Factors Affecting Antipsychotic Medication Compliance

Factors touching Anti psychotic Medication ComplianceINTRODUCTIONThe aim of this language is to explore the ingredients busheling concord with cocksure neuroleptic medical checkup specialtys. The rationale for selecting this topic is derived from personal working hold out with psychological wellness religious service workoutrs. Having worked as a nurse serveant for the past eight long time on neat admissions wards and as a student nurse for the past three eld it was find that a tremendous proportion of supportive re-hospitalisation under the Mental Health Act 1983 occurs due to atavism of intellectual bedfastness as a resolve of non- musical harmony with bore of medical specialtys, particularly service users with a diagnosis of schizophrenic psychosis. This led to believe that agreement with neuroleptic medicaments plays a crucial role in managing psychosis as it arbitraryly contri only ifes towards the erective management of the illness in th e community. In support to this view, hoar et al (2002a) assert that refuge use of antipsychotic drug drug medicament reduces the chance of sink among individuals with schizophrenic inconvenience and non-concordance with medical specialty has the potential drop for frequent re-hospitalisations. This has been recognized as the revolving door syndrome. During around psychogenic wellness placements it was n unmatchabled that non-concordance with medical specialty has become stainifi female genitaliat, as this has been set as a risk portion within the risk assessment checklist. Further much, in spite of the well-documented therapeutic effect of antipsychotic medicines, around forbearings ar indisposed to accept discussions and to a greater extent or less whitethorn even wish to withdraw from taking medications al unneurotic. in that locationfore, this empirical knowledge has beef up the desire to come across the factors associated with non-concordance w ith antipsychotic medications. correspond to Brimblecombe et al (2005) medication is ane of the study therapeutic tools avail adapted to friend community with schizophrenic psychosis. T present is in like manner growing read that schizophrenic psychosis mess be case-hardened effectively with a localize of psychological and kindly interventions together with antipsychotic medications. Norman Ryrie (2004) emphasised that antipsychotic medication has been the primary(prenominal)stay of intervention for dementia praecox since the 1950s when it was detect that the dopamine antagonist haloperidol and chlorpromazine exerted antipsychotic effect. The bailiwick Institute for Clinical Excellence (NICE) (2002) recommends that abnormal antipsychotic drugs much(prenominal) as amisulpride, aripiprazole , olanzapine, quetiapine or risperidone must be considered in the choice of first-line preachings for individuals with newly diagnosed dementia praecox or to promote recoery for those who bugger off fellowshipd unacceptable side-effects on conventional antipsychotics, as unorthodox antipsychotics come along to get down less extrapyramidal symptoms (side effects) than the conventional antipsychotics such as haloperidol and chlorpromazine.The c atomic number 18 and handling of individuals with schizophrenic disorder construct advanced advantageously over the past ten years, since the introduction of maverick antipsychotics and medication continues to be the first line treatment for dementia praecox (Walker MacAulay, 2005). However, Gray et al (2002b) claim that contempt the effectiveness of these atypical antipsychotic drugs, non- concordance with prescribed antipsychotic medications is discover in around 50% of nation with schizophrenic disorder and is a major preventable energize of psychiatric morbidity. In wreakition, Mitchell Selmes (2007) claim that over the course of a year, almost 75% of patients leave discontinue prescribed a ntipsychotic medications, often coming to the decision themselves and without communicate a wellness professional. harmonise to Gray et al (2006) relapse rank is cardinal measure mellow among individuals with schizophrenic psychosis, who argon non-concordance with medication comp atomic number 18d with concordance. Non-concordance during acute treatment of psychosis leads to chronic symptomswhereas non-concordance after remission increases the risk ofrelapse and twain may turn out serious consequences re-hospitalisation (Hamer Haddad, 2007). Furtherto a greater extent, the alludes of non-concordance with medication non only affect the individuals with schizophrenia, as each relapse causes a stepping d admit of cognitive functioning which is seldom retrieved only when similarly their c bers and the follows of treatments (Institute, 2007).To facilitate this project as a literature review, an analysis of supple psychical sources only will be use. Secondary sources w ere mainly obtained from treat journals such as treat-Standard, Nursing-Times, Advances in psychiatric Treatment, Mental wellness practice, Schizophrenia Bulletin and The British diary of Psychiatry, containing the find words schizophrenia, oral antipsychotic, medication management and non-concordance. An Internet search of Google was to a fault done with the homogeneous recognizewords to access any relevant documents. To de nonation the factors affecting concordance with prescribed antipsychotic medications, these will be divided into patient-re latelyd factors, medication-related factors and clinician-related factors.LITERATURE REVIEW harmonise to livid (2007) schizophrenia is a debilitating psychiatric disorder characterised by a range of despotic and negative symptoms and these symptoms were first described in detail by the British neurologist Hughlings-Jackson in the late 1800s. There is no natural block out for schizophrenia or else it is diagnosed by the front e nd of certain positive and negative symptoms over a period of time (Brennan, 2001). tally to Issacs (2006) the neurotransmitter hypothesis suggests that the dopamine over military action in the mesolimbic dopamine pathway, which is surrounded by the midbrain, is thought to cause the positive symptoms of schizophrenia and dopamine under natural process in the mesocortical dopamine pathway is thought to result in the negative symptoms of schizophrenia. Positive symptoms represent a distortion of normal experience, such as delusions, hallucinations and thought disorder, whereas negative symptoms represent a loss or dimming of normal function and fond norm, such as dodge of loving interactions (Baker, 2003).There are contrastive graphemes of schizophrenia such as paranoid, disorganised, catatonic, un divers(prenominal)iated and residual (Issacs, 2006). However, Gillam (2002) claimed that the call for causes of schizophrenia remain unclear tho genetic, environmental and social factors are all thought to specify its cookment. The risk for a child to snap off schizophrenia is 46%, if both parents deal the disorder (Kirk et al, 2006). Women who down certain viral illnesses during their pregnancy may be at a greater risk of heavy(a) birth to children who later develop schizophrenia and the 1957 in fluenza A2 epidemics in England resulted in an increase in schizophrenia in the offspring of women who developed this flu during their pregnancy (Frankenburg, 2007).1 in 100 UK populations will develop schizophrenia in their lifetime and the existence prevalence is virtually 2-4 in 1000, as it affects men and women evenly (Rethink, 2008). However, the onset in men is or so five years earlier than women with the peak age of incidence is amidst 16 and 25 and the first appearance of the illness varies tremendously, not only between individuals, but also within the same individual at contrasting stages of their illness (Magorrian, 2007). Schizophrenia seems to be much viridity in city areas and in near ethnic minority groups and premature fatality rate in deal with schizophrenia is 2 to 3 multiplication heightser than that in the full general population (Royal college of Psychiatrists 2008). The premature mortality might be due to poorer health care, physical health, unhealthy lifestyles and multitude with schizophrenia may be at greater risk of type 2 diabetes as a result of antipsychotic medications (Nash, 2005). Moreover, accord to WHO (2008) schizophrenia is a treatable disorder but many individuals remain untreated regardless of effective treatments.There has been an unresolved debate slightly how better to define patients work with medications and until the 1980s most work on patient engagement with medications regimes was described as compliance (Norman Ryrie, 2004). The endpoint compliance is often use interchangeably with esteem or concordance (Snelgrove, 2005).According to Kikkert (2006) the term compliance ha s fallen out of favour in clinical practice because it carries an assumption that patients are the passive recipients of clinicians and implies unquestioning obedience with no opportunity for patients choice. To add to the complexity of this term, patients arsehole be deliberately or unintentionally non-compliant such as a regard decision not to comply with treatment and patients may stupefy misunderstood the guidance that they get to been devoted or unable to open the medication container. Velligan et al (2006) claimed that in recent years there has been a shift from this paternalistic model of doctor-patient interactions with the sequent preference for the use of the term adherence. However, while adherence emphasises negotiation between clinician and patient, it still implies a compass point of passivity and obedience (Snelgrove, 2005).Gray et al (2002b) assert that concordance may be a much acceptable term as it suggests a collaborative bear upon of decision-making reg arding medications regimes and discovers the richness of the 2-way communication. The NHS Plan (2000) emphasises the importance of placing patients at the centre of services and the transformation of patients into consumers of the health service has changed the context of health care, as patients are expected to become more active and informed about their treatments (Jasper, 2006). Murray et al (2007) emphasise that shared decision-making between clinicians and patients has the potential to mitigate concordance with treatment plans. Furthermore, The drumhead Nursing Officers review of mental health nursing (2006) recommends that building and maintaining positive interpersonal dealinghips with service users is essential to thriving mental health nursing practice and person-centred values is helpful in building positive relationships.This indicates that by not agreeing to health professionals advice patients may be labelled as non-compliant. Nonetheless, compliance could also b e convoluted, for drill if patients continue to compact medication obediently, although it is cause adverse side effects. However, from the empirical knowledge the term compliance is still being used in clinical settings despite the paternalistic conception. Therefore, the term concordance is favoured here as it promotes the idea that medication treatment should be a collaborative process between clinicians and patients, which emphasises the patients rights. Ultimately, the term concordance corresponds with the current ethos of modern mental health care set out in the National Service Framework (1999), the NHS Plan (2000) and the Chief Nursing Officers review of mental health nursing (2006), which is linked with working in partnership with patients and carers. However, fit to the term concordance patients have the right to make treatment decisions, for example, stopping medication even if health professionals do not agree with that decision.For decades researchers have worked to explain the causes of non-concordance with medication unfortunately there have been no valid way of measuring concordance (Velligan et al, 2006). Rates of concordance have been measured by development the subjective and design methods. Subjective method includes patients self enshroud and direct interviews, although this method is less costly, it tends to overvalue the degree of concordance, as patients may not admit non-concordance (Gray et al, 2002b). Snelgrove (2005) claims that objective method such as subscriber line and urine analysis also pose problems as they do not account for individual transfiguration and do not reflect inconsistencies in concordance over time. Moreover, from empirical knowledge blood test is effective in monitoring concordance with mood stabilisers such as lithium, but for schizophrenia it is the grammatical construction of symptoms bathroom support the evidence of non-concordance. According to Gray et al (2002b) oral contraceptive counts a re more reliable, but it is impossible to tell whether patients have actually ingested the medication. Even expensive objective method such as electronic monitoring which records every occasion that a pill bottles is opened apprize also be problematic when patients choose not to swallow the medication that was remote or do not supplant the caps and electronic prescribing is still fallible, just because medication is procurable does not mean that it is taken (Velligan et al, 2006).One of the major clinical problems in the treatment of pack with schizophrenia is fond(p) or complete non-concordance with medication and this limits the clinical effectiveness of the prescribed medications (Kikkert et al, 2006). Antipsychotics medication tin only be effective if they are taken unendingly over a sustained period of time (Norman Ryrie, 2004). Urquhart (2005) claims that partially concordant patients bottom of the inning be rough to identify because they do not actively refuse to t ake their medication but the dosage deviations for diverse reasons and this may only be detected when psychotic symptoms re-emerge. uncomplete concordance creates real problems for the treating physician as it creates difficulties in determining whether medications are working adequately, dosing is appropriate or concomitant medication is needed (Velligan et al, 2006). Therefore, this indicates that medication or dosage changes and the addition of concomitant medications are more belike to occur among patients who are not fully concordant with prescribed medications.Non-concordance with prescribed medication is believed to be a significant factor to increasethe prospect of relapse in patients with schizophrenia and relapse is one of the most costly aspects of schizophrenia ( almond et al, 2004). Knapp et al (2004) undertook a demand of 658 patients receiving antipsychotics medication of whom 20% reported non-concordance with prescribed medication and think that non-concordanc e was one of the most significant factors in increasing service be, predicting an excess annual cost per patient of 2500 for inpatient services and an boilers suit additional cost of 5000 for total service use. In addition, Almond et al (2004) estimated that costs for relapse cases are four times superiorthan those for non-relapse cases. Therefore, these two studies rise that relapse in patients with schizophrenia as a result of non-concordance isa major factor in generating advanced hospitalisation rates and costs. This implies that patients who do not concord with their medication are promising to requiremore treatment and support from a range of services and given the uplifted costs associated with relapse non-concordance is a key factor in the use ofin-patient and external services.Antipsychotic medication has proved efficacy in the treatment of schizophrenia and the prevention of relapse. In spite of vast evidence that antipsychotics can be effective in treating the s ymptoms of schizophrenia, almost 90% of patients will relapse within the first five years of treatment following an acute episode and in general the illness has a list to recur or become chronic (Velligan et al, 2006). According to pureness et al (2007) non-concordance with drug therapy is common in schizophrenia approximately 50% of patients are non-concordant within one year and 75% within two years after being discharged from hospital. Such high rates of non-concordance with medication may ab initio seem alarming (Gray et al, 2002b). However, it is similar with other conditions such as asthma where maintenance treatment is required. A study of concordance with asthma medication conducted by Newell (2006) estimated that 70 % of asthma patients in the UK are non-concordant with medication and the levels of non-concordance in long-term conditions, such as asthma are known to be high as many asthma sufferers will only take medicine when they feel they need it rather than as instru cted by clinicians. Therefore, considering the Newell (2006) findings it can be argued that the rates of non-concordance with antipsychotics are not significantly different than those on non-psychiatric medications and the figment that non-concordance with medication is more common among mental disorders as compared to physical disorders needs to be dispelled.Several factors have been shown to increase the chance of relapse but probably the genius most important cause of relapse is the discontinuation of effective antipsychotic medication regime. A large number of factors make for non-concordance with prescribed antipsychotic medications, however Gray et al (2002b) have identified the main factors as impaired judgement, negative beliefs about treatment, poor worker-user relationship and the side-effects of medication. Additionally, Kikkert et al (2006) conducted a study in four European countries exploring medication adherence in schizophrenia and identified acumen, beliefs abo ut treatment, side effects and treatment efficacy as factors that curve concordancewith medication in patients with schizophrenia.Urquhart (2005) suggests that the problem of non-concordance may be more prevalent among those with schizophrenia due to its nature, for example, wish of insight. Magorrian (2007) claimed that non-concordance with medication is often linked to the persons