Managing Rapport through talk across Cultures Essay

Spencer-Oatey certainly does not neglect the concept of culture in her book, the second component of the rather lengthy title, though she concedes that ‘culture’ is ‘notoriously difficult to define’ (Spencer-Oatey, 1). In support of this, she cites several authors have noted that â€Å"†¦despite a century of efforts to define culture adequately, there was in the early 1990’s no agreement among anthropologists regarding its nature,† (Apte 1994, p. 2001) Due to the ambiguity of the term, Spencer-Oatey (2000, 2) defines culture as: â€Å"†¦a fuzzy set of attitudes, beliefs, behavioral conventions, and basic assumptions and values that are shared by a group of people, and that influence each member’s behavior and his/her interpretations of the ‘meaning’ of other people’s behavior. † This definition opens up the field for several issues. At one point, culture is manifested â€Å"at different layers of depth, ranging from inner core basic assumptions and values, through outer core attitudes, beliefs and social conventions, to surface level behavioral manifestations† (Spencer-Oatey, 2). The second issue concerns the sub-surface aspects of culture as influencing people’s behavior and the meanings they themselves attribute to the behavior of other people, i. e. personality. Due to the fact that the members of a cultural group â€Å"are unlikely to share identical sets of attitudes, beliefs and so on, but rather show family resemblances,† (Spencer-Oatey, 2), she puts forth the thesis that there is â€Å"no absolute set of features that can distinguish definitively one cultural group from another† (Spencer-Oatey, 2). This is of course stemming from the thesis that culture is associated with social groups. In the social sciences it is a given that all people simultaneously belong to a number of different groups and categories, e. g. ethnic groups, professional groups, gender groups, etc. Another important term directly related to culture is the concept of ‘cross-cultural,’ which for Spencer-Oatey (2000, 3) refers simply to comparative data, i. e. ‘data obtained independently from two different cultural groups. ’ A related term is that of ‘intercultural’ – interactional data obtained ‘when two different cultural groups interact with each other’ (Spencer-Oatey, 3). The speaking component highlighted in the book’s title itself refers to the management of social relations as a specific aspect of communication. Spencer-Oatey goes back to the work of earlier authors such as Watzlawick, Beavin and Jackson (1967, as cited in Spencer-Oatey, 1) who had initially proposed that â€Å"all language has a content component and relationship component. † In a similar study, Brown and Yule (1983) had identified two main functions of language: the transactional (information-transferring) and the interactional (maintenance of social relationships), with two corresponding goals – the coherent and accurate conveying of information (transactional) and communication of friendliness and good will in a comfortable and unthreatening manner (interactional). In both cases, culture definitely plays a significant role, and in the two studies it is utilized as an explanatory variable. Attempting to use culture as an explanatory variable to account for similarities and differences in communication across cultures necessitates appropriate ways to â€Å"unpackage† culture before it could be linked to communication outcomes and operative psychological constructs (Spencer-Oatey, 2000). There are dimensions to cultural variability which could be viewed as psychologically comparable among cultures, and these are often used as the tools to account for the differences. There remains however a number of problems in the use of cultural-level values to account for variability in communicative behavior across languages and cultural groups. Following Gudykunst (2000, as cited in Spencer-Oatey) cultural level variables, e. g. individualism and collectivism, prove to be insufficient if one aims to establish a framework providing causal explanations of social behavior. Cultural level variables may have a direct effect on social behaviors through its influence on cultural norms and the rules specific to a particular culture yet it is important to note that the members of a culture are not socialized in the same way, nor do they adopt a culture’s rules to the same extent. As such, the socialization processes at the individual level clearly play a mediating role in the influence of cultural level variables on social behaviors. With regards to communication, for Spencer-Oatey et al (2000) pragmatic variables, i. e. factors influencing how people both produce and interpret communicative behavior, can possibly yield important dimensions of cultural variability at the individual level. Of particular interest are two influential aspects of socio-linguistic pragmatics – interactional ‘rules’ (maxims) and contextual factors. The view that it has now become necessary to move beyond a value approach in the conceptualization of culture has merit, and Spencer-Oatey provides the needed empirical illustrations to give strength to the argument of the need to explore new ways of conceptualizing culture. Contemporary development in linguistics suggests two important ways in which culture can have an impact on language use: pragmatic maxims, and the conventions of use of a particular language (variety). In illustrating the limits of culture as an explanatory variable, a discussion on politeness theory is presented. ‘Politeness’ often refers to the â€Å"use of relatively formal and differential language† (Spencer-Oatey, 2), though as Fraser and Nolan (1981, 96) carefully point out, it is in actuality also a contextual judgment in the sense that â€Å"†¦no sentence is inherently polite or impolite. †¦it is not the expressions themselves but the conditions under which they are used that determine the judgment of politeness. † Furthermore, politeness maxims appear to have ‘universal valences,’ wherein one pole of a given dimension is always viewed as more desirable than the other (Spencer-Oatey 2000). Yet interestingly, in different cultures and even in different speech contexts within the same culture, there are different points on the continuum that are more favored over others. There is already a significant body of work researching the universal and culture-specific aspects of politeness behaviors available. House (2000, cited in Spencer-Oatey) conducted a series of analyses contrasting the English and German spoken and written discourses over the past two decades. Among the interesting findings is the tendency of German students to use less verbal routines than their English counterparts, which appear to lend credence to the insight that they are more direct, content-oriented and self-referenced (House, 162). A