Role Expansion of Support Staff in the NHS

Role Expansion of Support Staff in the NHS Abstract In this dissertation we examine the various aspects of role expansion of support staff within the confines of the NHS. We consider it on both a broad front and also make specific examination of those issues that concern staff connected with the operating theatres. We consider the background and political pressures that make role expansion desirable and possible. We also consider the implications of expansion in the NHS on both a professional and practical level. The issues are discussed in both specific and general terms. We illustrate three types of role expansion by reference to specific professional examples. One example is of the expansion from a caring role to that of the specialist provider, the second can be considered an example of role extension within a professional setting and the third is a natural expansion of the role which is required as technology and practice evolve. Methodology The methodology of this exploration was primarily by literature research. Progressive lines of enquiry were identified, researched and recorded. New lines of enquiry were identified as research progressed, and these were also examined for relevance and researched if considered appropriate to the theme of the dissertation. The literature search was mainly from library facilities. Local University, Post-Graduate hospital and public library facilities were extensively used together with some Internet based investigation. Some personal email enquiries were made from individuals who had experienced professional expansion and advice was taken in regard to both literature and direction of research. Introduction There is little doubt that the role of support staff has changed within the working lifetime of professionals currently working in the NHS. The thrust of this dissertation is to examine the means, the mechanisms and the degrees by which their role has changed. It barely needs stating that the NHS has changed. The political climate in which it operates has seen the NHS occupy varying positions of political prominence. Politicians are frequently seen publicly promising various sums of money for various projects of modernisation, expansion or generally to improve services. Every so often there is a major structural realignment of the management focus and mechanisms which, inevitably percolate through the tiers of control until the changes are felt at the level of the worker. In addition to this there are the technological changes which are largely independent of the politicians and the management structure. The rate of change in techniques, technology, support equipment and expertise appears to be increasing at an exponential rate. It clearly follows that the professional requirements of the support staff must keep pace with these changes and the training that they receive must inevitably reflect the needs of the ever changing working environment. (Ashburner L et al 1996) Evidence of change In any rational discussion, it is vital to work from a firm and secure evidence base. (EHC 1999). This requires careful and critical appraisal of the evidence and a decision as to just how applicable it is to the situation under consideration. In this dissertation we shall therefore be presenting evidence to support this evidence base together with appropriate assessments and judgements as to its validity. Most professionals working in the NHS would attest, if asked, to a perception of a continuous pace of change. Such anecdotal evidence, although interesting, is of little value to any form of critical appraisal. There are a number of reasonably â€Å"hard† statistics that give us much firmer evidence of change in the NHS. Let us consider some of the employment statistics published by the Department of Health for the NHS (whole of UK) and refers to non-medical staff. In 1997 the total number of NHS hospital and community based staff was 935,000. Of these 67% were direct care staff and 33% were management staff. The 67% direct care staff could be broken down into 330,620 nursing, midwifery and health visiting staff (246,010 being qualified) 100,440 scientific, therapeutic and technical staff 17,940 healthcare assistants 21,430 were managers the rest were estates, clerical and administrative staff 79% were women and 6% were from ethnic minorities (NSO 1998) If we compare this with the situation in 2000 by looking at the same parameters we can see: 346,180 nursing, midwifery and health visitor staff (256,280 were qualified). 110,410 scientific, therapeutic and technical staff 62,870 support staff and 23,140 healthcare assistants. 68% were direct care staff and 32% were management and support staff. 79% were women and 7% from the ethnic minorities (NSO 2001) And in 2001 we find a further difference, which is rather more dramatic: 458, 580 nursing, midwifery and health visitor staff (330,540 were qualified) 139,050 scientific, therapeutic and technical staff 23,140 healthcare assistants. 82% were women and 6% from the ethnic minorities (NSO 2002) If we go further back we can find evidence of 93,950 scientific, therapeutic and technical staff were employed, and there were 13,090 healthcare assistants in 1995 (NSO 1996) If we consider the documented trends in support staff we can trace 1995 93,950 1997 100,440 2000 110,410 2001 139,050 Over a comparatively short time there has clearly been a demonstrable increase in terms of numbers employed , nearly a 50% increase on the 1995 levels in six years. Reasons for change In opening this dissertation we made anecdotal reference to the political agenda that shaped the NHS. The NHS has historically been high in the public’s perception of a tangible measure of a Government’s success in delivering its regularly promised higher standard of living. It is partly for this reason, that successive governments have felt it politically expedient to invest increasing sums of money in measures for both expansion and improvement together with various drives aimed at increasing efficiency. (Ham C 1999) In the recent past there have been a raft of measures that have been produced which have all played their part in the evolution of the NHS to its current configuration and in doing so have expanded the role of not only the support worker but virtually all of the workers in the NHS at the same time. One of the first measures which was an overt indication of the forthcoming changes in working practice was the introduction of the performance indicators (Beecham L 1994) These were progressively introduced form 1992 onwards and in some respects could be considered the forerunner of the move towards National Service Frameworks. The original performance indicators imposed a duty or obligation on Trusts to carry out certain procedures within a specified maximum time. For example the indicators introduced in 1994-5 were on waiting times for first outpatient appointment and also for charters in General Practice. Although there were clear obligations on medical and nursing staff to make available sufficient sessions in order to see the patients, it is clear that the increased throughput of patients would clearly impact on the working practices (and work load) of the support staff. To a large extent, this can be seen from the figures presented at the beginning of this work. The 50% increase in staffing levels amongst the support staff reflects, in a large part, the changes that were consequent on the imposition of the performance indicators. The initial indicators proved to be quite onerous in terms of achieving compliance even though the later ones gave tighter requirements still. For example the 1994 indicators set a target of 90% of patients seen by a consultant within 26 weeks of a written referral letter being received from the General Practitioner in the major specialities of general medicine, general surgery and dermatology. (Editor BMJ 1994) It follows that this target is not quite as innocuous as it might at first appear. If we accept the fact that a substantial number of patients were already waiting for considerably longer than 26 weeks it represented a major shift in working practices to meet this particular deadline. Once the patients were seen it followed that they then had to have whatever treatment was thought to be appropriate. An increase in outpatients seen inevitably means an increase in patients waiting for inpatient treatment. So either the waiting lists go up further for inpatient treatment, or there is also a change of working practice to accommodate an increase in demand. This inevitably also impacts on the support staff as much as it does on the medical staff. (Langham S et al 1997) We shall consider this particular phenomenon in greater depth later when we consider the expansion of the nurse to specialist endoscopist and the running of one-stop clinics. Some novel methods were invoked to try to accommodate this shift in demand. There was a substantial increase in the frequency of day case surgery. Not only were a greater variety of surgical procedures being routinely carried out as day cases but it also resulted in more patients being assessed as suitable to undergo day case surgery. (HSE 2001) The same phenomenon of knock on effects arose form some of the other performance indicators. One of the original indicators was the percentage of patients seen within 5 mins of entering the casualty department. It follows that as hospitals strove to increase their performance indicators and the percentage of patients seen promptly rose, having been seen they then had to be treated and the same argument applies. Either there is an increase in the number of patients awaiting treatment in the A E departments, or there is a change in working practice to accommodate them and also to get them treated sooner. The organisation and efficiency of this system falls heavily on the support staff who clearly had to be able to accommodate this increased demand. (Langham S et al 1997) The indicators eventually began to involve inpatient statistics as well as outpatient ones. One, introduced in 1996, was on the number and availability of emergency operating theatres. More evidence of the reasons for this change comes from a paper by Scally and Donaldson (1998). We note that it was actually written by Liam Donaldson when he was a Regional Director of the NHS before he subsequently became Secretary of State for Health, so his comments can be taken with suitable gravitas. A critical analysis of the paper shows that it makes a number of points that are really overtly political, but it outlines the trend of change of emphasis where the improvements expected through clinical governance will not only be an â€Å"ideal goal† but will become a statutory requirement. This clearly pre-empts the changes prescribed in the NHS Plan. The paper outlines new goals â€Å"in which financial control, service performance, and clinical quality are