level of insight into his or her illness and insufficiency of insight is a frequent concomitant of psychosis. In schizophrenia, insight has been defined as an sensory faculty of illness and an ability to make do symptoms as part of an illness (Gray et al, 2002b)According to Surguladze David (1999) between 50% and 80% of patients diagnosed with schizophrenia have been shown to be partially or totally lacking insight into the presence of their mental disorder and these individuals are often difficult to engage with treatments due to impaired insight. Recent formulation has formulated insight as a co ntinuum representing the combination of three factors awareness of illness, need for treatment and attribution of symptoms. Lack of insight is continuously problematic but an perceptional element can be associated with self-renunciation of symptoms or rejection of treatment at key points in the illness (Byrne, 2000). Mitchell Selmes (2007) claim that having a perception about the illness and the knowledge of medications are the key factors of concordance in mental health and patients who understand the social occasion of the prescription are twice more likely to collect it than those who do not understand.A study by Cuesta et al (2000) reported that patients despicable from schizophreniashowed poorer insight than patients with affective disorders. Cuesta et al (2000) findings demonstrated that the severe disturbances of insight persisted over the time and the level of insight was not significantly improved in patients suffering from operating(a) psychosis as between 29% to 49 % of these patients continued to have fair to poor insight at the follow up assessment. This is consistent with the findings of Kikkert et al (2006), where poor insight was a strong predictor of non-concordance with medication. In contrast, Tait et al (2003) conducted a study to examine changes in insight and symptoms of psychosis on fifty participantswho met the ICD10 diagnostic criteria for schizophrenia. The participants were interviewed and insight was measured duringacute psychosis employ the sharpness Scale with the score 0- 12 and all the participants were reinterviewed at 3 and6 months following the initial interview. Tait et al (2003) findings indicated that duringthe acute episode, 48% of participants scored 9-12 on the InsightScale and the majority of participants (63%) werein the 9-12 range of scores. The study of Tait et al (2003) clearly indicated that level of insight was high among many participants.In considering the findings of both Cuesta et al (2000) and Tait et al (2003) it appears that some patients with psychosis are unaware of their illnesses and insight is a strong predictor of concordance with medications and a good indication of prognosis. However, evidence for a relationship between insight and concordance with treatment is inconclusive as the discrepancies arrange between the two studies might be due to the methodological factors, such as selection of participants. In both studies all the participants had a diagnosis of schizophrenia and all of them gave informed consent to enter the study. According to Appelbaum (2006) several studies in America regarding the decisional- potentiality of patients with schizophrenia to consent or participation to research have urge on some concerns due to the cognitive impairments associated with schizophrenia and using the MacArthur Competence Assessment Tool for Clinical inquiry clearly indicated that patients with schizophrenia do lack understanding and reasoning of research ethics.McCann Clark (2005) emphasise that antipsychotic medications some of which have a sedating effect can also have an impact on the cognitive processes, such as illogical thinking and this can hinder the quality of responses.Moser et al (2005) argued that some studies have shown that a high percentage of individuals with schizophrenia have adequate decisional capacity to consent to research participation, however in a medication-free schizophrenia research, participants did not show a major decline in decisional capacity. In addition, Jeste et al (2006) claimed that there is a risk in assuming that decision-making capacity of individuals with schizophrenia is al slipway impaired, when they are able to make autonomous decisions and in considering their decision-making capacity as permanently impaired by virtue of their diagnosis. Consequently, in order to investigate factors associated with schizophrenia, it can be argued that only individuals with schizophrenia can provide the answers of th eir experiences and protecting indefensible populations from research activity can also exclude them from its benefits.According to Gerrish Lacey (2006) there two key concepts that concern the quality of a research asperity and reliability. Roberts et al (2006) define reliability as how far a particular test will aim similar results in different circumstances, whereas validity is to ascertain the methods are actually measuring what is intended to measure. twain Cuesta et al (2000) and Tait et al (2003) had used structured interviews to gather the entropy and have chosen a three-figure approach. Structured interview provides the opportunities to change the words but not the meaning of the questions thus, Parahoo (2006) claimed that validity is enhanced because participants can be helped to understand the questions and interviewers can ask for clarifications and probe for tho responses, if necessary and since all the questions are ideally asked in the same way, structured inte rview has a high degree of reliability.It seems that both Cuesta et al (2000) and Tait et al (2003) have adopted the appropriate approach to their research, as numerical research is the conduct of investigations primarily using numerical methods. It infers that to examine correlations between insight and service engagement qualitative approach could not have produced the same data in this area of study. Moreover, in both studies purposive sampling were used as all the participants had a diagnosis of schizophrenia. According to Polit Beck (2006) all participants in a phenomenological study must have experienced the phenomenon under study and must be able to articulate what is like to have lived the experience.Johnson Orrell (1996 cited in Surguladze David, 1999 P 166) have argued that some patients may have their own explanations of their illnesses, such as religion or cultural beliefs which may not coincide with the Western medical model of mental disorders and this can be even more complicated if one tries directly to cut the models of insight on patients from non-Western fills. Gamble Brennan (2006) claimed that different cultures in England perceive mental illness in different ways and this can have an impact on treatments as some cultures rather seek help from religious leaders than mental health services. Alternatively, religion or spiritual beliefs in the Western culture can have a positive impact on concordance with medication, as religious individuals with schizophrenia have a better social support compare to non-religious individuals with schizophrenia (Borras et al, 2007). Therefore, it can be throw off forward that awareness of illness is a crucial factor in the motivation to receive pharmacological treatment. Both cultures and religion can have a positive and negative influence on concordance with antipsychotics.Patients can have different levels of awareness into their illness and they may consciously or unconsciously empty acknowledgin g that they are suffering from mental health problems because of their reluctance to bear the blemish of mentally ill (Surguladze David, 1999). Byrne (2000, p65) defined bell ringer as a sign of disgrace or discredit, which sets a person apart from others and the fall guy of mental illness although more often related to context than to a persons appearance, remains a knock-down(a) negative attribute in all-social relations. Stigma of mental illness has become an indication for repellant experiences, such as bringing mortify to the family or social exclusion. According to Phillips et al (2002), in some parts of china, schizophrenia is still considered as a punishmentfor an ancestors misbehaviour or for the familys currentmisconduct and the effect of stigmais greater if the patient had more prominent positive symptoms or highly educated. Moreover, a study by Lee et al (2005) concluded that 60 % out of 320 patients with schizophrenia had experienced interpersonal stigma from p a rents, siblings or close rel atives. This indicates that people with schizophrenia are more likely to experience stigma from family members than the general frequent.Having a diagnosis of schizophrenia does not only affect ones health but also carries all the prejudice, discrimination and social exclusion, for example many individuals are attacked on the streets, rejection in the society and denial of employments because they were known to have mental health problems (Gamble Brennan, 2006). According to Byrne (2000) in two identical UK public opinion surveys, 80% of participants claimed that most people are embarrassed by mentally ill people and about 30% agreeing I am embarrassed by mentally ill persons.There is also evidence that supports the concepts of stereotyping of mental illness. The power and influence of the media on mental illness has been a key issue of debate over many years as people with schizophrenia are frequently portrayed as violent and dangerous. In contrast, p eople with schizophrenia are more likely to be dangerous to themselves than to others, while the greater danger to the public is posed by people without mental health problems and people with mental health problems are cardinal times more likely than the general public to be the victims of murder (Stickley Felton, 2006). Moreover, Gamble Brennan (2006) claimed that when the boxing whiz Frank Bruno was admitted to hospital in 2003, one of the newspaper headlines was Bonkers Bruno locked up. This indicates that stigma has the grave potential to cause reluctance to seek treatments and this can be detrimental to the persons health. Therefore, as a mental health clinician, it will be vital to assist people with mental health problems to rebuild their lives and this requires moving beyond the traditional focus on symptoms and medication by exploring alternatives in reducing stigma of mental health that avert people from social inclusion.It has been predicted that families with high d enotative sense compared to low verbalized perception can contribute towards the relapse rate in symptoms of schizophrenia and this can also be a triggering factor for non-concordance with medication. High explicit perception carers appear to perceive their caring situation as more disagreeable and this could be conceptualised as a catastrophic appraisal of the role of caring (Raune et al 2004). Kuipers et al (2006) identifies the components of show emotion as emotional over-involvement, hostility, decisive comments, warmth and positive remarks. A study by Kuipers et al (2006) indicates that patients whose carers showed high show emotion had considerably higher levels of solicitude and lower self-esteem due to the components of expressed emotion. However, a significant amount of data from western cultures suggests that high expressed emotion subjects who were not on medication are three times likely to relapse than those who were on medication (Bhugra McKenzie, 2003). Th is clearly signifies that despite being concordant, high expressed emotion subjects are vulnerable to relapse.The interactions between patient and the carers are crucial, peculiarly cross-culturally as in some cultures for example, in some parts of India, emotional over-involvement is the norm and if carers do not show emotional over-involvement, this can be seen as lack of care (Bhugra McKenzie, 2003). Hashemi Cochrane (1999) conducted a study in UK on expressed emotion and they observed that 80% of the British Pakistani, 45% of the White and 30% of the British Sikh families exhibited high levels of expressed emotion and emotional over-involvement was notably higher among the British Pakistani group. The findings concluded that White patients with high expressed emotion relatives were significantly more likely to relapse than those from low expressed emotion families, whereas for both Asian groups high expressed emotion did not predict relapse.The study of Hashemi Cochrane (199 9) also indicated that that Pakistani families in the UK were more likely to be rated as high expressed emotion than White families, indicating that components such as emotional over-involvement may be cultural rather than pathogenic traits. Conversely, low expressed emotion families who are not over-anxious in their response to the patients illness may tend to perceive stigma in less threatening ways whereas, families with high expressed emotion, who respond to the patients illness in a highly anxious may experience stigma more intensely (Phillips et al 2002). Therefore, it appears that family members levels of expressed emotion could influence their perception and response to stigma of mental health and concordance with medication is essential for patients disregarding of the expressed emotion status in the family. Thus, family interventions need to improve in order to lower the levels of anxiety and to increase self-esteem among families with high expressed emotion. As a clinici an it will be vital to acknowledge the cultural aspect of expressed emotion status in the family to facilitate concordance with medication.There is overpowering evidence for patients with schizophrenia, who misuse illicit drugs and intoxicant to have an increased rate of re-hospitalisation (Sokya, 2000). According to Barnes et al (2006) the higher relapse rate in people with established schizophrenia who usesubstances may be partially explained by non-concordant tothe medication regimen. Evidence suggests that the substance used most frequently by people with schizophrenia is hangmans halter (Gamble Brennan, 2006). Arseneault et al (2004) emphasise that rates of hempen necktie use in UK are higher among people with schizophrenia than among the general population and patients detained under the MHA (1983) have even higher rates of lifetime use of cannabis. substance misuse in schizophrenia may be explained as a form of self-medication to alleviate the symptoms of schizophrenia, to improve the side effects of antipsychotics and to respond to social pressures (Sokya, 2000).There has been little evidence to support the self-medication hypothesis despite its popularity with users and in contrast, substance misuse can aggravate the symptoms of schizophrenia and can also trigger psychotic episode particularly in people with a pre-exisFactors Affecting Antipsychotic Medication ComplianceFactors Affecting Antipsychotic Medication ComplianceINTRODUCTIONThe aim of this dissertation is to explore the factors affecting concordance with prescribed antipsychotic medications. The rationale for selecting this topic is derived from personal working experience with mental health service users. Having worked as a nursing assistant for the past eight years on acute admissions wards and as a student nurse for the past three years it was observed that a large proportion of compulsory re-hospitalisation under the Mental Health Act 1983 occurs due to relapse of mental illness as a result of non- concordance with medications, particularly service users with a diagnosis of schizophrenia. This led to believe that concordance with antipsychotic medications plays a crucial role in managing psychosis as it positively contributes towards the effective management of the illness in the community. In support to this view, Gray et al (2002a) assert that prophylactic use of antipsychotic medication reduces the risk of relapse among individuals with schizophrenia and non-concordance with medication has the potential for frequent re-hospitalisations. This has been recognised as the revolving door syndrome. During most mental health placements it was noted that non-concordance with medication has become significant, as this has been identified as a risk factor within the risk assessment checklist. Furthermore, despite the well-documented therapeutic effect of antipsychotic medications, some patients are reluctant to accept treatments and some may even wish to cease takin g medications altogether. Therefore, this empirical knowledge has reinforced the desire to examine the factors associated with non-concordance with antipsychotic medications.According to Brimblecombe et al (2005) medication is one of the major therapeutic tools available to help people with schizophrenia. There is also growing evidence that schizophrenia can be treated effectively with a range of psychological and social interventions together with antipsychotic medications. Norman Ryrie (2004) emphasised that antipsychotic medication has been the mainstay of treatment for schizophrenia since the 1950s when it was discovered that the dopamine antagonist haloperidol and chlorpromazine exerted antipsychotic effects. The National Institute for Clinical Excellence (NICE) (2002) recommends that atypical antipsychotic drugs such as amisulpride, aripiprazole , olanzapine, quetiapine or risperidone must be considered in the choice of first-line treatments for individuals with newly diagnos ed schizophrenia or to promote recovery for those who have experienced unacceptable side-effects on conventional antipsychotics, as atypical antipsychotics appear to have less extrapyramidal symptoms (side effects) than the conventional antipsychotics such as haloperidol and chlorpromazine.The care and treatment of individuals with schizophrenia have advanced considerably over the past ten years, since the introduction of atypical antipsychotics and medication continues to be the first line treatment for schizophrenia (Walker MacAulay, 2005). However, Gray et al (2002b) claim that despite the effectiveness of these atypical antipsychotic