temporary cultural dissonance is said to result when participants are unable to retain emotional equilibrium (House, 2000), i. e. they are overcome by a sense of misunderstanding and disappointment. Emotional reaction for House (2000) is often a â€Å"major factor responsible for a deterioration of rapport and for the mutual attribution of negative personal traits which, in turn, prevent any recognition of real differences in cultural values and norms. † Crucial to Spencer-Oatey’s work is the concept of ‘rapport management’ as an analytical framework, of which a detailed discussed is presented in Chapter 2. As several attempts have already been undertaken to create language use universals, the concept of ‘face’ as a â€Å"universal human need and the key motivating force for politeness and rapport management† has been proposed by Brown and Levinson (1987, as cited in Spencer-Oatey 2000, 12-13). Two related aspects comprise the ‘face’- positive (representing the desire for approval) and negative (desire for autonomy). Meanwhile, critics such as Matsumoto (1988), Ide and Mao (1994) relegates prime importance to that of social identity, as illustrated in Chinese and Japanese cultures (as cited in Spencer-Oatey, 67-68). A discourse-processing approach is a powerful analytical tool towards in-depth comprehension of how rapport can be mismanaged across cultures through communication. It involves detailed descriptions of the processes utilized in the production and comprehension of discourses, as well as illustrations of how misunderstandings can occur between and within cultures. Emphasis is on the discourses invoked by the participants. With regards to communication processes, prime importance is given to how the discourses are socially constructed and then understood and internalized by the participants of the discourse. Contrastive discourse studies (Spencer-Oatey 2000) in particular, as illustrated by the researches presented in the second part of the book, are of prime importance when one aims to explain intercultural misunderstandings. Meanwhile, in a pragmatic transfer approach to the study of intercultural communication, its explanatory power in accounting for intercultural encounters is largely based on existing pragmatic knowledge in the communication process (Spencer-Oatey 2000). ‘Pragmatics’ is â€Å"the study of the relationships between linguistic forms and the users of those forms† (Yule, 4), i. e. it is mainly concerned with the notion of implied meanings. The pragmatic transfer framework draws on the perspective of relevance theory. For one to be able to communicate effectively and competently, one needs to know how to choose the appropriate form and the appropriate meaning in order to avoid inter-cultural pragmatic problems. Related to the first two frameworks, Accommodation Theory nonetheless presents a rather different theoretical perspective to account for intercultural discourse. Focus is on the various manner in which speakers themselves can ‘attune’ their talk more or less to each other (Spencer-Oatey 2000). Thus though all three frameworks are to some extent concerned with processes involved in communication, in contrast to the other two frameworks there is a strong dynamic aspect to human agency in Accommodation Theory, though the manner and extent wherein one can be accommodating in ‘talking’ is still within socio-culturally prescribed boundaries. In terms of the merits and weaknesses of methodologies, cross-cultural or comparative studies are very useful in providing a rich array of baseline data. However, comparative studies suffer when used for analytical purposes, particularly in providing a comprehensive analytical framework to account for intercultural encounters. As such, the researcher(s) have to go back to and rely on the explanatory power and analytical categorizations provided by theory in order to provide a comprehensive account of the factors influencing performance both in the individual and social levels. We find in Chapter 6, â€Å"Telephone Conversations in Greek and German: Attending to the Relationship Aspect of Communication† the uses of speech act analysis as a research method of collecting data. It recorded observations concerning the opening and closing sections of conversations in authentic Greek and German. Analysis involves a comparison between the two groups of their preferences to attend to the relationship aspect of communication, though of course there are significant limitations to the variables that could be studied, i. e. those which could possibly affect the management of rapport as it could not encompass all cultural groups and languages. Different styles and beliefs about argumentation of people in initial encounters, which are still largely facilitated by variables of culture, can have a negative effect on how people evaluate their initial interaction, as gleaned from Chapter 10’s empirical study of the negotiation of rapport in Chinese-German conversations. It utilized authentic conversation analysis between Chinese and German students meeting for the first time. Different methodologies have their own strengths and weaknesses, and a triangulation of methods (e. g. use of survey questionnaire and observational field data) is commonly utilized to cover more extensively the nature of the variables under study. A critical reading of the various inter-cultural studies presented in the book presents one the insight that selection of the appropriate methodology (e. g. conversation analysis, surveys, face-to-face interviews, among others) and analytical framework – discourse processing model, pragmatic transfer, accommodation theory, etc. – for a research undertaking ultimately depends on the nature of the questions being asked and the aims of the research, wherein one has to select the corresponding methodology which would facilitate the gathering of relevant data for analysis. Works Cited Birkner K. & Kern, F. (2000) Impression Management in East and West German Job Interviews 2000 In H. Spencer-Oatey (Ed. ) Culturally speaking: Managing rapport through talk across cultures. London: Continuum Gudykunst, W. B. (2000). Methodological issues in conducting theory-based cross-cultural research. In H. Spencer-Oatey (Ed. ) Culturally speaking: Managing rapport through talk across cultures (pp. 293-315). London: Continuum. House, J. (2000). Understanding misunderstanding: A pragmatic-discourse approach to anaysing mismanaged rapport in talk across cultures. In H. Spencer-Oatey (Ed. ), Culturally speaking – Managing rapport through talk across cultures (pp. 146-164). London: Continuum. Spencer-Oatey H. ed. (2000) Culturally speaking: Managing rapport through talk across cultures (pp. 293-315). London: Continuum. Yule, G (1996). Pragmatics. In H. G. Widdowson (ed. ) Oxford introductions to language study. Oxford University Press.