fully integrated at every level† are behind the major thrust of the piece. Careful reading of the paper strongly suggests that inherent in the restructuring plans is a change in emphasis onto expansion of professional roles and greater working flexibility between professions which is fundamental to our considerations here. (Gray C 2005). We also note that the â€Å"stage was being set† for the potential role change of healthcare professionals in general and the four main precepts of this paper impact on that belief, namely: Clinical governance is to be the main vehicle for continuously improving the quality of patient care and developing the capacity of the NHS in England to maintain high standards (including dealing with poor professional performance) It requires an organisation-wide transformation; clinical leadership and positive organisational cultures are particularly important Professional self regulation will be the key to dealing with the complex problems of poor performance among clinicians New approaches are needed to enable the recognition and replication of good clinical practice to ensure that lessons are reliably learned from failures in standards of care It is clearly significant that all of these points were implemented and indeed, expanded, when Donaldson was appointed to the office of Secretary of State for Health and they can be seen as both enhancing and reinforcing the points that we have presented relating to the guidance from the Nursing Midwifery Council about the expansion of professional roles. Because of their seminal importance in the examination of our subject, let us consider the background to these points further. We note that Donaldson was originally recruited from a business background and the record shows that he has chosen to apply a great many sound and proven business principles to both the structuring and the workings of the NHS. Many of his strategies and perhaps ideas, have a clear ancestry in the Cadbury Report (1992) which effectively analysed the overall impact of governance and issues of changing working practices and consequent responsibility in the business world. The report focused on the issues surrounding an expansion of responsibility and a consequent failure to take responsibility for one’s actions, frequently passing on the implied responsibility to another employee in the same company. It found this practice to be both counterproductive and inefficient and frequently would lead to defensive stances and attitudes being adopted. When problems arose, they were therefore far more difficult to actively solve. (Lakhani M 2005) Donaldson was instrumental in applying this strategy to a clinical setting within the working practices of the NHS. This particular paper takes the view that by promoting individual professional responsibility he would be encouraging a system that would allow:- NHS organisations to be accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. By implication this argument extends to the expansion and role realignment in general terms throughout the NHS. We shall consider the elements in this paper which are of relevance to these arguments. Staff self-esteem is of great value to an organisation. Frequently this is associated with increased responsibility and a firm professional footing. (Davies HTO et al. 2000). Donaldson and Scally clearly espouse the virtue of professional responsibility at all levels in an organisation and encourage staff to take, rather than to devolve responsibility for their actions and indeed seek to ideally provide a ambience that is conducive to expansion of responsibility which therefore generally benefits the whole organisation. Tools of change Although we are primarily considering the support worker in this dissertation we must first broaden the agenda in order to set our examination in an appropriate context. There have been a number of Government White Papers, consultative documents and advisory initiatives that have concerned the workings of the NHS. Some have greater practical significance than others. There appear to have been significantly more in the last decade than previously and anecdotal and observational evidence would seem to suggest that these too, are increasing at an exponential rate. One of the landmark plans in recent years has been the NHS Plan. It has been compared by some commentators as being on comparative magnitude as the original inception of the NHS in 1948 (Shortell SM et al 1998). It is quite possible that a cynical appraisal of the Plan would see it is little more than the result of political rhetoric and pre-emptive manoeuvring as a response to the perceived public disquiet about the state of the NHS. On the other extreme the optimist might view it as a positive plan for major improvement. (Moss et al 1995). Having the benefit of hindsight, there is no doubt that it has been the catalyst for a number of significant changes in the NHS, it is, of course, totally dependent upon your own particular viewpoint as to whether these changes are regarded as beneficial or otherwise. One has to be extremely careful in evaluating such comments as clearly it depends on the criteria chosen for evaluation as to whether the reform will appear to be positive or negative. (Bilsberry J. 1996) One only has to consider the debacle which ensued after the introduction of the Griffiths Report in the 1980s (Griffiths Report 1983). This was considered to be a major reform of the management structure of the NHS. There was general agreement that the management had become to unwieldy, detached and inefficient with too many layers of management. (Davies,C et al. 2000), The Griffiths Report was commissioned with the specific purpose of streamlining the management profile and was charged with the specific responsibility of improving both efficiency and accountability. The subsequent plan was unveiled and introduced piecemeal. In the words of the Government appointed reviewer of the episode :- These were a set of reforms that were designed to â€Å"streamline the administration â€Å" of the NHS. It involved a major change in emphasis in the way that the NHS was run, and in short, it was badly conceived, patchily implemented and introduced piecemeal. By any critical analysis it proved to be a complete disaster. (Davidmann 1988) It is not actually possible to pass judgement on whether the plan would have been successful or not as its method of introduction was generally seen to be its downfall. In essence, its introduction was not managed in any contemporary sense of the word, it was simply imposed and the chaos that ensued prompted the government to institute another report to glean what lessons it could form the whole affair. (Davidmann 1988). It is fair to comment that the majority of reforms that have been introduced since that time have been far more professionally managed and their introduction (whatever their eventual outcome) have generally been comparatively smooth and uneventful (Bennis et al 1999) The area of change management as a science and discipline is both extremely involved and complex. Changing the structure of a massive and established organisation such as the NHS is clearly difficult with established attitudes, working practices and inherent inertia. The lessons learned from the Griffiths Report appear to have been successfully applied to the introduction of the NHS Plan (Bryant 2005) In specific consideration of the NHS plan we should note that the specific stated aims of the plan were to:- Increase funding and reform Aim to redress geographical inequalities, Improve service standards, Extend patient choice. These aims have been, to some extent translated into reality. Let us examine each in detail. The increased funding was specifically delivered in the March 2000 budget settlement and has been honoured in successive budgets since. The Chancellor of the Exchequer stated that the money made available would ensure that the NHS would grow by one half in cash terms and by one third in real terms in just five years. Our examination of staffing levels (above) would seem to suggest that this trend has been successfully established. In addition, he promised a  £500 million â€Å"performance fund† for specific areas which were to be identified by separate investigation as being in particular need of assistance. (Halligan et al 2001) This certainly directly impinges upon our considerations of support staff and we shall return to this point later. The geographical inequalities and service standards are specifically addressed in the introduction of the National Service Frameworks which are mechanisms for specifically addressing inequalities and setting of both targets and goals of performance and excellence on a National rather than a local level, (Rouse et al 2001) and have been progressively rolled out across the country. These measures have been established in collaboration with assistance and guidance from bodies such as the National Institute for Clinical Excellence (NICE) which has a remit to examine both practices and facilities with the specific aim of achieving national standards. ( viz. NICE 2004) (NHS KSF 2004) It has made a number of recommendations which appear to have a firm evidence base. (Berwick D 2005) We should perhaps take this opportunity to note that the Institute, although undoubtedly set up in response to a worthy ideal, is already finding itself short of funding to do the job that it was originally conceived for. Spokesmen have already commented that it is short of money to achieve the research necessary to justify its continued activity (Shannon 2003) Patient choice is a far more complex issue that it might originally appear. Initial examination might suggest that to give patients the freedom to go where they wish to get their medical care is a fine objective, but closer examination of the issue would reveal that it has numerous pitfalls. In the specific terms of the NHS plan, it actually means that the patient’s primary healthcare team has a more wide-reaching choice of where they choose to refer the patient. (Wierzbicki et al 2001). A patient may consider any number of factors which may influence their choice of hospital including such factors as the general look of the buildings, the geographical site in relation to their friends and family and what they have read or heard anecdotally about the hospital. None of these factors have any major bearing on the treatment that they will receive. It may be that they will discover that the waiting list is shorter at hospital A than hospital B. what may well be less obvious to the patient is that hospital A may have a shorter waiting list because the local primary healthcare teams know that it has a number of serious shortcomings and so they tend to refer their patients to hospital B which consequently has a longer waiting list. Of course , we mustn’t ignore the possibility that hospital A is actually more efficient that hospital B or