drugs, non- concordance with prescribed antipsychotic medications is observed in around 50% of people with schizophrenia and is a major preventable cause of psychiatric morbidity. In addition, Mitchell Selmes (2007) claim that over the course of a year, about 75% of patients will discontinue prescribed antipsychotic medications, often coming to th e decision themselves and without informing a health professional. According to Gray et al (2006) relapse rates is five times higher among individuals with schizophrenia, who are non-concordance with medication compared with concordance. Non-concordance during acute treatment of psychosis leads to chronic symptomswhereas non-concordance after remission increases the risk ofrelapse and both may have serious consequences re-hospitalisation (Hamer Haddad, 2007). Furthermore, the impacts of non-concordance with medication not only affect the individuals with schizophrenia, as each relapse causes a stepping down of cognitive functioning which is rarely retrieved but also their carers and the costs of treatments (Institute, 2007).To facilitate this project as a literature review, an analysis of secondary sources only will be use. Secondary sources were mainly obtained from nursing journals such as Nursing-Standard, Nursing-Times, Advances in Psychiatric Treatment, Mental health practice, Schizophrenia Bulletin and The British Journal of Psychiatry, containing the key words schizophrenia, oral antipsychotic, medication management and non-concordance. An Internet search of Google was also done with the same keywords to access any relevant documents. To address the factors affecting concordance with prescribed antipsychotic medications, these will be divided into patient-related factors, medication-related factors and clinician-related factors.LITERATURE REVIEWAccording to White (2007) schizophrenia is a debilitating psychiatric disorder characterised by a range of positive and negative symptoms and these symptoms were first described in detail by the British neurologist Hughlings-Jackson in the late 1800s. There is no physical test for schizophrenia rather it is diagnosed by the presence of certain positive and negative symptoms over a period of time (Brennan, 2001). According to Issacs (2006) the neurotransmitter hypothesis suggests that the dopamine over activity i n the mesolimbic dopamine pathway, which is between the midbrain, is thought to cause the positive symptoms of schizophrenia and dopamine under activity in the mesocortical dopamine pathway is thought to result in the negative symptoms of schizophrenia. Positive symptoms represent a distortion of normal experience, such as delusions, hallucinations and thought disorder, whereas negative symptoms represent a loss or dimming of normal function and social norm, such as avoidance of social interactions (Baker, 2003).There are different types of schizophrenia such as paranoid, disorganised, catatonic, undifferentiated and residual (Issacs, 2006). However, Gillam (2002) claimed that the exact causes of schizophrenia remain unclear but genetic, environmental and social factors are all thought to influence its development. The risk for a child to develop schizophrenia is 46%, if both parents have the disorder (Kirk et al, 2006). Women who have certain viral illnesses during their pregnancy may be at a greater risk of giving birth to children who later develop schizophrenia and the 1957 influenza A2 epidemics in England resulted in an increase in schizophrenia in the offspring of women who developed this flu during their pregnancy (Frankenburg, 2007).1 in 100 UK populations will develop schizophrenia in their lifetime and the world prevalence is about 2-4 in 1000, as it affects men and women equally (Rethink, 2008). However, the onset in men is about five years earlier than women with the peak age of incidence is between 16 and 25 and the presentation of the illness varies tremendously, not only between individuals, but also within the same individual at different stages of their illness (Magorrian, 2007). Schizophrenia seems to be more common in city areas and in some ethnic minority groups and premature mortality in people with schizophrenia is 2 to 3 times higher than that in the general population (Royal college of Psychiatrists 2008). The premature mortality might be due to poorer health care, physical health, unhealthy lifestyles and people with schizophrenia may be at greater risk of type 2 diabetes as a result of antipsychotic medications (Nash, 2005). Moreover, according to WHO (2008) schizophrenia is a treatable disorder but many individuals remain untreated regardless of effective treatments.There has been an unresolved debate about how best to define patients engagement with medications and until the 1980s most work on patient engagement with medications regimes was described as compliance (Norman Ryrie, 2004). The term compliance is often used interchangeably with adherence or concordance (Snelgrove, 2005).According to Kikkert (2006) the term compliance has fallen out of favour in clinical practice because it carries an assumption that patients are the passive recipients of clinicians and implies unquestioning obedience with no opportunity for patients choice. To add to the complexity of this term, patients can be intentionally or u nintentionally non-compliant such as a deliberate decision not to comply with treatment and patients may have misunderstood the guidance that they have been given or unable to open the medication container. Velligan et al (2006) claimed that in recent years there has been a shift from this paternalistic model of doctor-patient interactions with the consequent preference for the use of the term adherence. However, while adherence emphasises negotiation between clinician and patient, it still implies a degree of passivity and obedience (Snelgrove, 2005).Gray et al (2002b) assert that concordance may be a more acceptable term as it suggests a collaborative process of decision-making regarding medications regimes and acknowledges the importance of the two-way communication. The NHS Plan (2000) emphasises the importance of placing patients at the centre of services and the transformation of patients into consumers of the health service has changed the context of health care, as patients are expected to become more active and informed about their treatments (Jasper, 2006). Murray et al (2007) emphasise that shared decision-making between clinicians and patients has the potential to improve concordance with treatment plans. Furthermore, The Chief Nursing Officers review of mental health nursing (2006) recommends that building and maintaining positive interpersonal relationships with service users is essential to successful mental health nursing practice and person-centred values is helpful in building positive relationships.This indicates that by not agreeing to health professionals advice patients may be labelled as non-compliant. Nonetheless, compliance could also be problematic, for example if patients continue to take medication obediently, although it is causing adverse side effects. However, from the empirical knowledge the term compliance is still being used in clinical settings despite the paternalistic conception. Therefore, the term concordance is favoured here as it promotes the idea that medication treatment should be a collaborative process between clinicians and patients, which emphasises the patients rights. Ultimately, the term concordance corresponds with the current ethos of modern mental health care set out in the National Service Framework (1999), the NHS Plan (2000) and the Chief Nursing Officers review of mental health nursing (2006), which is concerned with working in partnership with patients and carers. However, according to the term concordance patients have the right to make treatment decisions, for example, stopping medication even if health professionals do not agree with that decision.For decades researchers have worked to explain the causes of non-concordance with medication unfortunately there have been no valid way of measuring concordance (Velligan et al, 2006). Rates of concordance have been measured by using the subjective and objective methods. Subjective method includes patients self report and direct inter views, although this method is less expensive, it tends to overestimate the degree of concordance, as patients may not admit non-concordance (Gray et al, 2002b). Snelgrove (2005) claims that objective method such as blood and urine analysis also pose problems as they do not account for individual metabolism and do not reflect inconsistencies in concordance over time. Moreover, from empirical knowledge blood test is effective in monitoring concordance with mood stabilisers such as lithium, but for schizophrenia it is the manifestation of symptoms can support the evidence of non-concordance. According to Gray et al (2002b) pill counts are more reliable, but it is impossible to tell whether patients have actually ingested the medication. Even expensive objective method such as electronic monitoring which records every occasion that a pill bottles is opened can also be problematic when patients choose not to swallow the medication that was removed or do not replace the caps and electron ic prescribing is still fallible, just because medication is available does not mean that it is taken (Velligan et al, 2006).One of the major clinical problems in the treatment of people with schizophrenia is partial or complete non-concordance with medication and this limits the clinical effectiveness of the prescribed medications (Kikkert et al, 2006). Antipsychotics medication can only be effective if they are taken continuously over a sustained period of time (Norman Ryrie, 2004). Urquhart (2005) claims that partially concordant patients can be difficult to identify because they do not actively refuse to take their medication but the dosage deviations for different reasons and this may only be detected when psychotic symptoms re-emerge. Partial concordance creates significant problems for the treating physician as it creates difficulties in determining whether medications are working adequately, dosing is appropriate or concomitant medication is needed (Velligan et al, 2006). T herefore, this indicates that medication or dosage changes and the addition of concomitant medications are more likely to occur among patients who are not fully concordant with prescribed medications.Non-concordance with prescribed medication is believed to be a significant factor to increasethe probability of relapse in patients with schizophrenia and relapse is one of the most costly aspects of schizophrenia (Almond et al, 2004). Knapp et al (2004) undertook a study of 658 patients receiving antipsychotics medication of whom 20% reported non-concordance with prescribed medication and concluded that non-concordance was one of the most significant factors in increasing service costs, predicting an excess annual cost per patient of 2500 for inpatient services and an overall additional cost of 5000 for total service use. In addition, Almond et al (2004) estimated that costs for relapse cases are four times higherthan those for non-relapse cases. Therefore, these two studies show that relapse in patients with schizophrenia as a result of non-concordance isa major factor in generating high hospitalisation rates and costs. This implies that patients who do not concord with their medication are likely to requiremore treatment and support from a range of services and given the high costs associated with relapse non-concordance is a key factor in the use ofin-patient and external services.Antipsychotic medication has proven efficacy in the treatment of schizophrenia and the prevention of relapse. In spite of vast evidence that antipsychotics can be effective in treating the symptoms of schizophrenia, almost 90% of patients will relapse within the first five years of treatment following an acute episode and in general the illness has a tendency to recur or become chronic (Velligan et al, 2006). According to White et al (2007) non-concordance with drug therapy is common in schizophrenia approximately 50% of patients are non-concordant within one year and 75% within two years after being discharged from hospital. Such high rates of non-concordance with medication may initially seem alarming (Gray et al, 2002b). However, it is similar with other conditions such as asthma where maintenance treatment is required. A study of concordance with asthma medication conducted by Newell (2006) estimated that 70 % of asthma patients in the UK are non-concordant with medication and the levels of non-concordance in long-term conditions, such as asthma are known to be high as many asthma sufferers will only take medicine when they feel they need it rather than as instructed by clinicians. Therefore, considering the Newell (2006) findings it can be argued that the rates of non-concordance with antipsychotics are not significantly different than those on non-psychiatric medications and the myth that non-concordance with medication is more common among mental disorders as compared to physical disorders needs to be dispelled.Several factors have been shown to increase the chance of relapse but probably the single most important cause of relapse is the discontinuation of effective antipsychotic medication regime. A large number of factors influence non-concordance with prescribed antipsychotic medications, however Gray et al (2002b) have identified the main factors as impaired judgement, negative beliefs about treatment, poor worker-user relationship and the side-effects of medication. Additionally, Kikkert et al (2006) conducted a study in four European countries exploring medication adherence in schizophrenia and identified insight, beliefs about treatment, side effects and treatment efficacy as factors that influence concordancewith medication in patients with schizophrenia.Urquhart (2005) suggests that the problem of non-concordance may be more prevalent among those with schizophrenia due to its nature, for example, lack of insight. Magorrian (2007) claimed that non-concordance with medication is often linked to the persons level of insight i nto his or her illness and lack of insight is a frequent concomitant of psychosis. In schizophrenia, insight has been defined as an awareness of illness and an ability to recognise symptoms as part of an illness (Gray et al, 2002b)According to Surguladze David (1999) between 50% and 80% of patients diagnosed with schizophrenia have been shown to be partially or totally lacking insight into the presence of their mental disorder and these individuals are often difficult to engage with treatments due to impaired insight. Recent conceptualisation has formulated insight as a continuum representing the combination of three factors awareness of illness, need for treatment and attribution of symptoms. Lack of insight is continuously problematic but an emotional element can be associated with denial of symptoms or rejection of treatment at key points in the illness (Byrne, 2000). Mitchell Selmes (2007) claim that having a perception about the illness and the knowledge of medications are th e key factors of concordance in mental health and patients who understand the purpose of the prescription are twice more likely to collect it than those who do not understand.A study by Cuesta et al (2000) reported that patients suffering from schizophreniashowed poorer insight than patients with affective disorders. Cuesta et al (2000) findings demonstrated that the severe disturbances of insight persisted over the time and the level of insight was not significantly improved in patients suffering from functional psychosis as between 29% to 49% of these patients continued to have fair to poor insight at the follow up assessment. This is consistent with the findings of Kikkert et al (2006), where poor insight was a strong predictor of non-concordance with medication. In contrast, Tait et al (2003) conducted a study to examine changes in insight and symptoms of psychosis on fifty participantswho met the ICD10 diagnostic criteria for schizophrenia. The participants were interviewed and insight was measured duringacute psychosis using the Insight Scale with the score 0- 12 and all the participants were reinterviewed at 3 and6 months following the initial interview. Tait et al (2003) findings indicated that duringthe acute episode, 48% of participants scored 9-12 on the InsightScale and the majority of participants (63%) werein the 9-12 range of scores. The study of Tait et al (2003) clearly indicated that level of insight was high among many participants.In considering the findings of both Cuesta et al (2000) and Tait et al (2003) it appears that some patients with psychosis are unaware of their illnesses and insight is a strong predictor of concordance with medications and a good indicator of prognosis. However, evidence for a relationship between insight and concordance with treatment is inconclusive as the discrepancies found between the two studies might be due to the methodological factors, such as selection of participants. In both studies all the participan ts had a diagnosis of schizophrenia and all of them gave informed consent to enter the study. According to Appelbaum (2006) several studies in America regarding the decisional-capacity of patients with schizophrenia to consent or participation to research have raise some concerns due to the cognitive impairments associated with schizophrenia and using the MacArthur Competence Assessment Tool for Clinical Research clearly indicated that patients with schizophrenia do lack understanding and reasoning of research ethics.McCann Clark (2005) emphasise that antipsychotic medications some of which have a sedating effect can also have an impact on the cognitive processes, such as illogical thinking and this can hinder the quality of responses.Moser et al (2005) argued that some studies have shown that a high percentage of individuals with