How to Keep Up With College Reading

How to Keep Up With College Reading The level of out-of-class reading required in college can be pretty intense. If youre new to college, your reading load is likely significantly higher than what you experienced in high school; if youre a senior in college, the level seems to go up each year, just as you think youve adjusted. Regardless of your specific situation, knowing how to keep up with college reading can be a serious challenge. Fortunately, theres no right way to stay on track with your reading load. A manageable solution comes from finding something that works for your own learning style - and from realizing that being flexible is part of any long-term solution. Figure Out How You Best Make Progress on Your Reading Completing your assigned reading is more than just scanning your eyes across the page; its understanding and thinking about the material. For some students, this is best accomplished in short bursts, whereas others learn best by reading for longer periods of time. Think about and even experiment with what works best for you. Do you retain more by reading in 20-minute periods? Or do you learn better by spending an hour or two really diving into the reading and not doing anything else? Similarly, do you need to have background music on, be in a loud cafe, or have the quiet of the library? Each student has his or her own way of doing homework effectively; figure out which way is best for you. Schedule Reading Time Into Your Calendar Most students are great at scheduling things like club meetings, football games, classes, and other activities into their calendars. Additional things, like homework and laundry, often just get done whenever possible. This kind of loose scheduling with reading and assignments, however, can lead to procrastination and last-minute cramming. Consequently, write down (and make sure you keep) time in your schedule to do your reading each week. If you can make an appointment to attend a club meeting, you can certainly make a similar appointment to get your reading done. Read Effectively Some students take notes; some students highlight; some students make flashcards; others have their own system that works for them. Doing your reading involves more than just getting from page 1 to page 36; it involves understanding what youre reading and, possibly, having to use that knowledge later (like during an exam or in a paper). To prevent yourself from having to reread later, be effective during your first read-through. Its much easier, after all, to go back through your notes and highlights for pages 1-36 than it is to completely reread all 36 pages before your midterm. Acknowledge That You Can't Get Everything Done All of the Time Its a harsh reality - and great time management skill - to realize that doing 100% of your reading 100% of the time is nearly (if not actually) impossible in college. Its important to learn what you cant get done and then to go with the flow sometimes. Can you work with other students to break up the reading, and then discuss in a group later? Can you let something go in a class youre already doing well in and focus more on a class youre struggling in? Can you skim materials for one course, thereby allowing yourself to read materials for another course with more time and attention? Sometimes, you just cant get all of your college reading done, no matter how hard you try or how good your intentions are. And as long as this is the exception and not the rule, learning how to be flexible with and adjust to what youre realistically able to accomplish can, in fact, lead to you being more effective and productive with what youre able to do.