that hospital C provides a more comprehensive, courteous and efficient service with greater expertise than hospital D, but the primary healthcare teams are generally best placed to see the outcomes of their local hospitals and will generally know where their patients are served better in each individual circumstance. (after Donaldson L 2001) In the context of our examination here, all four of these aims have potential impact on our subject as each of these objectives are effectively resolved by expanding, and in some cases changing, the roles of staff within the NHS. Clearly the impact will vary between different disciplines and indeed, different geographical areas, but the overall objective of improving the efficiency and introduction of patient orientated goals has largely been met by the three expedients of: a) making more money available b) adopting progressive management strategies c) increasing staffing levels and redefining some roles within the NHS ( after Dixon et al 2003) It is perhaps useful to consider the whole of the NHS Plan as part of a reform continuum which has shaped the evolution of the NHS since its inception. We have already highlighted the Griffiths Reforms, but other landmark reforms that impact upon our considerations of change must include the Agenda for Change (2004) which is primarily staff and employment orientated and is concerned with a number of measures including staffing levels, staff role descriptions and staff pay levels. It has only recently been implemented (September 2005) and, for our purposes here, should be viewed in conjunction with another Government White Paper which is the complimentary NHS Knowledge and Skills Framework (KSF 2004). This particular paper targets the need for both recognising and rewarding specific speciality orientated enhancement of both skills and knowledge that are actually relevant to professional performance in both designated areas and in professional performance generally. Reading of the provisions reveals that the general provision of  £280 million over a three year period to â€Å"develop specific designated staff skills†. One of the proposed mechanisms is to set up individual learning accounts which will be worth  £150 per year. It is not yet clear what the impact will yet be on support staff in either specific or general terms. The impact of these reforms seems to be felt on many levels. There appears to be a move towards the redesignation of roles, flexible working, skill mix and the redesignation of professional boundaries. The NHS Plan itself calls for a number of changes to be made in working practices, both general (conceptual) and specific. It also calls for a change in the actual roles of some healthcare professionals, including support staff. It goes into great detail about the need for some of these changes need to be established but it also has to be observed that there is actually very little detail in the Plan as to how these changes are either to be introduced or managed. It refers to the changes in general terms, there is actually very little detail relating to what it expects these changes to actually be in reality. (Krogstad et al 2002) If one were to produce an analysis of the pre-2000 structure of the NHS one could conclude that it had three major problems which were not consistent with the function, structure and organisation of a typical 21st century industry a lack of national standards old-fashioned demarcations between staff and barriers between services a lack of clear incentives and levers to improve performance over-centralisation and disempowered patients. (Nickols 2004) One observation that is also relevant to our considerations here is the phrase â€Å"seamless interface† appears very frequently throughout the document. Although it is primarily applied to the interface between primary and secondary care, it is also, both explicitly and by implication, applied to the interface between different groups of professionals within both aspects of the service. (Rudd et al 1997) In direct consideration of our subject, we can take this to mean that there is a requirement for seamless interaction between all factions of the operating theatre staff and between them and the other professionals in the hospital. (Dixon et al 2003) Other significant milestones in the changes in the role of support staff were the introduction of the National Service Framework. These are a series of recommendations, stipulations and targets which are designed to raise the performance to the level of the best across the nation rather than to have pockets of excellence surrounded by a sea of mediocrity (White M 2005). The issues surrounding the National Service Frameworks are huge, as they collectively cover most of the major therapeutic areas in medicine. The reason for their inclusion in this particular consideration, is because of their collective impact on the role of the support staff, who have to expand their role and skills in order to comply with their requirements. It is completely impractical to consider all of the implications of the National Service Frameworks so, as a representative â€Å"sample† we will consider just one, the National Service Framework for the elderly. In distinct contrast to our comments in relation to the Griffiths Report earlier in this piece, the introduction of the National Service Frameworks could be considered nothing short of exemplary. There have been consultation periods, pre-implementation pilots and possibly most importantly, a well publicised and staged National roll-out programme which was designed to implement each of the strategies in a graded and controlled fashion with the intention of trying to ensure smooth implementation across the country. (Nickols F.2004). If we consider as an exploratory example, a small portion of the National Service Framework for the elderly Standard Two, this states that it should ensure that: Ensure that older people are treated as individuals and that they receive appropriate and timely packages of care which meet their needs as individuals, regardless of health and social services boundaries. One could perhaps reasonably hope that such aspirations would have been unnecessary, but behind the actual words are a number of other concepts that are central to our consideration to the expanding role of the support staff. The concept of â€Å"Person Centred Care† is a central precept of the Standard Two. It is described with the intention of trying to allow the elderly to feel entitled to be treated as individuals and also to allow them to retain responsibility for their own choices for their own care. The expansions of the roles of the support staff comes primarily in the adoption of the main tenet of the concept of Person Centred Care and that is the introduction of the Single Assessment Process (SAP). This recognises that there are effectively a great number of support agencies that potential can be involved to look after the needs of the elderly, both in hospital and after discharge. Prior to the introduction of the National Service Framework, it was common practice for each agency to separately make contact with the patient and make their own assessment in terms of their own distinct considerations. We shall discuss this point later in the context of insularity of specialities. The end result of this process was the fact that, very commonly, the same (or similar) facts are repeatedly elicited on different occasions with all the implications that this type of duplication has on inefficient working and waste of resources. (Fatchett A. 1998). The SAP is designed so that any member of the health care team can assemble the information in such a way and in such a format that it will be of use to the other members of the team, or for that matter any of the agencies who might have a legitimate need for the information. This particular role expansion is designed to assist in reducing the amount of red tape that appears to be an inevitable encumbrance of many of the measures that are designed to assist the elderly patient, and only appears to finish up by hampering them. (Gott M 2000). The adoption of the Single Assessment Process is no more than one example, perhaps not so much of an expansion of the role, but a realignment of the role of support staff. It is still a fairly new concept and is central to the aims of the National Service Framework that the needs and wishes of the patient should be at the heart of the whole process. Because it is new, the extent to which it can accommodate these aims and aspirations alongside the day to day practicalities of service provision still has yet to be fully assessed. (Mannion R et al 2005) In some ways, this new role expansion can be viewed in parallel with the concepts of seamless interfacing and multidisciplinary team working which we have examined elsewhere in this dissertation. Given the fact that the Single Assessment Process has only been operational since April 2004, but the move towards multidisciplinary team working and the concept of the seamless interface has been apparent and espoused for some years (Mason et al 2003). The latter were effectively translated into reality without major upheaval, one can be reasonably confident that the same will eventually be said for both the Single Assessment Process and its implications for both staff and patients. We have described this particular example of role expansion more as a realignment because, at first sight, its implications are quite subtle when compared to other examples that we shall be considering, but equally they are quite fundamental, as they impinge upon the role Role Expansion of Support Staff in the NHS Role Expansion of Support Staff in the NHS Abstract In this dissertation we examine the various aspects of role expansion of support staff within the confines of the NHS. We consider it on both a broad front and also make specific examination of those issues that concern staff connected with the operating theatres. We consider the background and political pressures that make role expansion desirable and possible. We also consider the implications of expansion in the NHS on both a professional and practical level. The issues are discussed in both specific and general terms. We illustrate three types of role expansion by reference to specific professional examples. One example is of the expansion from a caring role to that of the specialist provider, the second can be considered an example of role extension within a professional setting and the third is a natural expansion of the role which is required as technology and practice evolve. Methodology The methodology of this exploration was primarily by literature research. Progressive lines of enquiry were identified, researched and recorded. New lines of enquiry were identified as research progressed, and these were also examined for relevance and researched if considered appropriate to the theme of the dissertation. The