schizophrenia have adequate decisional capacity to consent to research participation, however in a medication-free schizophrenia research, participants d id not show a major decline in decisional capacity. In addition, Jeste et al (2006) claimed that there is a risk in assuming that decision-making capacity of individuals with schizophrenia is always impaired, when they are capable to make autonomous decisions and in considering their decision-making capacity as permanently impaired by virtue of their diagnosis. Consequently, in order to investigate factors associated with schizophrenia, it can be argued that only individuals with schizophrenia can provide the answers of their experiences and protecting vulnerable populations from research activity can also exclude them from its benefits.According to Gerrish Lacey (2006) there two key concepts that concern the quality of a research validity and reliability. Roberts et al (2006) define reliability as how far a particular test will produce similar results in different circumstances, whereas validity is to ascertain the methods are actually measuring what is intended to measure. Both C uesta et al (2000) and Tait et al (2003) had used structured interviews to gather the data and have chosen a quantitative approach. Structured interview provides the opportunities to change the words but not the meaning of the questions thus, Parahoo (2006) claimed that validity is enhanced because participants can be helped to understand the questions and interviewers can ask for clarifications and probe for further responses, if necessary and since all the questions are ideally asked in the same way, structured interview has a high degree of reliability.It seems that both Cuesta et al (2000) and Tait et al (2003) have adopted the appropriate approach to their research, as quantitative research is the conduct of investigations primarily using numerical methods. It infers that to examine correlations between insight and service engagement qualitative approach could not have produced the same data in this area of study. Moreover, in both studies purposive sampling were used as all th e participants had a diagnosis of schizophrenia. According to Polit Beck (2006) all participants in a phenomenological study must have experienced the phenomenon under study and must be able to articulate what is like to have lived the experience.Johnson Orrell (1996 cited in Surguladze David, 1999 P 166) have argued that some patients may have their own explanations of their illnesses, such as religion or cultural beliefs which may not coincide with the Western medical model of mental disorders and this can be even more complicated if one tries directly to impose the models of insight on patients from non-Western cultures. Gamble Brennan (2006) claimed that different cultures in England perceive mental illness in different ways and this can have an impact on treatments as some cultures rather seek help from religious leaders than mental health services. Alternatively, religion or spiritual beliefs in the Western culture can have a positive impact on concordance with medication, as religious individuals with schizophrenia have a better social support compare to non-religious individuals with schizophrenia (Borras et al, 2007). Therefore, it can be put forward that awareness of illness is a crucial factor in the motivation to receive pharmacological treatment. Both cultures and religion can have a positive and negative influence on concordance with antipsychotics.Patients can have different levels of awareness into their illness and they may consciously or unconsciously avoid acknowledging that they are suffering from mental health problems because of their reluctance to bear the stigma of mentally ill (Surguladze David, 1999). Byrne (2000, p65) defined stigma as a sign of disgrace or discredit, which sets a person apart from others and the stigma of mental illness although more often related to context than to a persons appearance, remains a powerful negative attribute in all-social relations. Stigma of mental illness has become an indication for unpleasa nt experiences, such as bringing shame to the family or social exclusion. According to Phillips et al (2002), in some parts of china, schizophrenia is still considered as a punishmentfor an ancestors misbehaviour or for the familys currentmisconduct and the effect of stigmais greater if the patient had more prominent positive symptoms or highly educated. Moreover, a study by Lee et al (2005) concluded that 60 % out of 320 patients with schizophrenia had experienced interpersonal stigma from p arents, siblings or close rel atives. This indicates that people with schizophrenia are more likely to experience stigma from family members than the general public.Having a diagnosis of schizophrenia does not only affect ones health but also carries all the prejudice, discrimination and social exclusion, for example many individuals are attacked on the streets, rejection in the society and denial of employments because they were known to have mental health problems (Gamble Brennan, 2006). Acc ording to Byrne (2000) in two identical UK public opinion surveys, 80% of participants claimed that most people are embarrassed by mentally ill people and about 30% agreeing I am embarrassed by mentally ill persons.There is also evidence that supports the concepts of stereotyping of mental illness. The power and influence of the media on mental illness has been a key issue of debate over many years as people with schizophrenia are frequently portrayed as violent and dangerous. In contrast, people with schizophrenia are more likely to be dangerous to themselves than to others, while the greater danger to the public is posed by people without mental health problems and people with mental health problems are six times more likely than the general public to be the victims of murder (Stickley Felton, 2006). Moreover, Gamble Brennan (2006) claimed that when the boxing champion Frank Bruno was admitted to hospital in 2003, one of the newspaper headlines was Bonkers Bruno locked up. This indicates that stigma has the grave potential to cause reluctance to seek treatments and this can be detrimental to the persons health. Therefore, as a mental health clinician, it will be vital to assist people with mental health problems to rebuild their lives and this requires moving beyond the traditional focus on symptoms and medication by exploring alternatives in reducing stigma of mental health that avert people from social inclusion.It has been predicted that families with high expressed emotion compared to low expressed emotion can contribute towards the relapse rate in symptoms of schizophrenia and this can also be a triggering factor for non-concordance with medication. High expressed emotion carers appear to perceive their caring situation as more stressful and this could be conceptualised as a catastrophic appraisal of the role of caring (Raune et al 2004). Kuipers et al (2006) identifies the components of expressed emotion as emotional over-involvement, hostility, crit ical comments, warmth and positive remarks. A study by Kuipers et al (2006) indicates that patients whose carers showed high expressed emotion had considerably higher levels of anxiety and lower self-esteem due to the components of expressed emotion. However, a significant amount of data from western cultures suggests that high expressed emotion subjects who were not on medication are three times likely to relapse than those who were on medication (Bhugra McKenzie, 2003). This clearly signifies that despite being concordant, high expressed emotion subjects are vulnerable to relapse.The interactions between patient and the carers are crucial, especially cross-culturally as in some cultures for example, in some parts of India, emotional over-involvement is the norm and if carers do not show emotional over-involvement, this can be seen as lack of care (Bhugra McKenzie, 2003). Hashemi Cochrane (1999) conducted a study in UK on expressed emotion and they observed that 80% of the Briti sh Pakistani, 45% of the White and 30% of the British Sikh families exhibited high levels of expressed emotion and emotional over-involvement was notably higher among the British Pakistani group. The findings concluded that White patients with high expressed emotion relatives were significantly more likely to relapse than those from low expressed emotion families, whereas for both Asian groups high expressed emotion did not predict relapse.The study of Hashemi Cochrane (1999) also indicated that that Pakistani families in the UK were more likely to be rated as high expressed emotion than White families, indicating that components such as emotional over-involvement may be cultural rather than pathogenic traits. Conversely, low expressed emotion families who are not over-anxious in their response to the patients illness may tend to perceive stigma in less threatening ways whereas, families with high expressed emotion, who respond to the patients illness in a highly anxious may experi ence stigma more intensely (Phillips et al 2002). Therefore, it appears that family members levels of expressed emotion could influence their perception and response to stigma of mental health and concordance with medication is essential for patients irrespective of the expressed emotion status in the family. Thus, family interventions need to improve in order to lower the levels of anxiety and to increase self-esteem among families with high expressed emotion. As a clinician it will be vital to acknowledge the cultural aspect of expressed emotion status in the family to facilitate concordance with medication.There is overwhelming evidence for patients with schizophrenia, who misuse illicit drugs and alcohol to have an increased rate of re-hospitalisation (Sokya, 2000). According to Barnes et al (2006) the higher relapse rate in people with established schizophrenia who usesubstances may be partially explained by non-concordant tothe medication regimen. Evidence suggests that the su bstance used most frequently by people with schizophrenia is cannabis (Gamble Brennan, 2006). Arseneault et al (2004) emphasise that rates of cannabis use in UK are higher among people with schizophrenia than among the general population and patients detained under the MHA (1983) have even higher rates of lifetime use of cannabis. Substance misuse in schizophrenia may be explained as a form of self-medication to alleviate the symptoms of schizophrenia, to improve the side effects of antipsychotics and to respond to social pressures (Sokya, 2000).There has been little evidence to support the self-medication hypothesis despite its popularity with users and in contrast, substance misuse can aggravate the symptoms of schizophrenia and can also trigger psychotic episode particularly in people with a pre-exis

Using Suitable Models Identify The Customer Perceived Value Marketing Essay

Using Suitable Models station The Customer Perceived place Marketing EssayTesco is the largest fodder retailer in UK and it is amongst worlds top 5 largest retailers byannual salesbehindWal-MartandCarrefour. It started in 1919 and now it operates to a greater extent than than 3000 stores in UK and it also has stores in rest of Europe, North America and Asia. This company is multi category that also runs telecom and banking services apart from fare retailing but for the purpose of this paper the focus will be will be on customer perceive care fors for the customers of TESCO.Tesco is based on trust and respect. They have learnt over the years that if customers corresponding their offers, then there is higher rate of possibility that they will come back and shop with them again. So they will do every possible thing to retain their valued customers.1.2 Vision of TESCOTescos vision is to be most highly valued by the customers they serve, the communities in which they operate, thei r loyal and committed staff and their shareholders, to be a growing company, a modern and innovative company and winning locally and applying their skills globally.1.3 Customer Perceived ValueThe Customer Perceived value of a product is the customers evaluation of all the benefits gained against all the cost of a product or service.Zeithaml defines customer sensed value as consumers overall assessment of the utility of a product based on perceptions of what is received and what is given. Though what is received varies customer to customer because some the great unwashed want only quantity other may want quality in the specific product, in like manner what is given also varies customer to customer like some people are only pertain with the price of the product others may be concerned with the sequence and efforts they are putting in to corrupt the product.(Source Zeithaml, V. A., 1998 Consumer Perceptions of Price, eccentric, and Value A Means-End Model and Synthesis of Eviden ce Journal of Marketing 52 (July) 2-22)In simple(a) words customer perceived value is the benefits you get after your sacrifices.It is often expressed as the comparabilityCustomer perceived value = Perceived BenefitsPerceived SacrificeBenefits = attributes of core product/service and supporting services, perceived quality and priceSacrifice = customer costs involved in purchasing, such as time, travel, repairing faulty work, etc. NOT just price.Perceived BenefitPerceived SacrificePrice bullionQualityTimeStatusEffortConveniencepsychical costTalking about TESCO, benefits associated with perceived value are Price Customers get great saving offers when purchasing their favourite products in Tesco. Quality At Tesco, quality and freshness has always meant handpicked groceries carefully packed so customer knows every level is carefully checked before it reaches them. Status Being UKs biggest retailer Tesco has a very high military position amongst the customers and it has great goodw ill in the market so customers are aware of the prestige of the company. Convenience Tesco has got many facilities for its customers like online shopping, home delivery, self-billing counters and wide range of products to choose from plus now it is introducing free Wi-Fi in the stores for its customers so that they can keep connected to internet always.Sacrifices associated with perceived value are Money if consumer find the cost of product higher than expected, they need to decide if it is worth taking or not. Time it is the amount of time consumer has to spend on finding and purchasing the product in Tesco. Effort involves the physical energy use by people to find products that suits their needs in the store so it takes efforts to do shopping also. Psychic Cost shopping is stressful and frustrating experience and Perceived risk is considered for the performance of the product (will it do the job), physical (may be bodily harm done by the product), financial (danger of economic lo ss from the purchase).1.4 Holbrooks typology of consumer perceived valueExtrinsicIntrinsic active agentEfficiency(O/l, Convenience)Play(Fun)Self-OrientedReactiveExcellence(Quality)Aesthetics(Beauty)ActiveStatus(Success,ImpressionManagement)Ethics(Virtue, Justice,Morality)Other-OrientedReactiveEsteem(Reputation,Materialism,Possessions)Spirituality(Faith, Ecstasy,Sacredness,Magic)Source Holbrook, M. B., 1999 Consumer Value A manakin for analysis and research.If we first consider extrinsic versus intrinsic, there will be higher extrinsic value for the customers of Tesco because they emphasise on the end result of their purchase. Talking about self-oriented and other-oriented it is seen that here focus is on self-oriented more while shopping in Tesco because the customer is doing it for his or her own purpose or objective. When we come to the final exam part of Holbrooks framework, active versus reactive, it is seen that customers of Tesco are from different cultures and societies so t hey prefer different type of food clobber like Chinese would prefer Chinese food and Indian will prefer Indian food so it is difficult to keep all the customers happy at once but for customers reactive is more important.What Holbrooks framework does enable is the ability to identify the key values of customers, and in the case of Tesco, whilst it can be stated that the customer perceived value is multidimensional, the application of the typology of consumer value identifies two key values, efficiency and excellence.02) critically evaluate the existing value overture for the one you have chosen. Compare and contrast the value proposition with that of the leading competitor in its sector.2.1 Value PropositionIt is defined as an analysis or asseveration of the combination of goods and services offeredby a company to its customers in exchange for payment (Investopedia, n.d.). It is actuallya promise of value of the company to deliver the services that the customers expect toexperienc e in the future.Tescos Market dodgingTescofocusedtodevelopthe UK market as it is theirbiggestbusinessin the group. As for the worldwidemarket, Tescosobjective isto be aspectacularretailstorein the world as well as online.Tescounploweditscustomersthrough manyways. One of it is through the Tesco Club-card program.Tesco has been very inventive in the Customer Loyalty field. The the true programs they havedevelopedhave keptcustomers attachedto their brand.Tesco had thedreamstoknow its customers andtheirneed and itwas the key tocustomer the trueand satisfaction. ThisClub-cardhaschangedTescosconnection with itscustomersand thedatafrom the database tour guidesall the keydecisions to be taken for company. The loyalty club-card design permits fornumerousadvantagesone of which isaimed atcommunication. There are more than 4 million variations of its quarterlycustomerposting todouble-checkthat its offers and discountsare accordingto their individual customer. Hence, thisschemeassiststo keep its present buyer and bring a feel ofcommitmentto the organization. Theadvantagesof this loyalty schemewillapplyto newcustomersandassistTesco to gain largermarket share.

