drugsà ¯Ã‚ ¿Ã‚ ½. British Journal of Psychiatry 185, (2004): 152-156 103. Merrill, D. B.; Dec, G. W.; Goff, D. C. à ¯Ã‚ ¿Ã‚ ½Adverse cardiac effects associated with clozapineà ¯Ã‚ ¿Ã‚ ½. Journal of Clinical Psychopharmacology 25, (2005): 32-41 104. Happel, B.; Manias, E.; Rooper, C. à ¯Ã‚ ¿Ã‚ ½Wanting to be heard: mental health consumer.s experiences of information about medicationà ¯Ã‚ ¿Ã‚ ½. International Journal of Mental Health Nursing 13, (2004): 242-248 105. Paton, C.; Gill-Banham, S. à ¯Ã‚ ¿Ã‚ ½Prescribing errors in psychiatryà ¯Ã‚ ¿Ã‚ ½. Psychiatric Bulletin 27, (2003): 208-210

Physical Properties of the Element Chromium

Chromium is element atomic number 24 with element symbol Cr. Chromium  Basic Facts Chromium Atomic Number: 24 Chromium Symbol: Cr Chromium Atomic Weight: 51.9961 Chromium Discovery: Louis Vauquelin 1797 (France) Chromium Electron Configuration: [Ar] 4s1 3d5 Chromium Word Origin: Greek chroma: color Chromium Properties: Chromium has a melting point of 1857/-20 °C, a boiling point of 2672 °C, a specific gravity of 7.18 to 7.20 (20 °C), with valences usually 2, 3, or 6. The metal is a lustrous steel-gray color which takes a high polish. It is hard and resistant to corrosion. Chromium has a high melting point, stable crystalline structure, and moderate thermal expansion. All chromium compounds are colored. Chromium compounds are toxic. Uses: Chromium is used to harden steel. It is a component of stainless steel and many other alloys. The metal is commonly used for plating to produce a shiny, hard surface that is resistant to corrosion. Chromium is used as a catalyst. It is added to glass to produce an emerald green color. Chromium compounds are important as pigments, mordants, and oxidizing agents. Sources: The principal ore of chromium is chromite (FeCr2O4). The metal may be produced by reducing its oxide with aluminum. Element Classification: Transition Metal Chromium Physical Data Density (g/cc): 7.18 Melting Point (K): 2130 Boiling Point (K): 2945 Appearance: very hard, crystalline, steel-grayish metal Atomic Radius (pm): 130 Atomic Volume (cc/mol): 7.23 Covalent Radius (pm): 118 Ionic Radius: 52 (6e) 63 (3e) Specific Heat (20 °C J/g mol): 0.488 Fusion Heat (kJ/mol): 21 Evaporation Heat (kJ/mol): 342 Debye Temperature (K): 460.00 Pauling Negativity Number: 1.66 First Ionizing Energy (kJ/mol): 652.4 Oxidation States: 6, 3, 2, 0 Lattice Structure: Body-Centered Cubic Lattice Constant (Ã…): 2.880 CAS Registry Number: 7440-47-3

Attachment Theory For Understanding Risk And Protection...

This essay will comprise, firstly, on past research looking into what attachment/ attachment theory is, focusing on Bowlby’s (DATE) research into why an infant’s first attachment is so important. Followed, by the work of Ainsworth et al (1978) bringing to light the findings from the strange situation, and how the research can explain mental illness. From this and in-depth discussion looking at how the previously discussed pieces of research have an effect on two particular disorders, depression and anxiety; while keeping a holistic approach considering other variables within attachment theory which have been linked with the development of these disorders. Through-out, the impliationsof knowing about this potential link between attachment and mental health will also be discussed. Finally, a conclusion will be made to whether there is a strong link with attachment and mental illness. 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Nursing Case Study Finance - Get a free sample on Nursing