literature search was mainly from library facilities. Local University, Post-Graduate hospital and public library facilities were extensively used together with some Internet based investigation. Some personal email enquiries were made from individuals who had experienced professional expansion and advice was taken in regard to both literature and direction of research. Introduction There is little doubt that the role of support staff has changed within the working lifetime of professionals currently working in the NHS. The thrust of this dissertation is to examine the means, the mechanisms and the degrees by which their role has changed. It barely needs stating that the NHS has changed. The political climate in which it operates has seen the NHS occupy varying positions of political prominence. Politicians are frequently seen publicly promising various sums of money for various projects of modernisation, expansion or generally to improve services. Every so often there is a major structural realignment of the management focus and mechanisms which, inevitably percolate through the tiers of control until the changes are felt at the level of the worker. In addition to this there are the technological changes which are largely independent of the politicians and the management structure. The rate of change in techniques, technology, support equipment and expertise appears to be increasing at an exponential rate. It clearly follows that the professional requirements of the support staff must keep pace with these changes and the training that they receive must inevitably reflect the needs of the ever changing working environment. (Ashburner L et al 1996) Evidence of change In any rational discussion, it is vital to work from a firm and secure evidence base. (EHC 1999). This requires careful and critical appraisal of the evidence and a decision as to just how applicable it is to the situation under consideration. In this dissertation we shall therefore be presenting evidence to support this evidence base together with appropriate assessments and judgements as to its validity. Most professionals working in the NHS would attest, if asked, to a perception of a continuous pace of change. Such anecdotal evidence, although interesting, is of little value to any form of critical appraisal. There are a number of reasonably â€Å"hard† statistics that give us much firmer evidence of change in the NHS. Let us consider some of the employment statistics published by the Department of Health for the NHS (whole of UK) and refers to non-medical staff. In 1997 the total number of NHS hospital and community based staff was 935,000. Of these 67% were direct care staff and 33% were management staff. The 67% direct care staff could be broken down into 330,620 nursing, midwifery and health visiting staff (246,010 being qualified) 100,440 scientific, therapeutic and technical staff 17,940 healthcare assistants 21,430 were managers the rest were estates, clerical and administrative staff 79% were women and 6% were from ethnic minorities (NSO 1998) If we compare this with the situation in 2000 by looking at the same parameters we can see: 346,180 nursing, midwifery and health visitor staff (256,280 were qualified). 110,410 scientific, therapeutic and technical staff 62,870 support staff and 23,140 healthcare assistants. 68% were direct care staff and 32% were management and support staff. 79% were women and 7% from the ethnic minorities (NSO 2001) And in 2001 we find a further difference, which is rather more dramatic: 458, 580 nursing, midwifery and health visitor staff (330,540 were qualified) 139,050 scientific, therapeutic and technical staff 23,140 healthcare assistants. 82% were women and 6% from the ethnic minorities (NSO 2002) If we go further back we can find evidence of 93,950 scientific, therapeutic and technical staff were employed, and there were 13,090 healthcare assistants in 1995 (NSO 1996) If we consider the documented trends in support staff we can trace 1995 93,950 1997 100,440 2000 110,410 2001 139,050 Over a comparatively short time there has clearly been a demonstrable increase in terms of numbers employed , nearly a 50% increase on the 1995 levels in six years. Reasons for change In opening this dissertation we made anecdotal reference to the political agenda that shaped the NHS. The NHS has historically been high in the public’s perception of a tangible measure of a Government’s success in delivering its regularly promised higher standard of living. It is partly for this reason, that successive governments have felt it politically expedient to invest increasing sums of money in measures for both expansion and improvement together with various drives aimed at increasing efficiency. (Ham C 1999) In the recent past there have been a raft of measures that have been produced which have all played their part in the evolution of the NHS to its current configuration and in doing so have expanded the role of not only the support worker but virtually all of the workers in the NHS at the same time. One of the first measures which was an overt indication of the forthcoming changes in working practice was the introduction of the performance indicators (Beecham L 1994) These were progressively introduced form 1992 onwards and in some respects could be considered the forerunner of the move towards National Service Frameworks. The original performance indicators imposed a duty or obligation on Trusts to carry out certain procedures within a specified maximum time. For example the indicators introduced in 1994-5 were on waiting times for first outpatient appointment and also for charters in General Practice. Although there were clear obligations on medical and nursing staff to make available sufficient sessions in order to see the patients, it is clear that the increased throughput of patients would clearly impact on the working practices (and work load) of the support staff. To a large extent, this can be seen from the figures presented at the beginning of this work. The 50% increase in staffing levels amongst the support staff reflects, in a large part, the changes that were consequent on the imposition of the performance indicators. The initial indicators proved to be quite onerous in terms of achieving compliance even though the later ones gave tighter requirements still. For example the 1994 indicators set a target of 90% of patients seen by a consultant within 26 weeks of a written referral letter being received from the General Practitioner in the major specialities of general medicine, general surgery and dermatology. (Editor BMJ 1994) It follows that this target is not quite as innocuous as it might at first appear. If we accept the fact that a substantial number of patients were already waiting for considerably longer than 26 weeks it represented a major shift in working practices to meet this particular deadline. Once the patients were seen it followed that they then had to have whatever treatment was thought to be appropriate. An increase in outpatients seen inevitably means an increase in patients waiting for inpatient treatment. So either the waiting lists go up further for inpatient treatment, or there is also a change of working practice to accommodate an increase in demand. This inevitably also impacts on the support staff as much as it does on the medical staff. (Langham S et al 1997) We shall consider this particular phenomenon in greater depth later when we consider the expansion of the nurse to specialist endoscopist and the running of one-stop clinics. Some novel methods were invoked to try to accommodate this shift in demand. There was a substantial increase in the frequency of day case surgery. Not only were a greater variety of surgical procedures being routinely carried out as day cases but it also resulted in more patients being assessed as suitable to undergo day case surgery. (HSE 2001) The same phenomenon of knock on effects arose form some of the other performance indicators. One of the original indicators was the percentage of patients seen within 5 mins of entering the casualty department. It follows that as hospitals strove to increase their performance indicators and the percentage of patients seen promptly rose, having been seen they then had to be treated and the same argument applies. Either there is an increase in the number of patients awaiting treatment in the A E departments, or there is a change in working practice to accommodate them and also to get them treated sooner. The organisation and efficiency of this system falls heavily on the support staff who clearly had to be able to accommodate this increased demand. (Langham S et al 1997) The indicators eventually began to involve inpatient statistics as well as outpatient ones. One, introduced in 1996, was on the number and availability of emergency operating theatres. More evidence of the reasons for this change comes from a paper by Scally and Donaldson (1998). We note that it was actually written by Liam Donaldson when he was a Regional Director of the NHS before he subsequently became Secretary of State for Health, so his comments can be taken with suitable gravitas. A critical analysis of the paper shows that it makes a number of points that are really overtly political, but it outlines the trend of change of emphasis where the improvements expected through clinical governance will not only be an â€Å"ideal goal† but will become a statutory requirement. This clearly pre-empts the changes prescribed in the NHS Plan. The paper outlines new goals â€Å"in which financial control, service performance, and clinical quality are fully integrated at every level† are behind the major thrust of the piece. Careful reading of the paper strongly suggests that inherent in the restructuring plans is a change in emphasis onto expansion of professional roles and greater working flexibility between professions which is fundamental to our considerations here. (Gray C 2005). We also note that the â€Å"stage was being set† for the potential role change of healthcare professionals in general and the four main precepts of this paper impact on that belief, namely: Clinical governance is to be the main vehicle for continuously improving the quality of patient care and developing the capacity of the NHS in England to maintain high standards (including dealing with poor professional performance) It requires an organisation-wide transformation; clinical leadership and positive organisational cultures are particularly important Professional self regulation will be the key to dealing with the complex problems of poor performance among clinicians New approaches are needed to enable the recognition and replication of good clinical practice to ensure that lessons are reliably learned from failures in standards of care It is clearly significant that all of these points were implemented and indeed, expanded, when Donaldson was appointed to the office of Secretary