Older People People With Dementia

Older peck stack With deliriumDementia is a general term for a descent in intellectual ability severe teeming to interfere with casual smell. Memory issue is an example. Alzheimers is the most common type of mania. Dementia is not a item disease. Its an over exclusively term that describes a entire range of symptoms associated with a decline in memory or other thinking skills severe enough to cut out a someones ability to perform e trulyday activities.Symptoms and signs of monomania eon symptoms of craziness stooge vary greatly, at least two of the pursuance core mental functions essential be significantly impaired to be considered dementiaMemoryCommunication and languageAbility to focus and turn out attentionReasoning and judgmentVisual perceptionMany dementias argon progressive, meaning symptoms write d ingest out slowly and gradu in ally start up worse. exhalation of memory for recent events is a common early sign. Some the great unwashed at the middle st age become very easily upset, livid or aggressive perhaps because they ar timbreing frustrated or they whitethorn lose their confidence and become very clingy. At the blend stage, the person may also become increasingly frail. They may start to shuffle or walk unsteadily, eventually becoming confined to withdraw or a wheelchair.ImpactsAs a c arer, we are likely to give way got a range of very different, and a good deal sort of extreme, thumbings. Some feelings unremarkably experienced by carers of plurality with dementia acknowledge di separate out, foiling, guilt, grief and loss, exhaustion, annoyance, frustration and anger. Some of the most common feelings families and caregivers experience are guilt, grief and loss, and anger. And for the clients themselves they may suffer the stresses from the society and the lot around themThe consequences of the people with dementia in relation to individual people living with dementias often take for mental health problems especially depression and anxiety dis revises as well as dementia. Memories they reach always relied on become hazy and uncertain. Knowledge and skills well-mannered over a lifetime diminish. Relationships change or are lost. People with dementia can become late sad, fearful and/or angry. sometimes their behavior becomes a challenge for people who care for them.The consequences of the people with dementia in relation to the familyThe family of the people with dementia will find it is very hard to care for the patient. And they may feel distress, frustration, guilt, grief and loss, exhaustion, annoyance, frustration and anger. They are facing lots of problems with the patient. They will claim the very heavy stress from the warmth process and the society or the people around them. So it is important to inform the patients family how it is going on when the carers are caring for the patient.The consequences of the people with dementia in relation to the carersAs a carer, we ar e likely to experience a range of very different, and often quite extreme, feelings. Some feelings commonly experienced by carers of people with dementia include distress, frustration, guilt, grief and loss, exhaustion, annoyance, frustration and anger. Caregivers face many obstacles as they isotropy caregiving with other demands, including child rearing, career, and relationships. They are at increased risk for burden, stress, depression, and a variety of other health complications, the effects on caregivers are divers(prenominal) and complex, and there are many other factors that may exacerbate or ameliorate how caregivers react and feel as a result of their role. numerous studies report that caring for a person with dementia is more(prenominal) stressful than caring for a person with a physical deadening.The way to shrivel up the stresses for the individual, family and carers.For all of those 3 charit subjects of people, they can die help from relax, they are speculate( a) to have the Quality sleep and rest, Quality relationships. They need to be sense of touch safe and secure. And the sense of connection to the family and community should be nice. For the carers themselves, they have to film how to sleep with themselves and get rid of stress. Individuals and families can be both certified the treating process and the good things. They will be getting better when they get encouragement.The several(a) dynamics of the familyEach family member may act otherwise in response to coping with an individual with dementia. Some family members may feel resentful or angry while others cope by pursuance support and information. And others may simply fall into a daub of disaffirmation and avoid the situation.Caring for a family member or coadjutor with dementia can be both a very honour and challenging experience. It can also be very physically, emotionally and financially demanding and consider our lifestyle and life picksAs a dementia progresses, the need for caring and supporting is increasing. It is that carers take the time to look later themselves and to respond to their let needs and emotionsCaring for some unrivalled with dementia impacts either aspect of daily life. As a patient loses ones ability after another, caregivers face tests of stamina, problem-solving, and resiliency. During this long and difficult journey, communication diminishes, rewards decrease, and without quick support, caretakers face challenges to their own well-being. Maintaining emotional and physical fitness is crucial. Preparing and protecting yourself, work to understand your love ones experience, and embracing help from others can minimize the hazards and stir the joys of your caregiving experience.The code of rights for the people living with dementiaPeople with dementia and their carers have the right to be provided with accessible information and the support they require in order to enable them to exercise their right to accede in f inales which preserve them.People with dementia and their carers have the right to live as singly as possible with access to recreational, leisure and cultural life in their community.People with dementia and their carers have the right to full participation in care needs assessment, planning, deciding and arranging care, support and treatment, including advanced decision making.People with dementia and their carers have the right to be assisted to participate in the formulation and implementation of policies that affect their well-being and the exercise of their homophile rights.People with dementia and their carers have the right to be able to enjoy human rights and fundamental freedoms in every part of their daily lives and wherever they are, including full respect for their dignity, beliefs, individual circumstances and privacy.Public and private bodies, volunteer(prenominal) organisations and individuals responsible for the care and treatment of persons with dementia shoul d be held accountable for the respect, security and fulfilment of their human rights and adequate steps should be adopted to discipline this is the case.People with dementia and their carers have the right to be free from variation based on any grounds such as age, disability, gender, race, informal orientation, religious beliefs, companionable or other status.People with dementia have the right to have access to appropriate levels of care providing protection, rehabilitation and encouragement.People with dementia have the right to help to attain and maintain maximum independence, physical, mental, social and vocational ability, and full inclusion and participation in all aspects of life.People with dementia and their carers have the right to access to opportunities for community teaching and lifelong come uponing.People with dementia have the right to access to social and legal services to enhance their autonomy, protection and care.People with dementia have the right to he alth and social care services provided by professionals and lag who have had appropriate training on dementia and human rights to break the highest quality of service.People with ternary impairmentsMultiple disabilities are a disability category under IDEA. Children with eight-fold disabilities have two or more disabling conditions that affect learning or other important life functions. To qualify for special education services under this category, both of the students disorders must be so significant that her educational needs could not be met in programs that are designed to address one of the disabilities alone.Symptoms and signs of denary impairmentsPeople with severe or multiple disabilities may exhibit a wide range of characteristics, depending on the combination and severity of disabilities, and the persons age. There are, however, some traits they may share, includingLimited speech or communicationDifficulty in base physical mobilityTendency to forget skills through di suseTrouble generalizing skills from one situation to another and/orA need for support in major life activities (e.g., domestic, leisure, community use, vocational).It is a cross-classification of disabilities that involves significant physical, sensory, intellectual, and/or social-interpersonal performance differences. The need for extensive services and supports is evident in all environmental settings.ImpactsFor the clients themselves, they may be suffered the Discrimination from others, they may have the pinch on themselves, so there should be a positive person to care them. And for their family, they are going to have a long-term twinge from the society and they may have some problems with the finance.The consequences of the People with multiple impairments in relation to individualFor the clients themselves, they may be suffered the Discrimination from others, there are multiple stresses on this client because they have more than one kind of impairment. There should be a pos itive person to care them. clog up and encourage them to have a good mood in order to let them getting heal. People with multiple impairments can become deeply sad, fearful and/or angry. Sometimes their behavior becomes a challenge for people who care for them.The consequences of the People with multiple impairments in relation to their familyThe family of the people with multiple impairments will find it is very hard to care for the patient. And they may feel distress, frustration, guilt, grief and loss, exhaustion, annoyance, frustration and anger. They are facing lots of problems with the patient. They will have the very heavy stress from the caring process and the society or the people around them. So it is important to comfort the family while caring the client.The consequences of the people with multiple impairments in relation to the carersAs a carer, we are likely to experience a range of very different, and often quite extreme, feelings. Some feelings commonly experienced by carers of people with multiple impairments include distress, frustration, guilt, grief and loss, exhaustion, annoyance, frustration and anger. They are at increased risk for burden, stress, depression, and a variety of other health complications, the effects on caregivers are diverse and complex, and there are many other factors that may exacerbate or ameliorate how caregivers react and feel as a result of their role. So the caregivers are supposed to relax and do not take it so hard, they need to find some ways to decompressThe way to reduce the stresses for the individual, family and carers.For all of those 3 kinds of people, they can get help from relax, they are supposed to have the Quality sleep and rest, Quality relationships. They need to be aroma safe and secure. And the sense of connection to the family and community should be nice. For the carers themselves, they have to learn how to enjoy themselves and get rid of stress. Individuals and families can be both communic ate the treating process and the good things. They will be getting better when they get encouragement.The diverse dynamics of the familyDifferent family may act differently in response to coping with an individual with multiple impairments. Some family member may feel resentful or angry while others cope by seeking support and information. And others may simply fall into a place of denial and avoid the situation. Caring for a family member or friend with multiple impairments can be both a very rewarding and challenging experience. It can also be very physically, emotionally and financially demanding and affect our lifestyle and life choicesCaring for someone with multiple impairments impacts every aspect of daily life. As a patient loses ones ability after another, caregivers face tests of stamina, problem-solving, and resiliency. During this long and difficult journey, communication diminishes, rewards decrease, and without strong support, caretakers face challenges to their own we ll-being. Maintaining emotional and physical fitness is crucial. Preparing and protecting yourself, working to understand your loved ones experience, and embracing help from others can minimize the hazards and enhance the joys of your caregiving experience.The code of rights for the people living with multiple impairmentsThe people with multiple impairments should always be treated with respect, including respect for your culture, values, beliefs and personal privacy.No-one should withdraw against the people with multiple impairments or push you into doing something or making a decision that you are not comfortable with.The care for the people with multiple impairments and treatment let you live a dignified, independent life.the people with multiple impairments have the right to be listened to, understood and receive information in whatever way you need. Where possible, an interpreter should be provided if you need one.It is your decision whether to go ahead with treatments or not and the people with multiple impairments are able to change yourthe mind at any time.In most situations, the people with multiple impairments can have a support person of the choice with the people with multiple impairments if he/she wish.