Question: Discuss about the Report on Nursing Case Study in Finance? Answer: Introduction The given report reflects about the costs and budgetary analysis of the medical unit of 33- west. The organization is suffering from the variances of costs to meet the requirements of the concerned patients. The total amount of Hours per patient day (HPPD) is taken as 4.2 hours. However, it may be seen that the actual amount of HPPD may be more than 4.2 hours. Based on the given analysis, several recommendations can be given to the nursing unit to minimize the total amount of costs and variances of their cash budget. 1 Positions Variable FTEs % by Position FTEs by Position RN 34 0.65 22.1 LVN 34 0.2 6.8 NA 34 0.15 5.1 Total 34 Table 1: Calculation of FTEs by Position The above table reflects that the total amount of FTEs is 34. With the help of the segmentation of the total amount of variables of FTEs of the unit and total amount of percentage by position, the total amount of FTEs by position has been calculated. 2 Positions FTEs Salary Hours Salary Subtotals Benefits Total MANAGER 1 80,000 860 80,000 12000 92,000 RN 22.1 35 860 665210 99781.5 764991.5 LVN 6.8 24 860 140352 21052.8 161404.8 NA 5.1 13 860 57018 8552.7 65570.7 US 2.2 11 860 20812 3121.8 23933.8 Totals 1,107,901 Table 2: Personal budget of the unit There are different forms of human resources that are present in the respective hospital unit. These are the manager, RN, LVN, NA, US. All the respective amount of salary, hours and subtotals has been calculated based on the number of hours estimated. The fringe benefits are estimated to be around 15 percent and is calculated based on the salary subtotals of the nursing unit. By adding up the total amount of salary subtotals and fringe benefits, the respective total has been calculated for all the FTEs and nursing manager of the firm. There are the total amount of FTEs that are present in the respective amount of units. The salary of the manager is 80000 per year. Consequently, the total amount of salary and the respective budget has been prepared for all the other FTEs as well as the total amount of US (Noh, 2015) The given personal budget reflects that total amount of personal budget required is 1,107,901. It is also assumed that the Hours per patient day (HPPD) are 4.3 hours. In addition to this, a total amount of working days is assumed 200 days. 3: Calculation of Hours per patient day Acuity Mix Average Hours of Care Required Average Daily Census Total Hours of Care Per Day (ADC) I 1.5 3 4.5 II 4.3 14 60.2 III 5.7 21 119.7 IV 9 4 36 Totals 220.4 Hours per patient day (HPPD) 5.247619048 Table 3: Calculation of Hours per patient day (HPPD) Result of such variances The above table reflects that that HPPD is coming 5.24. It is more than 4.3. Therefore, it will have a negative implication on the personal budget of 3-West. In addition to this, several changes are also required in terms of personal budget analysis. Therefore, the given unit will require an additional number of nurses to take care of the patients. Apart from this, the unit will also incur the additional amount of budget will also increase by a considerable amount. The total amount of variances is coming to be 5.2-4.3 = 0.9. It is a significant amount of variance as it may a pivotal impact on the resources of the unit. The total amount of capacity of the unit may also have to reduce to keep it at par with the required amount of budget (Bekaert and Hodrick, 2012) Implications of Nurse Manager The given variances in Hours per patient day can have a major implication on the nursing manager of the respective unit. The average amount of salary of the nursing manager will increase due to the higher amount of HPPD. The nurse manager may also find it difficult to allocate the total number of duty hours among the 34 FTEs. The total amount of supply costs, Average Daily Census, and overtime costs may also increase by a considerable percentage. Apart from this, the total percentage of fringe benefits will increase by 15 percent due to the total amount of overcome costs. On the other hand, the total amount of supply costs of the resources will also increase from the previously planned budget. Average Daily Census may also decrease to control the total amount of costs of the budget. Due to this reason, the nursing manager will have to face several problems due to a higher amount of HPPD while allocation of resources. There is no scope of overtime hours for the respective FTEs as it w ill further increase the total amount of fringe benefits as well as the salaries of all the human resources (Grieve, 2013). 