of State for Health and they can be seen as both enhancing and reinforcing the points that we have presented relating to the guidance from the Nursing Midwifery Council about the expansion of professional roles. Because of their seminal importance in the examination of our subject, let us consider the background to these points further. We note that Donaldson was originally recruited from a business background and the record shows that he has chosen to apply a great many sound and proven business principles to both the structuring and the workings of the NHS. Many of his strategies and perhaps ideas, have a clear ancestry in the Cadbury Report (1992) which effectively analysed the overall impact of governance and issues of changing working practices and consequent responsibility in the business world. The report focused on the issues surrounding an expansion of responsibility and a consequent failure to take responsibility for one’s actions, frequently passing on the implied responsibility to another employee in the same company. It found this practice to be both counterproductive and inefficient and frequently would lead to defensive stances and attitudes being adopted. When problems arose, they were therefore far more difficult to actively solve. (Lakhani M 2005) Donaldson was instrumental in applying this strategy to a clinical setting within the working practices of the NHS. This particular paper takes the view that by promoting individual professional responsibility he would be encouraging a system that would allow:- NHS organisations to be accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. By implication this argument extends to the expansion and role realignment in general terms throughout the NHS. We shall consider the elements in this paper which are of relevance to these arguments. Staff self-esteem is of great value to an organisation. Frequently this is associated with increased responsibility and a firm professional footing. (Davies HTO et al. 2000). Donaldson and Scally clearly espouse the virtue of professional responsibility at all levels in an organisation and encourage staff to take, rather than to devolve responsibility for their actions and indeed seek to ideally provide a ambience that is conducive to expansion of responsibility which therefore generally benefits the whole organisation. Tools of change Although we are primarily considering the support worker in this dissertation we must first broaden the agenda in order to set our examination in an appropriate context. There have been a number of Government White Papers, consultative documents and advisory initiatives that have concerned the workings of the NHS. Some have greater practical significance than others. There appear to have been significantly more in the last decade than previously and anecdotal and observational evidence would seem to suggest that these too, are increasing at an exponential rate. One of the landmark plans in recent years has been the NHS Plan. It has been compared by some commentators as being on comparative magnitude as the original inception of the NHS in 1948 (Shortell SM et al 1998). It is quite possible that a cynical appraisal of the Plan would see it is little more than the result of political rhetoric and pre-emptive manoeuvring as a response to the perceived public disquiet about the state of the NHS. On the other extreme the optimist might view it as a positive plan for major improvement. (Moss et al 1995). Having the benefit of hindsight, there is no doubt that it has been the catalyst for a number of significant changes in the NHS, it is, of course, totally dependent upon your own particular viewpoint as to whether these changes are regarded as beneficial or otherwise. One has to be extremely careful in evaluating such comments as clearly it depends on the criteria chosen for evaluation as to whether the reform will appear to be positive or negative. (Bilsberry J. 1996) One only has to consider the debacle which ensued after the introduction of the Griffiths Report in the 1980s (Griffiths Report 1983). This was considered to be a major reform of the management structure of the NHS. There was general agreement that the management had become to unwieldy, detached and inefficient with too many layers of management. (Davies,C et al. 2000), The Griffiths Report was commissioned with the specific purpose of streamlining the management profile and was charged with the specific responsibility of improving both efficiency and accountability. The subsequent plan was unveiled and introduced piecemeal. In the words of the Government appointed reviewer of the episode :- These were a set of reforms that were designed to â€Å"streamline the administration â€Å" of the NHS. It involved a major change in emphasis in the way that the NHS was run, and in short, it was badly conceived, patchily implemented and introduced piecemeal. By any critical analysis it proved to be a complete disaster. (Davidmann 1988) It is not actually possible to pass judgement on whether the plan would have been successful or not as its method of introduction was generally seen to be its downfall. In essence, its introduction was not managed in any contemporary sense of the word, it was simply imposed and the chaos that ensued prompted the government to institute another report to glean what lessons it could form the whole affair. (Davidmann 1988). It is fair to comment that the majority of reforms that have been introduced since that time have been far more professionally managed and their introduction (whatever their eventual outcome) have generally been comparatively smooth and uneventful (Bennis et al 1999) The area of change management as a science and discipline is both extremely involved and complex. Changing the structure of a massive and established organisation such as the NHS is clearly difficult with established attitudes, working practices and inherent inertia. The lessons learned from the Griffiths Report appear to have been successfully applied to the introduction of the NHS Plan (Bryant 2005) In specific consideration of the NHS plan we should note that the specific stated aims of the plan were to:- Increase funding and reform Aim to redress geographical inequalities, Improve service standards, Extend patient choice. These aims have been, to some extent translated into reality. Let us examine each in detail. The increased funding was specifically delivered in the March 2000 budget settlement and has been honoured in successive budgets since. The Chancellor of the Exchequer stated that the money made available would ensure that the NHS would grow by one half in cash terms and by one third in real terms in just five years. Our examination of staffing levels (above) would seem to suggest that this trend has been successfully established. In addition, he promised a  £500 million â€Å"performance fund† for specific areas which were to be identified by separate investigation as being in particular need of assistance. (Halligan et al 2001) This certainly directly impinges upon our considerations of support staff and we shall return to this point later. The geographical inequalities and service standards are specifically addressed in the introduction of the National Service Frameworks which are mechanisms for specifically addressing inequalities and setting of both targets and goals of performance and excellence on a National rather than a local level, (Rouse et al 2001) and have been progressively rolled out across the country. These measures have been established in collaboration with assistance and guidance from bodies such as the National Institute for Clinical Excellence (NICE) which has a remit to examine both practices and facilities with the specific aim of achieving national standards. ( viz. NICE 2004) (NHS KSF 2004) It has made a number of recommendations which appear to have a firm evidence base. (Berwick D 2005) We should perhaps take this opportunity to note that the Institute, although undoubtedly set up in response to a worthy ideal, is already finding itself short of funding to do the job that it was originally conceived for. Spokesmen have already commented that it is short of money to achieve the research necessary to justify its continued activity (Shannon 2003) Patient choice is a far more complex issue that it might originally appear. Initial examination might suggest that to give patients the freedom to go where they wish to get their medical care is a fine objective, but closer examination of the issue would reveal that it has numerous pitfalls. In the specific terms of the NHS plan, it actually means that the patient’s primary healthcare team has a more wide-reaching choice of where they choose to refer the patient. (Wierzbicki et al 2001). A patient may consider any number of factors which may influence their choice of hospital including such factors as the general look of the buildings, the geographical site in relation to their friends and family and what they have read or heard anecdotally about the hospital. None of these factors have any major bearing on the treatment that they will receive. It may be that they will discover that the waiting list is shorter at hospital A than hospital B. what may well be less obvious to the patient is that hospital A may have a shorter waiting list because the local primary healthcare teams know that it has a number of serious shortcomings and so they tend to refer their patients to hospital B which consequently has a longer waiting list. Of course , we mustn’t ignore the possibility that hospital A is actually more efficient that hospital B or that hospital C provides a more comprehensive, courteous and efficient service with greater expertise than hospital D, but the primary healthcare teams are generally best placed to see the outcomes of their local hospitals and will generally know where their patients are served better in each individual circumstance. (after Donaldson L 2001) In the context of our examination here, all four of these aims have potential impact on our subject as each of these objectives are effectively resolved by expanding, and in some cases changing, the roles of staff within the NHS. Clearly the impact will vary between different disciplines and indeed, different geographical areas, but the overall objective of improving the efficiency and introduction of patient orientated goals has largely been met by the three expedients of: a) making more money available b) adopting progressive management strategies c) increasing staffing levels and redefining some roles within the NHS ( after Dixon et al 2003) It is perhaps useful to consider the whole of the NHS Plan as part of a reform continuum which has shaped the evolution of the NHS since its inception. We have already highlighted the Griffiths Reforms, but other landmark reforms that impact upon our considerations of change must include the Agenda for Change (2004) which is