Factors That Affect The Achievement Of The Operational Excellence Business Essay

Factors That Affect The Achievement Of The Operational faithfulness moving in EssayOne of the or so competitive industries in the knowledge domain is the pharmaceutic assiduity. For a long time, the operation of the pharmaceutic companies has been subject to scrutiny, especi exclusivelyy by the political science of each field of operation. The underlying reasons for the strict attention allow in the cost of medicines and doses unattached for purchase, the reduced life cycle of mathematical product developing, the technological advancements which impact operations and the nature of the health c atomic number 18 systems. More over, the pharmaceutic labor, banalized other backupes, is affected by factors such as the issues of human imaginations suppuration and sensitivity to shade and diversity. In fact, they all render influenced the birth of the smart and improved meaning of operative excellence.The increasing demands for an improved productivity and manufacturin g be open been the growing concern of pharmaceutical companies right away. The involve to meet the lush ever-changing require of the market for a much lavishlyer standard and quality drugs has besides resulted to change magnitude expectations not only from the consumers entirely from all stakeholders (suppliers, investors, employees and the government). However, the quest for a much potent product is a truly signifi fuckt issue. The common goal is to reduce the attrition array in bringing mod medicines in the market as well as in creating a fair and efficient standard in choosing the best pharmaceutical f vagabondrnity to award the patent. As more(prenominal) and more consumers argon becoming concern of the drug s its short-term efficacy and its long-run side make, marketing for the drug has also be line up more sophisticated and active. In this view, the operating(a) processes and engineering for pharmaceutical product has come to a sunrise(prenominal) level. IntroductionThe old adage Health is Wealth is in the main true nothing can be more valuable than creation healthy and alive. The objective of the government of e actually country around the dry land to provide its public with health c be services has been notable but still incomplete and unwinnerful. Not only the poor and underdeveloped countries are the ones having problems with high health check costs and insurances but even the developed or economically strong countries. There are many an(prenominal) factors that contribute to the in talent of the government to properly provide for its great deal in terms of health misgiving, for one, the health service is truly an expensive part of man s need to live and the costs of services are high beca economic consumption medical equipments are expensive not mentioning the maintenance cost of every hospital. Hence, the need to secure the health benefits of the mickle has father the motivating factor for the government to demo in an agenda, its health objectives for the American Nation.Statement of the ProblemThe pharmaceutical business is one of the most great industries in the world. The benefits people make water from the results of query and development conducted by the pharmaceutical firms, which take on discoveries of the cures for many diseases, and the lessen time required to treat the patient that lead to saving of lives, cannot be equated with money. Even the wealthiest soulfulness on earth gets sick and requires medicine. Sick people and their families are happy whenever they learn that in that location is a cure for their diseases and that their lives are lengthened by the healing power of medicine. However, with the high cost of production, fast(a) competition, and the ever-changing government legislations, pharmaceutical companies are facing major challenges. mend the time to bring the pharmaceutical product in the market quickens, the run a risk involved in the cost recovery and i ndustry survival increases for many pharmaceutical companies. In this view that the selected problem is titled Achieving Operational Excellence in the pharmaceutical Industry.The selected question problem values the operational and engineering processes utilize by the pharmaceutical companies. Achieving operational excellence requires that pharmaceutical companies understand the factors which may affect their operations, such as the changing human resources relative to ethnic diversity and manpower bulge outsourcing, the impact of the environmental factors, which may include changing government legislations, market trends and future opportunities and threats and the future trends, operational systems, collaborative efforts (merging, tie-ups, etc.) that give all make a difference in the midst of weighed down competition and highly selective customers. The selected statement of the problem hopes to reveal the doable solutions to the challenges and in the end provide a wider p erspective based on the data presented, evaluated and analyzed.Purpose of the StudyThe goal of this search is to find out the relevant factors that affect the achievement of the operational excellence of the firms in the pharmaceutical industry. It also hopes to learn and understand what makes a successful pharmaceutical company and how operational excellence can be achieved.Significance of the StudyThe findings of this research leave alone serve as useful nurture on understand the pharmaceutical industry as a whole. Readers will also have a full view of the pharmaceutical industry from its begging up to the current time. look forers of the same issue will have a cover basis of analyzing and evaluating for the same. pharmaceutical companies will have a wider perspective of the industry where they exist, providing them with more information useful in the creation of marketing st stridegies and operational upgrades. The government will also benefit from this research because, it will present a different interpretation of the light upon factors affecting the pharmaceutical industry. look QuestionsThis paper looks into the avocation issues(1) How should the current pharmaceutical industry be depict in terms ofa. Operational processes and engineeringb. pharmaceutic applied sciencec. unsanded product development, Research and development and Product life cycled. end product systems (total quality management, total productive maintenance, etc.) ande. Factors that characterize operational excellence (best practices)?(2) How are performances evaluated?a. The Porter s diamond concept in a pharmaceutical setting(3) What are the challenges of achieving operational efficiency in view ofa. esthesia to culture and diversity with respect to a unified corporate cerebrationb. Globalization andc. Human resources development?(4) What are the expected future trends? background knowledgePharmaceutical firms are reason according to the nature of their business opera tions they are the research-based firms manufacturing-based firms and a combination of research-based and manufacturing-based firms. Characterized by its two distinct utilisations research and development (RD), and manufacturing, the pharmaceutical industry was reported as a $600 one million million million worth of gross sales in the year 2006 (economywatch). Specifically, at that place was a 7 per cent increase on the sales of prescription medicines global or a total of $602 one thousand million based on the report of round major pharmaceutical and medical information firms. These pharmaceutical firms are either, earlier engaged in Research and Development (RD) alone, studying diseases and advancing drugs and medicative potency while other firms focus on the drug manufacturing process. Large, financially-able and world renowned pharmaceutical companies engaged in both activities.The US is considered as having the number one pharmaceutical market and an increasing trend in the pharmaceutical industry all over the world. According to statistics the highest recorded annual sales of pharmaceutical products and services in the US alone is $252 billion and increases at around 5.7 per cent annually (economywatch). According to a pharmaceutical industry report, the leading countries in the world in terms of capableness market are India, China and the coupled States. The report specifically declared that The report proved that there is an increasing demand and market for the pharmaceutical industry because of the increasing health awareness of the people all over the world.Literature ReviewMarket intelligence data from IMS Health, a research company providing on pharmaceutical and health care industries proved that in 2002, the estimated worldwide sales for prescription drugs was about $400 billion and that the United States phthisis on prescription drugs in 2002, was roughly 200 billion dollars which accounted for around half of all sales worldwide. Bu t despite this high costs, the United States ranked as the 21st rate on infant deathrate in the world, way below Greece and South Korea and only a raciness higher in Poland. Also, the United States ranked at the 17th rate in terms of life expectancy all over the world. The research agency also reported that in 2008, the US prescription drugs sales had amounted to a whopping $291 billion dollars every year (sourcewatch).In this view, the challenges face up by the pharmaceutical industry around the world are big (Sherk). One of the main reasons is the pressure of bringing down the prices of medicines and drugs that are considered contributive to the escalating costs of the health care services (Sherk). The cost of health care in the United States is generally double compared to other developed countries in Europe such as Britain, France and Germany. (yahoonews) Furthermore, the United States has reportedly spent 7, 290 dollars per person in the year 2007 but provided no meaningful advantage in terms of quality of care, and placed far behind the averages in the key indicators such as the infant mortality and life expectancy rate compared to the previously mentioned countries. The proposed health care reform in the United States, includes the evaluation of the drug costs and the possibility of creating legislations that will regulate the operations of pharmaceutical companies.Research DesignThe research physical body that will be apply to evaluate and answer the selected problem titled Achieving Operational Excellence in the Pharmaceutical Industry is qualitative research. The decision to use the qualitative research design was based on the following factors limited time available, and also, the use of standby data. In order to answer the general and specific questions, the tec uses the descriptive research as a type of qualitative method of research. The researcher gathers secondary data from previous researches, statistical reports, surveys, demographic i nformation, and online resources. The data poised are listed, sorted and analyzed in order to answer the problems undertaken.FindingsThe following are the findings that were gathered using secondary information, specifically from previous researches, statistical reports, and other sources.(1) How should the current pharmaceutical industry be described in terms of(a) Operational Processes and Engineering in the Pharmaceutical Industry dose Approval and Registration ProcessAs applyed by the food medicine and Cosmetic Act, the strict compliance of the law should be notice in all stages of the operational process and engineering in the Pharmaceutical Industry, primarily, in the registration (FDA, 2010) The Food Drug Administration (FDA) s innate mission is protect the public health is the collection of this information, which is used for important activities such as post-market surveillance for serious adverse drug reactions, reappraisal of drug manufacturing and processing facil ities, and monitoring of drug products imported into the United States. Comprehensive, accurate, and up-to-date information is fine to conducting these activities with efficiency and effectiveness. (FDA, 2010)(b) Process Analytical technologies (PAT)One of the new systems that are being used in the pharmaceutical industry is cognise as the Process Analytical technologies (PAT). The term Process Analytical Technologies (PAT) has been used to describe a system for designing and controlling manufacturing through and through well timed(p) measurements (i.e. during processing) of critical quality and performance attributes for raw and in-process materials and also processes with the goal of ensuring final product quality. The PAT initiative focuses on building quality into the product and manufacturing processes, as well as continuous process improvement. (pharmainfo.net)c) Industry operational ProceduresThe pharmaceutical industry, just like other industries uses the US standard o f bill GAAP (irs.gov). Pharmaceutical companies have to apply for the registration of their newly notice drugs or medicines. Before a drug can be tried and true in people, the drug company or sponsor performs laboratory and savage tests to discover how the drug drubs and whether its likely to be safe and work well in humans. Next, a series of tests in people is begun to tempt whether the drug is safe when used to treat a disease and whether it provides a real health benefit. The process must be based on the steps set by the Food and Drug administration of the country of operation. The development and Approval Process of Drugs in the United States is believed to be the safest and the most advanced pharmaceutical system in the world. Another unique operational process used by the pharmaceutical companies is in the area of marketing. opposed, the traditionalistic selling and buying area of many products, selling drugs is a very complicated issue. Before companies can sell drugs , they have to seek commendation and license from the FDA. Marketing in the pharmaceutical industry is commonly through salesmen.(2) How are performances evaluated?Porter s Five Forces of Industry Analysis of the Pharmaceutical IndustryThe pharmaceutical industry has high barriers to entry, primarily because great is capacious in this business. The need to allocate heavily on research and development is highly important if one will enter this industry, not mentioning high threat from government policies, and longer or no rescue on investment. The supplier power has low impact because material supplies are whole for pharmaceutical companies alone, and shelf life of chemicals is longer than any ordinary supplies. emptor power depends on the kind of medicine being produced, if the medicine has no other substitute, then buyer power is low, and vice versa. The threat of substitutes is also low in the pharmaceutical industry, because although generics have been gaining popularity an d acceptance, still, many consumers believe mark medicines are more effective. In terms of competitive rivalry, the pharmaceutical industry is highly competitive. Mullins (2006) reported that the industry was overpopulated and not one company has more than 5 percent market share. In addition, market growth rate is also minimal.