A New Airplane Program of Boeing 767 Case Study - 1

A New Airplane Program of Boeing 767 - Case Study Example At the same time, in 1966 company was facing a lot of pressure for the development of new plane as it had been long since the last plane was launched. There were a lot of apprehensions among the directors as the company had not enough experience of developing a plane of their own. Project Uncertainty and Risk Management, the project management was not effective in Boeing 767 program, is the first weakness. Since the company did not have any past experience of cockpit design for two persons, it resulted in many difficulties in the successful execution of the final product. There should have been a thorough analysis of design before getting the final approval. Another weakness was that the geographic locations of production were also not considered. This hence became a major weakness as the transportation of parts was important on time. Time also became critical also due to the change in the design of cockpit. The strength was that the conversion of conversion from two-person to the three-person cockpit, which a very big risk was handled very intelligently. First strength was that the delivery of the planes was just one month delayed. This conversion also raised project uncertainty concern. As the parts were designed for two-person cockpit and payments were already made. The strength of project management was that it was decided that modification experts will fix this problem once parts are installed. This resulted in minimization of the risk of production disruption. Hence the projected uncertainty arising from risk was avoided. This made the design of new cockpit more adaptable to changes. In terms of quality management, another weakness aroused due to this conversion for space. This risk seemed to disrupt the modification of the thirty planes which were almost ready and were also ready to be flown. However, many managers opposed this approach as it violated the fire control systems and may result in working environment without fire system for some time till the new system gets installed again

Art History Essay Example | Topics and Well Written Essays - 1000 words - 6

Art History - Essay Example Roy Lichtenstein is a pop artists and contemporary of Andy Warhol. He used parody using old-fashioned comic strip. He was a teacher before venturing to Pop art based on commercial images such as advertisement painting focused on bard-edged figures. His 1961 Look Mickey used Be-Day dots or a technique comparable to Pointillism (Lobel, 33). Since then, he has produced more art works combining oil or Magana paint exemplified in Drowning Girl and the pop art diptych Whaam! He has influenced other DC comics artists (Lobel, 60). Liechtenstein is an iconography in pop art that until today amaze collectors and contemporary comic book fans. While he may be regarded by some as quite commercial for his techniques and use comic-style graphics, he is one artist to reckon with. Charles Atlas is a filmmaker and video artist. In his online biography, Charles Atlas came from St. Louis, Missouri and born in 1958. Video art uses the video tape as a statement of exploration on the medium or against commercial, entertainment video and may not have any logical presentation or narrative plot except for juxtaposition of images and scenes (Knight, 49). Atlas worked both on stage, screen, museum, and television and also had video installation works. He is considered to have pioneered the â€Å"media-dance, a genre in which original performance work is created directly for the camera† (PBS, P 2) and worked with the Merce Cunningham Dance Company for ten years. He collaborated with choreographers, dancers, and performers such as Yvonne Rainer, Michael Clark, Douglas Dunn, Marina Abramovic, Diamanda Galas, John Kelly, and Leigh Bowery. His four-hour montage â€Å"Television Dance Atlas† on Dutch television used dance styles of ballet, burlesque, and figure skating (PBS P 3). His video installation â€Å"The Hanged One† used rotoscopes, motorized mannequins, and theatrical lighting and may be considered evolving in its various presentations. He