primarily staff and employment orientated and is concerned with a number of measures including staffing levels, staff role descriptions and staff pay levels. It has only recently been implemented (September 2005) and, for our purposes here, should be viewed in conjunction with another Government White Paper which is the complimentary NHS Knowledge and Skills Framework (KSF 2004). This particular paper targets the need for both recognising and rewarding specific speciality orientated enhancement of both skills and knowledge that are actually relevant to professional performance in both designated areas and in professional performance generally. Reading of the provisions reveals that the general provision of  £280 million over a three year period to â€Å"develop specific designated staff skills†. One of the proposed mechanisms is to set up individual learning accounts which will be worth  £150 per year. It is not yet clear what the impact will yet be on support staff in either specific or general terms. The impact of these reforms seems to be felt on many levels. There appears to be a move towards the redesignation of roles, flexible working, skill mix and the redesignation of professional boundaries. The NHS Plan itself calls for a number of changes to be made in working practices, both general (conceptual) and specific. It also calls for a change in the actual roles of some healthcare professionals, including support staff. It goes into great detail about the need for some of these changes need to be established but it also has to be observed that there is actually very little detail in the Plan as to how these changes are either to be introduced or managed. It refers to the changes in general terms, there is actually very little detail relating to what it expects these changes to actually be in reality. (Krogstad et al 2002) If one were to produce an analysis of the pre-2000 structure of the NHS one could conclude that it had three major problems which were not consistent with the function, structure and organisation of a typical 21st century industry a lack of national standards old-fashioned demarcations between staff and barriers between services a lack of clear incentives and levers to improve performance over-centralisation and disempowered patients. (Nickols 2004) One observation that is also relevant to our considerations here is the phrase â€Å"seamless interface† appears very frequently throughout the document. Although it is primarily applied to the interface between primary and secondary care, it is also, both explicitly and by implication, applied to the interface between different groups of professionals within both aspects of the service. (Rudd et al 1997) In direct consideration of our subject, we can take this to mean that there is a requirement for seamless interaction between all factions of the operating theatre staff and between them and the other professionals in the hospital. (Dixon et al 2003) Other significant milestones in the changes in the role of support staff were the introduction of the National Service Framework. These are a series of recommendations, stipulations and targets which are designed to raise the performance to the level of the best across the nation rather than to have pockets of excellence surrounded by a sea of mediocrity (White M 2005). The issues surrounding the National Service Frameworks are huge, as they collectively cover most of the major therapeutic areas in medicine. The reason for their inclusion in this particular consideration, is because of their collective impact on the role of the support staff, who have to expand their role and skills in order to comply with their requirements. It is completely impractical to consider all of the implications of the National Service Frameworks so, as a representative â€Å"sample† we will consider just one, the National Service Framework for the elderly. In distinct contrast to our comments in relation to the Griffiths Report earlier in this piece, the introduction of the National Service Frameworks could be considered nothing short of exemplary. There have been consultation periods, pre-implementation pilots and possibly most importantly, a well publicised and staged National roll-out programme which was designed to implement each of the strategies in a graded and controlled fashion with the intention of trying to ensure smooth implementation across the country. (Nickols F.2004). If we consider as an exploratory example, a small portion of the National Service Framework for the elderly Standard Two, this states that it should ensure that: Ensure that older people are treated as individuals and that they receive appropriate and timely packages of care which meet their needs as individuals, regardless of health and social services boundaries. One could perhaps reasonably hope that such aspirations would have been unnecessary, but behind the actual words are a number of other concepts that are central to our consideration to the expanding role of the support staff. The concept of â€Å"Person Centred Care† is a central precept of the Standard Two. It is described with the intention of trying to allow the elderly to feel entitled to be treated as individuals and also to allow them to retain responsibility for their own choices for their own care. The expansions of the roles of the support staff comes primarily in the adoption of the main tenet of the concept of Person Centred Care and that is the introduction of the Single Assessment Process (SAP). This recognises that there are effectively a great number of support agencies that potential can be involved to look after the needs of the elderly, both in hospital and after discharge. Prior to the introduction of the National Service Framework, it was common practice for each agency to separately make contact with the patient and make their own assessment in terms of their own distinct considerations. We shall discuss this point later in the context of insularity of specialities. The end result of this process was the fact that, very commonly, the same (or similar) facts are repeatedly elicited on different occasions with all the implications that this type of duplication has on inefficient working and waste of resources. (Fatchett A. 1998). The SAP is designed so that any member of the health care team can assemble the information in such a way and in such a format that it will be of use to the other members of the team, or for that matter any of the agencies who might have a legitimate need for the information. This particular role expansion is designed to assist in reducing the amount of red tape that appears to be an inevitable encumbrance of many of the measures that are designed to assist the elderly patient, and only appears to finish up by hampering them. (Gott M 2000). The adoption of the Single Assessment Process is no more than one example, perhaps not so much of an expansion of the role, but a realignment of the role of support staff. It is still a fairly new concept and is central to the aims of the National Service Framework that the needs and wishes of the patient should be at the heart of the whole process. Because it is new, the extent to which it can accommodate these aims and aspirations alongside the day to day practicalities of service provision still has yet to be fully assessed. (Mannion R et al 2005) In some ways, this new role expansion can be viewed in parallel with the concepts of seamless interfacing and multidisciplinary team working which we have examined elsewhere in this dissertation. Given the fact that the Single Assessment Process has only been operational since April 2004, but the move towards multidisciplinary team working and the concept of the seamless interface has been apparent and espoused for some years (Mason et al 2003). The latter were effectively translated into reality without major upheaval, one can be reasonably confident that the same will eventually be said for both the Single Assessment Process and its implications for both staff and patients. We have described this particular example of role expansion more as a realignment because, at first sight, its implications are quite subtle when compared to other examples that we shall be considering, but equally they are quite fundamental, as they impinge upon the role

Candides Growth Essay -- Philosophy

In the story "Candide" Voltaire uses satire to criticize the philosophical views of the enlightenment period and illustrate his outlook of how an individual should view their own existence by Candide's character development throughout the story. Voltaire is able to do this by introducing Candide into two contrasting philosophical views of characters that play a large role in his life, Pangloss and Martin. At the beginning of Candide's quest he followed Pangloss's theory of the best of all possible worlds. Pangloss's ideas hinder Candide on his satire filled journey to find Cunegonde because he is overly optimistic. On his journey his outlook changes by the pessimistic influence of Martin. Which helps him develop into his own character at the end of the story. The first theory that Candide is introduced to is the oracle of the house that he was raised in Dr. Pangloss. Voltaire writes that " Pangloss gave instruction in metaphysico-theologico-cosmoloonigology" this is a satire of the German philosopher Gottfried Leibniz (Lawall "Candide" 520) . Leibniz created the doctrine of optimism which claims "which holds that our world is the best of all those possible" (Strickland 18). Lloyd Strickland states "the most obvious objection to optimism, namely that this world contains far too much evil to be plausibly identified as the best. claimed, for instance, that Voltaire's aim in Candide was to refute, or confound Leibniz by 'bombarding him, so to speak, with the evil of the world" It is obvious to the reader that this is Voltaire's motive (Strickland 19). Voltaire continues to insult Leibniz view by writing "He proved admirably that there cannot possibly be an effect without a cause and that in this best of all possible worlds the Baron... ...tudies 31.2 (2002): 199. Academic Search Premier. Web. 29 Feb. 2012 Lawall, Sarah. The Norton Anthology of World Literature "Candide". 2nd. New York: W. W. Norton and Company, 2002. 522-580. Print. Kasten, Madeleine, and Curtis Gruenler. "The Point Of The Plow: Conceptual Integration In The Allegory Of Langland And Voltaire." Metaphor & Symbol 26.2 (2011): 143-151. Academic Search Premier. Web. 3 Apr. 2012. Putnam, LuElla. "Boredom, Insignificance, And Death In Voltaire's Candide, Charles Baudelaire's The Flowers Of Evil, And Paulo Coelho's Veronika Decides To Die." Atenea 30.1-2 (2010): 67- 78. Academic Search Premier. Web. 3 Apr. 2012 Strickland, Lloyd. "False Optimism? Leibniz, Evil, And The Best Of All Possible Worlds." Forum Philosophicum: International Journal For Philosophy 15.1 (2010): 17-35. Academic Search Premier. Web. 3 Apr. 2012.