(3) What are the challenges of achieving operational efficiency in view of (a) esthesia to culture and diversity with respect to a unified corporate sentiment (b) Globalization and (c) Human resources development.The changing landscape of business due to the forces of the new and changing environment have become the major influences in the agency in which leading function in the cheek is done today. Unlike the traditional leadership process, global leadership extends its functions to new horizons and length that increased values for businesses, hence an increased risks. Leaders are more flexile and multi-skilled today. Thus, new business horizons that of fer new and improved opportunities are available for global leaders to take advantage of. With the right attitude and qualifications, success in the business is possible for global leaders. The secrets however, lie on the ability of the leader to understand these new concepts and challenges.Human Resource Management or HRM is an activity that is focused on recruiting, managing and developing the people in an plaque. This function also deals with the issues regarding employee compensation, hiring, performance evaluation, safety, development, wellness, communication, training and development. The human resource management in the organization plays a big role in making strategical and coherent approach to managing the company s most important asset its people. The HRM function is seen by most companies as a major alter factor in aligning specific assignment to the employee s capabilities. In doing so, the company will be able to efficiently achieve its goals at a minimum required r esources. Factors that affect staffing and staffing turnover are considered to be a big problem faced by human resource managers. Pinkerton (2001) made an effort to know the reasons that influence the staffing needs of hospitals. The answers vary depending on the hospital, the top three include, teamwork or no teamwork/unit cohesiveness, chaos factors impacting the deliverance of nursing care and effectiveness of communication.The factors affect staffing which can be categorized under external and internal. The external factors include the level of education, the prevailing attitudes in alliance (the kind of attitude toward work), the many laws and regulations that directly affect staffing, the economic conditions, and the supply of and demand for the manpower outside the enterprise. Organizational goals, tasks, technology, organization structure, the kinds of people employed by the enterprise, the demand for and the supply of managers within the enterprise, the reward system, and variant kinds of policies are the internal factors which may affect staffing. For example, the use of high technology in most industries requires extensive and intensive education and training.The organization s ability to effect change is largely affected by the organisational culture because it serves as the basic nature and characteristics of the whole organization. Where organizational culture is deep seated and forms underlying subcultures, it is more difficult to change and and so sets a more challenging role for leaders who want to implement change in the organization. The tendency to resist change is higher when organizational culture is more cohesive and more symbolical. Since the organization comprises of people that have different behaviors, talents, skills, knowledge, values, personality and many other differences, working together they come on terms to manage each other s differences. gardening is the behavior which formed when the people in the organization meet and concord verbally and nonverbally and creates rule for doing the task. (Heathfield)DiversityThe diversity in the organization was previously seen as a negative factor, but in today s environment where change is inevitable, it adds up to the company s flexibleness in order to survive the competition in the market. In an organization where diversity is high, the leader must understand and know how to deal with it and use them effectively as a competitive advantage. Nowadays, many organizations employ assorted group of employees because they want to create a unique culture which adds up to the value of the organizational workforce. Common diversities in the organization include racial mixes, foreign workforces, women on the job, and disabled workers.(4) What are the expected future trends?major(ip) transformations are occurring in the delivery of healthcare worldwide. Medical and healthcare technologies are increasingly impacting the clinical as well as the administrative dimensio ns of healthcare care delivery. Innovations introduced in the last decade have created accumulated effects that will be compounded with the continuing technical progress in medicine. Areas such as telemedicine, telehealth, computerized medical records, e-health and use of the Internet in B2B and B2C applications in healthcare are some of the milestones in the almost total revamping of the healthcare landscape. Medical and healthcare technologies are already transforming the operations, design and mission of hospitals. In this regard, the challenges for the future are an exciting opportunity for study, reflection, planning, and intervention. technology assessment (TA) arose in the mid-1960s from an appreciation of the critical role of technology in modern society and its potential for unintended, and sometimes harmful, consequences. Congress commissioned independent studies by the theme Academy of Sciences, the National Academy of Engineering (NAE), and the Legislative Reference ass istance of the Library of Congress that significantly influenced the development and application of TA. These studies and further congressional hearings led the National Science Foundation to establish a TA course and, in 1972, Congress to authorize the congressional Office of Technology Assessment (OTA), which was founded in 1973, became operational in 1974, and established its health program in 1975.Another factor that is considered as a threat not only to pharmaceutical industry but all industries is the globalization. Globalization has been creating impacts to respective(a) industries and individuals. The possibilities associated with it are countless. Hence, it also poses higher threats to many. Globalization has influenced major transformations on the organizational structures, and the processes of firms whether locally or internationally operated. Globalization also redefined the functions and roles of the intermediaries. Distribution of products has become entirely depende nt on the intermediaries. Companies are trying to lessen interaction costs and because of this, have outsourced services from other countries to take advantage of the economies of scale. industrial sectors have to undergo extensive structural changes which become more viewable in the sectors that are based highly on the advanced technologies. Examples include the car industry, pharmaceutical industry and the telecommunications, among others.Conclusions and RecommendationsBased on this research study, there are several lessons which could be learned from the evaluation of and analysis performed in the pharmaceutical industry. Primarily, the safety and security of our lives depend on the ability of the FDA (Food and Drug Administration) and, CDC (Centers for Disease Control and Prevention), the AMA (American Medical Association) and APA (American Pharmacists Association), to screen and select the safest medicine, drugs and vaccines. The criteria set should forever and consistently be tested, proven, and communicated to all industry players. Second, the operations of the pharmaceutical companies are generally affected by the changes in the industry. The relative amount of information available in understanding or describing a situation can significantly help in making valuable decision regarding the business operation.Third, the threat on the human resources because of globalization is considered a very critical issue even in the pharmaceutical industry. In the situation where there is limited available resources, need is high for an effective HR planning. maximise employee performances through devising appropriate training is also vital to the needs of the company. The approach will also help in maximizing the return on investment of the any organization s human capital and minimizing the financial risk is the main objective of human resources. Finally, it should therefore be concluded that the operational excellence in the pharmaceutical industry will only be achieved when companies learn to adapt the changes and developments brought about by the globalization.

Masculinity In Hong Kong Action Films Film Studies Essay

Masculinity In Hong Kong Action Films Film Studies EssayThe occupy of icon masculinity still t fires to concern itself with the products of local society. The focus of the set about is to equal a close approach to masculinity in Hong Kong cinema. Chinese emeritus traditional genres such as Kung Fu, historical costume drama, and the Chinese opera had been the staples of Hong Kong cinema misdeedce it has been established (Kei, 1994). This essay analyses twain trains of a uniquely Hong Kong perspective. The two main titles referred in this essay atomic number 18 A Better tomorrow ( cost, 1986), the mobster image that revitalized the delineationmaker s cargoner by the success of his first mobster movie, and metropolis on bring up ( play, 1987), produces a city on fire sea parole of impudently type of hush-hush operator movie early time in Hong Kong. Each celluloid represents typical and raw Hong Kong gangster movie on earlier 80s. both(prenominal) of these two directors created a raw(a) gangster and cop genius in look ats, they defined a local cultural identity in Hong Kong film industry and influence the stylist of west action cinema (Vesia, 2002). This essay approaches the study of masculinist text of my emotion tone and feels of the two films, and attends to address political theory of male descent and gender difference as a masquerade.A Better Tomorrow tags with Hong Kong gangster leaders whose name be Ho (cast by Lung Ti) and pock (cast by Yun-Fat cabbage), and Ho was double-crossed and arrested in Taiwan. After he was released, Mark tries to persuade him to go to their hoar criminal life. be posts, Ho is much concern about his brother Kit (cast by Leslie Cheung) who is a Hong Kong practice of law officer, and his responsibility for the remainder of their stick. And Ho s gang leader was replaced by his old subordinate, Shing (cast by Waise Lee) who plays brother against brother Ho. At the end, Mark and Shing die, opus Ho and o utfit were reunited and head back to prison.City on Fire concerns Ko Chow (cast by Yun-Fat Chow) is an underground agent who betrayed his criminal jock to the police force. The criminal boss Fu (cast by Danny Lee), whose gang is terrorizing the town with legion(predicate) robberies and the forthcoming, big robbery of a jewelry store. Ko and Fu become whizzs as coss mission is again to go underground to Fus gang and buckle under dilates to the police about the robbery. so the criminals could be arrested and sent to prison. Unfortunately, Ko notices it is too late to undo what hes done again, again he finds himself betraying a friend, but this time the results be more horrific.As described above, these are some features in reciprocal in these two films both of them are extremely violent both starred by Yun-Fat Chow who was the well-nigh famous Asian character both revolve al virtu each(prenominal)y the fiction of gangster and police and both are talk about undivided comp anionship and commit custodyt of male character. It is possible that gangsters and cops have something in common in our real world. It is overly possible that an undercover has true familiarity with a gangster while they are in the black eye target of the law. Furthermore, It is not surprising that the descent surrounded by gangster and cop put up reduced by true friendship. It is clear that the brave police and thriller gangster other side of them. If the main ele custodyts are cop and gangster, thusly it encompass the deep inside of unknown natural character is the paint evidence to solve.However, from Man on the Brink (Cheung, 1981) to On the Edge (Yau H. , 2006), undercover film seems trapped in a frame set an undercover agent end with a tragic death. However, there is no specific detail on describing the agent s mental activities that how to convince themselves to become an undercover agent, while they have a mission. Most of this genre of film tho pays attention to the strategy and courage of agent. There is not on the characters imposter on deep inside activities. While the undercover film has already manipulated by director nowadays, City on Fire is one of the mutation or a stage that undercover film goes to a high levels of representing. It is earlier to be accepted by the audience as these undercover become a real part of film. Ringo Lam and John apostrophize both are likely to represent the brotherhood in the film. beg s undercover philosophy mind is If there is something reason whitethorn not from themselves, they have to do is to do , while Lam s philosophy is I would rather not to do it instead of Betraying my friends . Furthermore, the brightness and color of these undercover films are cold, dally s film presenting a romantic atmosphere, whereas Lam invariably manifest warm and funny scene. For example, the wear police chase scene in City on Fire, the primer coat music is the allegro of Christmas songs, and originally the preceding is very depressed. These two directors are also goodness at editing some humor and diagram on the film, such as By throwing food to attract ravishing women pay attention to small scene to rich a film so-called giant inside, detail outside in Lam s film.In my opinion, the difference between Lam and Woo is the theme of from each one film. Woos theme always is to strike back for friendship, brother, and lover, and this routine will never end with. While Lam s theme is to bury alive with the dead for friendship, brother, and lover, it is enough for regretless while lives. Different from Woo s films, they tended to romanticise the gangster figure without any moralistic judgment (Vesia, 2002). It is the main reason Lams film conveys this message to audiences. Finally, the myth letter in City on fire, Ko s lover to leaves audience an message that does she wait for Ko in Hawaii? Instead of the issue if China is relevant to lead and scout Hong Kong s future tense later on 1997. Then, it can be utter that nothing is perfect to make up to audience taste. Thus, Lam s films earn the success of Yun-Fat Chow, and Chows performance is accomplishing Lams film.Yi-Qi ( mandate of trades union) in Hong Kong gangster films politys such as brotherhood, filiality and loyalty are not just one sign to look at the masculinity onscreen, it also is familiar to the Chinese cinema which links to the favorable holy effect both in the film and the society outside. Fuery points that law order signs as well as provide rules of exclusion, combination, and hierarchy (Fuery, 1997). As such, code in the kindly order of Chinese films representation is a hearty justice and the moral domain in spite of appearance different national and non-national settings (Berry Ann, 2006). It represents the symbols of heathen heritage and the myth old tradition of a nation.The concept of YiQi ( ) is Code of Brotherhood which includes Loyalty (Zhong ), Filiality (Xiao), Benevolence ( Ren ), Brotherhood (Yi ) to explore the wide debates around societal structure, gender and nation in Chinese nation. These codes are the substance of Chinese law and custom that the ordered nation refer to the debates within the Chinese moral health and local structure of the social problems. The Code of Brotherhood reflects reciprocal family-based relationships which with male privilege (Berry Ann, 2006). The family code think to the social and nation networks of power. It focuses on codes of behavior between subject and ruler, between father and sons, and between brothers.These rules often operates the Chinese mythic underworld-JiangHu ( )-it have its own rules in this world but it does not exist in the real world. There, Woo s gangster movies value Chinese traditional rules of family and friendship in Hong Kong modern society, brotherhood involves strong customary rules that translate into a get of genres, from revolutionary comrade films to soldierly arts and gangster movi es. And the code of watch applies to heroes on both sides of the law. In A Better Tomorrow, Ho and Mark are at ease only in all-male societies the gang, or the hack company in where Ho found the job. On the family ties, Kit refuses his gangster brother because of Ho s responsibility to their father s death, so Mark becomes Ho brother, in other words is to replace kit to be a substitute. Ho is trying to be a good man, but kit does not trust him. They father die for his son Ho. and Ho save Shing, Mark is crippled when he is revenged Ho. It is a sensitiveness that is well illustrated through Woo s characterization of Mark as a humble hero representing traditional codes of honour and bravery in a modern era (Vesia, 2002). Then, Ho and Mark steal the read for Kit to risk their lives. This is a chain rule around Mark, Ho and Kit indicates the Code of Brotherhood that is typical Chinese hero.Furthermore, the Code of Brotherhood has mythic status in terms of the contemporary Chinese de stination and the order of society. Joseph wrote that the rules such as Filiality (Xiao) were right in Chinese old tradition (Needham, 1954). In City on Fire, the protagonist undercover employs death defying stunts. But, Lam ends his gangster film for memories the death of Ko Chow to penalize criminals. In the last battle scene, Ko said to Fu (Danny lee Sau-Yin) I was an undercover agent, please shoot me, you still have time for it, because i own you too much. It was a kind of humanitys struggle with the friend and brother. They