Why are the events surrounding the South Sea Company often described Essay

Why are the events surrounding the South Sea Company often described as a financial bubble Identify at least one other famous bubble and discuss what feat - Essay Example With desires to get rich quickly, ambitious investors hurriedly and haphazardly invested on stocks of a particular company without first assessing its real situation. The result is the vital drop not only of a single firm but also of the entire national economy. This is the predicament that the South Sea Company in England in the 18th century experienced. Considered as one of the worst financial disasters in a capitalistic society, the South Sea Bubble is a proof that avarice can lead a single person, firm or even an entire nation’s economy to collapse. In those days, the British Empire reigned over the entire world. It was a time of affluence and prosperity for British people enabling them to invest. The exuberance of investors to gain more out of the company’s monopoly of the South Seas compelled the company issued more stocks that were also sold out by greedy investors. The lavish and generously enamored company office ostentatiously displayed the opulence and success of Britain on its industrial revolution. With the notion spread by speculators that this company â€Å"could never fail,† its share price skyrocketed tenfold from its original value, making its investors rich overnight. It was at this point that the reality set in, bursting the bubble of the company’s overpriced share prices. South Sea Company’s heyday ended when its management realised that they failed to manage and operate the company properly. They realized that the company was not generating profit at all. The funds came basically from selling stocks and not from actual commerce. News that the company was actually profitless instigated panic stocks selling. Useless stocks were sold frantically leading to a stock market crash. Many British people lost their fortune because of this. From 950 pounds per 100 pound par value it slid down to 290 pounds in less than 4 months. The invention of the personal computer

Social Media Essay Example | Topics and Well Written Essays - 1750 words

Social Media - Essay Example Social media is such a rich source of information that it has become very easy for people to know the root-causes of problems, and make informed decisions as to what side they should support. Just like everything has certain positive and negative aspects to it, social media also has both kinds of effects on the society. Positive effects of social media include creation of awareness in the society regarding the real issues whereas the negative effect of social media is primarily the disorganized and uncivilized retaliation and protest of the people after they realize the potential ways in which they have been targeted. Positive Effects of Unbiased Reporting by Social Media Creation of Awareness in the Society about the Real Issues News channels like CBS and Fox News have lost credibility in the eyes of public since people learnt how these channels have tried to manipulate them and feed them with wrong information about the threats to the USA from Iraq, when there were none. There are a lot of ways in which the television channels tend to dodge the audiences in order to streamline their perceptions according to their agenda. An example of the ways in which the television channels play with the audiences is here; â€Å"The Big Three (ABC, CBS, NBC) Wednesday evening newscasts devoted more than 9 minutes (9 minutes, 28 seconds) to the flap over Mitt Romney's statement criticizing the administration's handling of the Libyan crisis but spent just 25 seconds on questions regarding Barack Obama's Middle-East policy, a greater than 20-to-1 disparity† (Dickens). This was intentionally done to make the audiences’ attention increasingly diverted towards Romney’s criticism of Obama’s policies and at the same time male the audiences overlook or pay least attention towards the Middle-East policy of the president. In many cases, interests of the television channels are aligned with the interests of specific political parties either in charge or in o pposition and the channels make use of its programs include talk shows, news, and discussions to brainwash the audiences in the best interest of the political parties which the channels serve. There are numerous factors that contribute toward making the news spread through social media more reliable. A person’s profile on such a social media website as Facebook is essentially his/her virtual identity. People know him/her in the virtual world by that profile. Owing to this fact, people tend to remain as much truthful and honest in the expression of their views and opinions on the social media websites as possible because whatever they write on their profile has an effect on their image in the public eye. In order to construct good image and avoid their image from getting tarnished in the public eye, people support what is right and condemn what they really think is wrong on the ethical grounds. Another concrete example of reliability of social media is that it is a fairly accu rate medium where one can learn cultural perceptions about the latest events around the world as well as debatable topics like gay marriage and euthanasia. All one needs to do is read the comments under the videos on Youtube, and one can know what the people of a certain country generally think about a certain issue. Not only can one understand the generic

Non Medical Independent Supplementary Prescribers Nursing Essay

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