Kids :: essays research papers

Introduction: A) Broad discussion of topics: Discuss Kristin's thesis 1. Evolution and understanding of it Macro vs. Micro VIST framework Darwin/Mayr 2. Tools-language Open vs. Close ended questions How vs. why questions Best way of asking to reveal causal framework -explain causal framework: Essentialism (Gelman), Teleology (Keleman), Bloom, and Theory of Mind Ultimate Cause (natural) Why questions Proximate cause How questions 3. Children's and adults understanding of biology/evolution/metamorphosis Evans Species-proximity to humans Mayr 4. Natural kinds vs. artifacts 5. Creationist-God...wanted, created, gave, made Naturalistic-need, adaptations, evolve, growth Intelligent design- intention, purposeful B) Rationale for this study 1. Give close-ended questions to younger children so they can understand the broad questions and because they may not be able to ellaborate or communicate well enough. Hood/Bloom: When children start answering causal questions of parents and when they start asking questions of their own. C) Hypothesis (still being established...have to wait until finished coding Kristin's data to predict the results of mine) Method subjects: 20-25 Age: 5 and 6 years Gender: 1/2 male and 1/2 female open-ended questions -divided into how and why - questions taken from coding results of previous study done by Krisitn - analyzed and took the most typical explanations Present the most frequent of those close-ended questions presented to older age group with 1 explanation per pattern : 4 reasoning patterns: (Will be inserted in paper with actual questions once the data has all been coded and analyzed from Kristin's study) Questions altered to fit all items Use item used with older kids to see if they are giving the answers the older kids did. Procedure 4 parts of the procedure will be given sequentially: 1. Warm-up 9 items (pictures) looking at interacting Ask child if the card is an animal or a human to see if they understand 2. Card practice agree/disagree face cards 3. Open-ended questions "how/why do you think..." between subjects footnote Kristin's study 4. Close-ended questions 3 humans, 3 butterflies, 3 frogs, 3 mammals, 3 artifacts order randomly determined without replacement once item is chosen: They will be told

023 Understand Child and Young Person development Essay

Age range Explain the sequence and rate of development 0-3 months When born, babies show innate reflexes, such as swallowing and sucking, rooting reflex, grasp reflex, startle reflex, walking and standing reflex; in the first month babies become less curled up and the startle reflex is starting to fade; toward the end of the third month babies start lifting and turning their heads. 3-6 months When lying on front babies can lift their arms and legs balancing on their tummies; they can reach and grab a toy and they can pass it from one hand to another; they can also roll from their backs to front; around sixth month babies are becoming able to sit with support (e. g. high chair). 6-9 months Babies can sit without support; they are beginning to crawl or find other ways of being mobile (bottom-shuffling); starting to use fingers to feed. 9-12 months Babies are becoming very mobile, fast crawling, standing up by the furniture, some babies walk along the furniture using their hands to hold on; developing abilities to handle objects and putting them into containers; babies able to feed themselves with fingers. 1-2 years At the beginning of this period babies are beginning to walk and around 18 months they are becoming more and more skilful on their feet, moving faster; toddlers around this age begin to sit and push with their legs to move on the sit-and-ride toys. Towards their second year children walk confidently, they can run and climb; towards the end of the second year some children are becoming ready to start potty training. 2-4 years In the third year children start potty training; they become able to push with feet or peddle a tricycle; children can walk upstairs alternating their feet; towards the end of the this period children are skilful enough to feed and dress themselves; they are able to do threading, pouring and they can use scissors. 4-7 years Physical development less rapid, however skills are becoming more refined and movements more coordinated. Ability to kick and control ball; development of fine motor skills essential for handwriting. 7-12 years Good coordination of small and large movements; growing physical skilfulness means task can be done quicker, more accurately and more confidently; neater drawing and writing; accurate cutting. Between 9 and 12 children gain even better coordination and speed in fine and gross motor skills. Around 11th year the bodies of some girls are starting to change (growing breasts) and some might start their periods. 12-16 years Gradual body changes in both girls and boys (girls physically mature quicker [around 15/ 16] than boys [around 17/18]. Fast body changes may affect spatial awareness which can become occasionally poor as a result. 16-19 years The maturing of the body is finishing with the full development of sexual organs; the body is taking a distinctive female or male shape. 023 Table 2: Intellectual and cognitive development Age range Explain the sequence and rate of development 0-3 months Quite early on babies are able to recognise the smell of their mother and her voice; later they become familiar with voices of important others and they can be calmed when they hear them; they are interested in faces. In their 3rd month babies start to differentiate between day and night (settled routine); babies become interested in mobiles and other objects around them. 3-6 months Babies are becoming interested in what is happening around them, turning their head in the direction of interest; objects are being explored by hands and mouth. 6-9 months Developing fine motor skills allow babies for a better exploration of objects by handling and touching with fingers; around 8 or 9 months babies understand object permanence (objects continue to exists even when out of sight). 9-12 months Babies are more aware of what is happening around them, they are starting to understand routines through signals (bib = food) 1-2 years Children enjoy pop-up and posting toys and in their 2nd year they are starting to have a go at simple jigsaw puzzles and building bricks. 2-4 years Children pretend play with miniature world; they more interested in books, mark making and painting. In their fourth year children are able to concentrate and focus longer on activities which which caught their interest. 4-7 years Children begin to do some simple counting and calculations, recognizing letters is followed by gradual decoding of simple words and later by reading. 7-12 years Reading and writing is becoming easier, children start reading silently to themselves. Play becomes more organized and follows rules. Development of thinking and reasoning is demonstrated through independent problem solving. 12-16 years Further development of reasoning and problem solving; children are gradually starting to understand more abstract concepts. 16-19 years Cognitive abilities are becoming further refined, leading to high level skills in young people. 023 Table 3: Communication development Age range Explain the sequence and rate of development 0-3 months To start with babies express their hunger, tiredness or other discontent through crying; around 5th/6th week babies start to coo when content; in the third month babies start smiling and reciprocate smiles. 3-6 months Babies starting to understand a little of what is being said and they are starting to give some communication signals themselves (e. g. raised arms when they want to be picked up). 6-9 months Babies become quite vocal, babbling with a differentiated tuneful string of sounds. They are also starting to understand various important key words connected with their routines (e. g. ?dinner? ). 9-12 months Babies clearly show they understand more of what is being said around them/ to them. Babbling is still main way of communication. 1-2 years First meaningful sounds/ words are beginning to emerge around 13 months, and at the end of 2nd year children might have a vocabulary of about 200 words. 2-4 years Language is becoming a powerful means of communication. From connecting two words first children are beginning gradually to build up sentences and their talking is becoming understandable even to those who are not in regular contact with the child. Even though there might be the odd mistake in the sentence structure, the language toward the end of this period is becoming fluent and children ask questions and generally enjoy expressing themselves through language. 4-7 years Children are becoming involved with written language – they are starting to learn to read and write. 7-12 years Reading and writing becomes easier now; at the beginning of this period children enjoy telling jokes to others; apart from chatting, children are beginning to be able to form a simple argument and be persuasive, they are becoming increasingly able to negotiate with others. Their writing shows more grammatical awareness as well as own imagination. 12-16 years Reading and writing skills are becoming very good and children are becoming increasingly skilful in negotiating and persuasion of others (peers and adults). 16-19 years Communication with peers is becoming very important; differentiation between formal and informal language and its use in real life is becoming more and more important; young people use different means to communicate (via phones, mobile messaging, emails, facebook, etc. ). 023 Table 4: Social, emotional and behavioural development Age range Explain the sequence and rate of development 0-3 months First social contacts are being established mainly during feeding; at the end of the first month babies start to show first smiles which then gradually become response to familiar faces. 3-6 months Babies smile and squeal with delight when playing with familiar others. 6-9 months Babies try to stay close to their primary carers and around 8 months babies may become distressed when their primary carer leaves. 9-12 months Babies are fixed on their carers and do not want to be with strangers. 1-2 years Children start notice other children around them and they show some interest in them and later start parallel play. They also start show some frustrations and tantrums as they gradually discover some boundaries. 2-4 years Children play alongside others and may start copying their actions. Around the third year children become more aware of others and their needs which also reflects in their play which is gradually starting to be more and more cooperative. Children enjoy being praised by adults. 4-7 years Developing language is helping children to form better relationships and children begin to show some preferences in friendships. 7-12 years Friendships are becoming more stable and more important and may influence decision making (if my friend is doing something I might be more likely doing it also). Gender specific play is becoming more apparent. Children start to compare themselves to others. Children enjoy being given some responsibilities. 12-16 years Friends and friendships are very important and gradually opinions from friends might feel more important that those of parents/ carers. This leads to exploration and challenge of the boundaries of relationships as well as learning to deal with disagreements, arguments, etc. There are anxieties coming from pressures from school. 16-19 years Young people enjoy being with their friends, they are finding discovering their own identity and sense of belonging to a group/ groups of specific characteristics which defines for them who they are (religious groups, sport group, goth, etc. ) 023 Table 5: Moral development Age range Explain the sequence and rate of development 0-3 months 3-6 months 6-9 months 9-12 months Children might start paying attention to â€Å"no† and might stop their behaviour for a moment. 