opposite position have been upgrade to a new level of the friendship. Ko resists on his bottom line of the distinction between gangster and undercover. But its a human debt on the friendship have never been fixed. Thus, at the end of City on Fire, Kos death perhaps is the better way to end his friendship debt. Because Ko was suffered by betrayed a friend earlier, his nightmare of intense fear, horror and distress feeling leads to He always blames himself d ue to betray his friends. It perhaps to arrange this death of character is to let off the injustice, violence as ongoing features of society. Both of the death of Mark and Ko is to the result of Loyalty (Zhong) to his friendship. And also it explains the Righteousness (Yi) why the true friendship is worth to risk their lives or sacrifices themselves for their brothers and friends.Finally, the Code of Brotherhood of Chinese masculinity, in other words, male bonding is one metaphor way to presents the Hong Kongs future relationship with China. Specifically, these films seem to represent the fantasy of a relationship between equals (analogous to a relationship between men) rather than between unequals (i.e., between men and women) and it is a fear of China that makes the homoerotic element such a compelling fantasy (Sandell, 1994). Male and man power can be seductive and attractive indorse to focus on the representation of Chinese cinema.the balance between sexual difference in cinema s which indicates fair relationship of brotherhood and unfair relationship between men and women. In A Better Tomorrow, The result to plot only one woman who is Kits wife and she is facing sharing suffering, and hinges on a male ethos of loyalty. In contrast, City on Fire is around the theme of loyalty and friendship between gangster and undercover agent at opposite position of the law. Kos lover appears in the film is slowing down the tension of the undercover, and it prevents the universal progress towards in terms of approach the reality of personal inter-relationship. Thus, it is no-hit to treat women in similar depth. When a woman is discussed, it becomes a wider study in Chinese cinema.Influence to the westReid point out that Woo has remade traditional martial arts genres by replacing swords and knives with guns (Reid, 1993-4). Woo said his action film was most exalt by earlier Hong Kong martial arts. Especially his mentor Zhang Che, his film is not only representing stron g masculinity, loyalty, knightliness figures on the martial art action, but also he is furiousness on the symbolic slow motion to express this movement. However, Woo s stylistic influence upon Reservoir Dogs (Quentin, 1992) and True Romance (Scott Tarantino, 1993). Quentin also inspired from City on Fire (Lam, 1987) and it is upon the themes of city on fire season to express his passion and admiration to Hong Kong filmmakers. One might certainly dissolve from this that Hong Kong action film industry achieves an oversea and cross-culture to such international visibility. Therefore, Kung Fu was the most popular elements both in Eastern and Western films.Kill broadside I II (Tarantino, 2003-4) describes how a woman overthrows patriarchal authority to revenge for her daughter. In the coffin box, Beatrix Kiddo (Uma Thurman) was bury by Budd (Michael Madsen), then she use her teaching from Chinese martial arts master Bai Mei (Chia Hui Liu) and gather all strength on one hand for b reaking the coffin and then she can escape outside. Within the martial artists performance, clarity can be achieved not only through the precision of the movement but also an effort to focus the entire bodys energy in each communicate (Yau E. C., 2001). To compare earlier Hong Kong film patriarchal society, Tarantino s film represents the penalization of patriarchal hegemony. His work aims to explore the origins of the cool and the way in which images (or reputations) are echoed in the realm of popular culture (Poleg, 2004). And he is exhibitioning that there is no different between man and woman in our modern society. It also critics the corresponding to patriarchal authority of Hong Kong cinemas to arousing people conscience and social justice then seeking for the solution of the gangster in sin city. For instance, the yellow suit of protagonist Beatrix Kiddo in Kill Bill is to show his admiring to martial arts master Bruce Lee.ConclusionChinese cinematic notional provides a r ich store of regimes of justice and power through which men relate to, and fight with each other (Berry Ann, 2006). Both Woo and Lam are dealing with the tension of loyalty and friendship and social order of Chinese traditional heritage, and also apply to heroes on both side of law. The difference is the theme Woo s revenging and Lam s bury for friendship, brother, and lover, they heroes from both side of the law is to justice the male bonding related to the unsteady society tone and the anxiety of Hong Kong s future after recover it in 1997. Both Woo and Lam focus on the relationship of male to indicate the changing representation of Hong Kong cinema. They are the new wave pioneering directors in order to balance the theme of the human relationship and entertainment with vision and sound effects. Moreover, western critics and film scholars also began to engender Hong Kong action into mainstream theatre cinema seriously and made many key figures and films part of their canon of w orld cinema. In short, Hong Kong cinema defines a new genre of hero image in action film valuing traditional distinctive feature of patriarchal authority. It also produces superstars such as Yun-Fat Chow who became a worldwide popularity star due to his cool performance. However, as the festering of the modernization, directors pay attention to these women who are economic independence and autonomy character in order to appealing audience taste of female onscreen.

The History Of The Electoral College Politics Essay

The History Of The electoral College Politics EssayThe electoral College is a body of cullors chosen by the political parties in each carry to choose the President of the U.S .The electoral College was created because the Framers were wary of giving the raft the causation to directly elect the President. They felt the good deal were not educated plenteous to elect the national leader. The Founding Fathers established the Electoral College as a compromise amid preference of the President by a take in Congress and preference of the President by a universal choose. The presidential alternative became a collection of state elections, which would get out in a national scene. The Electoral College consists of 538 electors, which atomic number 18 divided up between the states according the number of representatives in the House, plus 2 votes for each of the Senate members. The political parties pick electors for each state. A volume of 270 electoral votes is required to ele ct the President. Article Two of the Constitution states, Each state sh all appoint, in such(prenominal) manner as the Legislature thereof may direct a number of electors, check to the whole number of Senators and Representatives to which the States may be entitle in the Congress. (U.S. Constitution,art.2,sec. 2.)Although ballots list the names of the presidential basedidates, citizens do not vote for the President directly. People are suffrage for an elector in the college who, in turn, leave vote on the states behalf. These electors votes will decide who the President is, and not necessarily the pop vote. These presidential electors in turn cast electoral votes for the presidential Candidate.The winner take all frame, also known as the plurality voting system, awards all of the Electoral College votes to the winning presidential aspect from each state. In this voting system the single winner is the mortal with the intimately votes, there is no requirement that the winner gain an living majority of votes. The winner will take all the votes and the loser will get none. For example, all 55 of Californias Electoral votes go to the winner of the touristy vote in the state election, even if the margin of victory is only 50.1 percent to 49.9 percent.The Electoral College system plays a role in how Presidential Candidates campaign by making the candidates focuses all their attention on acquire electoral votes. Parties focus on the electors because they exact to convince the electors to vote for them not so much as the people themselves The parties also convince state on large states that have more electoral votes than the junior-grade states. Big states with the intimately electoral votes are the key to winning the election so they boil down their power in them.Most commonly, Presidential candidates also heavily concentrate their attention on a handful of closely divided sphere states, or swing states. These states dont have a lot of electoral vot es besides dummy up will decide the out scrape of the race because they do not favor a particular political party or change their preference each election. In these states, campaigning will have the most impact since a small change in popular votes could result in a big win in electoral votes. Consequently, other(a)wise states considered either safe or hopelessly disconnected and are mostly ignored in the campaign. In the elections, small states and swing states are overrepresented in the Electoral College while leaving the rest of the nations voters on the sidelines.The Electoral College hinders tertiary party candidates because the tertiary party is over shadowed by the majority vote, so 3rd parties almost never get electoral votes. master take all minimizes the influence of third parties. However, this can also decline fair representation to positive 3rd parties. For example if a 3rd party gets 25% of the votes in one state those votes does not content because of the w inner take all majority of the Electoral College. The power of a 3rd party is in spoiling an election by taking votes from one of the major parties that is most like it. To avoid this, major parties may take up causes and ideas from the 3rd party to keep them from becoming in addition popular.Although, 62% of people said they would change the electoral college system, over the recent 200 years over 700 proposals have been introduced in Congress to repossess or eliminate the Electoral College, (Office of the Federal Register, Electoral College oft Asked Questions. Archives) scarce very little has been done to change it. The Electoral College has not been abolished because the small states and swing states would have to turn back up power and be equal to everyone else. The House of Representatives passed an amendment in 1969, backed by President Richard Nixon, to directly elect the president (niemanwatchdog.org Is it time to do away with the tyrannical Electoral-College system ?) solely the amendment was blocked in the Senate, in part by Southern senators who contrary any changes they saw as weakening states rights.The Electoral College system can end up putting in office someone who lost the popular vote, which is contrary to democracy. For example the Presidential election in 2000, George scrubbing won the electoral votes and Al Gore won the popular vote. (Oyez) The fairest rootage is to have a Presidential election solely on a popular vote. This will solve the disconnect of the American people and election process. Candidates would need to care about voters across the nation, not honest opened voters in a handful of swing states and the large states. Almost all Americans think that democracy is oneness Person, One voting, and all votes are reckon equally, but The Electoral College violates that fundamental American principle. Some people do not participate in elections because they know that their vote will not matter in the Presidential electi ons.One Person One right to vote means that each person has an equal amount of representation in government. Government should be for the people, not the electors deciding the fate of the country (Annenberg Classroom). all vote, by everyone, would be relevant and equal in Presidential elections. The election should change from a winner take all system to a proportional system. The winner does not need to reach a majority, just a plurality. The candidates with the most overall percent of votes will win. This will give a stronger chance for 3rd party groups in the elections, by still having their votes count and not be outshined by the two major parties. some other improvement is the use of ranked base voting where voters order the candidates from least(prenominal) preferred to most preferred. To be practical, the top three choices could be chosen. The election is decided by picking everyones top choice and removing the candidate with the least votes. This process is repeated so th at candidate is removed and the top preferences are only counted for each elimination round. This allows a voter to pick the candidate they sine qua non the most for their top choice followed by a slenderly lesser desired candidate. And the third choice could be a main party safety candidate. This allows for a 3rd party candidate to come in and not steal votes away from a similar party. The system has been used in San Francisco since 2004. Its been proposed everywhere from Los Angeles to Modesto, but only the three Alameda County cities have signed on for it. (Williams, Lance California Watch)The Electoral College does not put forward a straightforward process for selecting the President. Instead, it can be extraordinarily mazy and has the potential to undo the peoples will at many points in the tenacious journey from the selection of electors to counting their votes in Congress, (George Edwards). The government should be for the people and the Electoral College is not since i t treats people unequally. Many American people want the Electoral College abolished, but so little has been done to improve the over-the-hill system. It makes the candidates campaign rawly, making them focusing on swing states and forgetting all other states. The winner takes all system over shadows 3rd parties giving them unfair representation in the elections. The US needs to elect Presidents by popular vote it is fair to all people. One Person One Vote should be used to ensure equality in voting. The American people should be able to choose their leader as equals.Work CitedBach, Stanley, and dogshit Maskell . Overview of Electoral College Procedure and the Role of Congress . Library of Congress congressional Research Service. electoralcollegehistory.com, November 17, 2000. Web. 7 Sep 2012. .BUSH v. GORE. Oyez. Oyez, n.d. Web. 7 Sep 2012. . scrubbing v. Gore United States Supreme Court Oral Arguments. American Rhetoric. americanrhetoric, n.d. Web. 7 Sep 2012. .Edwards III, Ge orge C., Martin P. Wattenberg, and Robert L. Lineberry. Government in America People, Politics and Policy. AP 12. Illinois Pearson Longman, 2006. Print.Edwards III, George C. (2011) (in English). Why the Electoral College is Bad for America (Second edition ed.). New Haven and London Yale University Press. pp. 1, 37, 61, 176-7, 193-4. ISBN 978-0-300-16649-1.. .Electoral College Frequently Asked Questions. Archives The Electoral College. Office of the Federal Register, 9/26/2012. Web. 26 Sep 2012. .. Electoral College (United States). Wikipedia, the free encyclopedia. Wikipedia, the free encyclopedia, 18 September 2012 at 1938.. Web. 26 Sep 2012. Fobes, Richard. VoteFair Ranking. votefair.org. N.p., 13 2012. Web. 13 Dec 2012. .Kimberling, William C.. The Electoral College . The Electoral College . N.p., n.d. Web. 7 Sep 2012. .. Is it time to do away with the undemocratic Electoral-College system?. http//niemanwatchdog.org. N.p., 13 2012. Web. 13 Dec 2012. .Leip, David The Pros and Con s of the Electoral College System. The Electoral College. US Selection Atlas, n.d. Web. 7 Sep 2012. http//uselectionatlas.org/INFORMATION/INFORMATION/electcollege_procon.phpNeale, Thomas H. . The Electoral College How it Works in Contemporary Presidential Elections . Library of Congress congressional Research Service . electoralcollegehistory.com, July 21, 1999 . Web. .. . One Person, One Vote. Annenberg Classroom. Annenberg Classroom, 02 2001. Web. 13 Dec 2012. .One Person, One Vote. One Person, One Vote. Ciros Books, Inc., 2008. Web. 26 Sep 2012. .. Plurality voting system. Wikipedia, the free encyclopedia. Wikipedia, the free encyclopedia, 2 September 2012 at 2136.. Web. 26 Sep 2012.U.S. Constitution,art.2,sec. 2.Williams, Lance. Ranked-choice voting complicates elections. californiawatch.org. California Watch, 13 2012. Web. 13 Dec 2012. .