4 Positions FTEs Salary Hours Salary Subtotals Benefits Total Previous Variances MANAGER 1 68,000 1048 68,000 10200 78,200 RN 24.1 35 1048 883988 132598 1016586.2 LVN 4.8 24 1048 120730 18109 138839.04 NA 6.6 13 1048 89918 13488 103406.16 US 2.2 11 1048 25362 3804.2 29165.84 Totals 1,366,197 1107901 258,296 Table 4: Adjusted Personal budget of the unit Based on the requirements of the unit, the organization has set up an updated variable cost. With a proper allocation of the resources and by making HPPD 5.24 from 4.3, the newly formed budget has a total amount of 258,296. Therefore, the firm has failed to minimize the total amount of unfavorable variances. Several allocations of resources were implemented by the respective firm. However, the variances are still on the higher side. Before the allocation of resources, the total amount of variances was more than 258,296. It has minimized after the changes in hours of some of the FTEs. It is recommended that organization needs to minimize the total amount of costs of all the respective FTEs. In addition to this, the total amount of fringe benefits may be increased to cut down the total amount of costs. On the other hand, the total amount of resources is also required to be rearranged to minimize the effect of the variances. However, the total amount of FTEs requires to be increased due to minimize the total amount of resources (Lach, 2014). It is important to cut down the costs of the salaries of all the managers to minimize and curtail down the variances of the total amount of costs. In addition to this, it is also essential to prepare a variances cost sheet to rectify in what areas the total amount of variances is required. It will further assist the medical unit to recover from the higher amount of expenses that resulted from a higher amount of Hours per patient day of the surgical unit. 5 Positions FTEs Salary Previous Salary Hours Previous hours Salary Subtotals Benefits Total Previous Variances MANAGER 1 40,000 80,000 1152.8 860 40,000 6000 46,000 52,000 -6,000 RN 22.1 30 35 1152.8 860 764306.4 76430.64 840737 917168 -76,431 LVN 3.8 20 24 1152.8 860 87612.8 8761.28 96374.08 105135 -8,761 NA 6.6 10 13 1152.8 860 76084.8 7608.48 83693.28 91302 -7,608 US 3.2 10 11 1152.8 860 36889.6 3688.96 40578.56 44268 -3,689 Totals 36.7 40070 80083 5764 4300 1004893.6 102489.36 1,107,383 1107901 -518 Table 5: Recommended Personal budget of the unit The above table reflects that; there are several changes are required to be made to minimize the total amount of variances. With the help of the given recommended budget, the respective unit can totally minimize the overall variances of the given personal budget. The major changes that took place are a minimization of the resources of LVN and increase of US. On the other hand, the total amount of salary of the nursing manager will be minimized by around 50 percent of the respective amount. The rate of fringe benefits can be minimized from 15 percent to 10 percent. This will further help to minimize the total amount of variances by a considerable percentage. The total amount of hours is taken as 5.2 hours per day; therefore, the total amount of hours has increased annually by comparing with the previous budget of the nursing unit. In addition to this, the salaries of all the FTEs have decreased to meet the requirements of the treatments of the patients effectively (Li, 2013) Conclusion The above report concludes the importance of maintaining the effective cash budget for every industry. The key findings of the report are that the actual amount of (HPPD) Hours per patient day is 5.28, while 4.3 is the targeted HPPD of the unit. In order to attain the concerned targets, an effective cash budget is recommended to the nursing unit. The recommended budget reflects the importance of minimization of costs in terms of their salary structure. The main target of the organization is to provide (HPPD) Hours per patient day of around 5.28 hours. In accordance to that, the personal budget of the firm has been modified. References Bekaert, G. and Hodrick, R. (2014).International financial management. Harlow, Essex: Pearson. Brooks, R. (2013).Financial management. Boston: Pearson. Dalbor, M., Hua, N. and Andrew, W. (2014). Factors that Impact Unsystematic Risk in the U.S. Restaurant Industry.The Journal of Hospitality Financial Management, 22(2), pp.89-96. Grieve, I. (2013).Microsoft Dynamics GP 2013 financial management. Birmingham, UK: Packt Pub. Lach, H. (2014). Financial Conflicts of Interest in Research.Nursing Research, 63(3), pp.228-232. Li, S. (2013). The Challenge of Managing Government-Industry Relationships.JFRM, 02(04), pp.84-86. Li, S. and Qiu, J. (2014). Financial Product Differentiation over the State Space in the Mutual Fund Industry.Management Science, 60(2), pp.508-520. Madura, J. (2012).International financial management. Mason, OH: South-Western, Cengage Learning. Noh, Y. (2015). Financial effects of open innovation in the manufacturing industry.Management Decision, 53(7), pp.1527-1544.