1-2 years Children are beginning to understand â€Å"no† and they start using it themselves. 2-4 years At the beginning of this phase still no understanding what is right or wrong but children understand when they are said â€Å"No†. Later they become able to follow some simple rules. Around 4 years children are becoming thoughtful at times but most of the times will decide what to do on the basis of adult approval. 4-7 years Children are beginning to understand rules; they try to understand them, follow them and may attempt to create their own rules where no rules are given (made-up game with friends). 7-12 years Children share their knowledge of rules with others and will readily point out if someone breaks the rules. Later they are becoming more aware of behaviour consequences and they are generally becoming more thoughtful. 12-16 years Children are beginning to be aware of a bigger picture – rules of communities and societies and they are beginning to understand the need for that. 16-19 years There is a interest in moral issues, finding out that right and wrong is not always black and white. Questioning and testing of rules. A2 Answer the following questions. 1. What is the difference between ‘sequence’ of development and ‘rate’ of development? 2. Why is the difference important? (Ref 1. 2) Q1. What is the difference between a sequence of development and rate of development? Sequence of development is the order in which development occurs, e. g. children are able to sit before they learn to crawl. The order of the sequences in development are always the same (even though there might be some individual differences: babies always learn to move about before standing up and walking, but some babies bottom-shuffle instead of crawling). Rate, on the other hand, is the speed in which individuals go through the stages/ sequences of development. Most children learn to walk when they are about 12 months old. However, some babies might be ready to walk when they are 10 months old and others when they are 15 months old. Individuals might also be developing with different rate in different areas, e. g. some children might be developing quickly physically, but their speech might be delayed. These individual differences are results of genetic predispositions and other biological influences as well as environmental stimulation. Q2. Why is the difference important? Knowing the sequences of development in different areas is important for practitioners to be able to plan accordingly and therefore to support the development in individuals. The rate of the development is important in terms of recognizing any atypical development and recommending/ searching any additional interventions when needed. TASK B Complete table; Research and report B1 Complete a table as shown on the following page, identifying the different personal and external factors that influence children and young people’s development. (Ref 2. 1, 2. 2) B2 Produce a report to demonstrate your knowledge and understanding of differing theories of development. This report should identify how these theories have influenced current practice and include the following: Cognitive (e. g. Piaget) Psychoanalytic (e. g. Freud) Humanist (e. g. Maslow) Social learning (e. g. Bandura) Operant conditioning (e. g. Skinner) Behaviourist (e. g. Watson) Social pedagogy. Over the years there have been many theories trying to explain certain aspects of development, behaviour, learning, etc. In the following text we will look at the most influential theories which are being used by practitioners in better understanding as well as day to day work with children and young people. After a brief description of how an individual theory was founded, we will discuss the key points for work at nurseries. Theory of cognitive development (Constructivist approach) Theory of cognitive development is connected with the name of Jean Piaget (1896-1980) who through work on intelligence tests started to notice how children at same stages make very similar mistakes in their tasks and problem solving approaches. Piaget then closely observed his own children, capturing their development in details and later using these observations to create a theory of cognitive development. Piaget considered children as active learners who create ? schemas? (believes) about the world based on their experiences. This is how they make sense about what is happening around them. However, a child? s schemas are going to be challanged time to time by new and unexpected experiences and as a result existing schema will have to adapted to fit these in (e. g. touching something hot will alter the notion that everything is safe to touch and child will learn that certain objects can hurt when being touched). Piaget? s theory influenced the practice by having a ? child-centred? approach. In our setting, for example, we make regular observations on what our children are interested in and what they like to play/ do. After careful evaluations and identifications of possible next steps of development we plan activities which as well as reflecting children? s interest also further challenge them to encourage the development. Psychoanalytic theory of personality Sigmund Freud (1856-1939) suggested that every personality has got three parts to it – id, ego and superego. We all are born with id, which is the part of our personality that is driven by our desires and reflects in pleasure-seeking behaviour. Id is selfish and passionate and it is purely after satisfying its needs, known as ? gratification?. However, through social contact and learning babies/children gradually learn to be aware of the outside world and eventually of needs of others. They will be developing ego, which is able to plan the actions so the needs of the individual can still be met but in more socially desired way, e. g. ability to wait for once turn when the food is being served at pre-school settings. This is called ? differed gratification?. Later, as a result of further parenting and learning about social and cultural values, the superego is developed. Superego could be described as an internalised parent as the child is starting to be aware of what is good and what is bad without external reminder – e. g. I must not hit because it hurts. If the behaviour trespasses the imperatives of the superego, the individual will feel guilt as they are now aware that their behaviour was bad (this is referred as ? conscience? ). Apart from judging conscience, superego has got a notion of an ego-ideal to which it will strive. When ego demonstrates good behaviour the ego-ideal part of superego will reward this, e. g. feeling good after doing something for someone else even when external praise is not present. Even though Freud has been criticised for basing his description and explanations of development on sexual motives, some of his theoretical concepts are now widely accepted (e. g. the concept of unconscious mind – id and most of superego). One could say that orientation on children? s needs might be partly inspired by Freud? s ideas about the dynamics of id, ego and superego. Too strong superego and suppressed unconscious id will lead to many problems in adult life, where individual tries to live mainly by what is required by the outside world rather than allowing themselves to follow own desires. In early years healthy development of ego can be supported by putting the child and their needs in the centre of our attention; activities and work with children is individualized and child-led, yet still well planned and safe. For example, in our setting we might notice that a particular child enjoys opening and closing doors, gates, etc. Instead of completely discouraging him from doing that we might identify situations when it might be appropriate for him/her to do so and explain the necessary things around it in a child-friendly way (e. g. : When everybody has got their shoes on, you can open the door, Henry. , We will keep the gate closed now, because we are going to play in the yard now. , Mind your fingers when closing the door – you could close them in and that would really hurt. , etc. ). If we say ? no? to children it is good to make sure that the child knows about the reasons behind our decisions (even though they might find it hard initially anyway, they are more likely to come round and understand it in their own time). Humanistic theory of motivation and personality – Abraham Maslow (1908-1970) Maslow studied motivation in people and came up with what is now known as Hierarchy of Needs. Maslow divided the needs into five categories (physiological, safety, love/belonging, esteem, self-actualisation) and put them in hierarchical order from the most essential and basic needs to higher-order needs. Maslow argues that it is necessary to fulfil the needs from from the bottom of the hierarchy first to be able to meet the needs of higher order. Only when all the other lower needs are met, an individual can focus on fulfilling the highest needs of self-actualisation, such as creativity, problem solving, morality, etc. In our practice we are aware, that when a child is for example overtired and hungry (the most basic physiological needs), there is no space to try to fit in other things, e. g. ?wait for your turn? , ? say please? ,†¦. (which would be working on their higher order needs, such as love/belonging (friendship) or esteem (respect for others, respect by others). This child at that stage needs to be fed and put to sleep as soon as possible and other input has to wait until the child is again able to tune to it/ receive it. Social cognitive theory Social cognitive theory has its roots in behaviouristic approach. However, Albert Bandura (born 1925), even though accepting learning by conditioning, argued that lots of learning happens through social observations (? observational learning? ). Observational learning is when children copy what other children or adults do; in comparison to conditioning, observational learning happens spontaneously and often without the need for reinforcement. Cognitive abilities seem to play an important role in observational learning as children need to be capable to notice the activity itself as well as remember it accurately. As staff we need to be mindful in the way we act and interact in front of children as they are likely to copy our behaviour. In accordance with the social cognitive theory we try to set good examples to the children in our settings by showing good manners and being courteous to them as well as to one another. Behaviourist approach to learning – operant conditioning Operant conditioning is based on classical conditioning (I. P. Pavlov; J. B. Watson), which teaches that certain behaviour/ reaction can be connected with a stimulus through conditioning, e. g. fear of cats after a bad experience with a cat. F. B. Skinner (1904-1990) however took this a bit further and through experiments mainly with pigeons and rats showed that learning can be strengthen by reinforcements, such as positive reinforcement (praise, sticker, attention, etc. ), negative reinforcement (this is removing something which is negative from the situation so it no longer poses a ? threat? or causes negative emotions and the whole experience becomes more positive, e. g. child does want to play with a toy because it is scared of the noises it makes – by switching the sound off, the child is able to explore the toy) and punishers (negative consequence which is likely to prevent individuals to repeat their behaviour – e. g. touching hot iron). Skinner researched most effective ways to retain the learnt behaviour and he found out that even though continuous positive reinforcement is good at the beginning of the learning, later unpredictable positive reinforcement keeps the learnt behaviour in place for longer period of time. This is because even though the reward comes frequently, we are not sure when it is going to come next and therefore we keep doing the behaviour. At our setting we might be using operant conditioning for example when we are helping a child to potty train. First every sitting on the potty, regardless of results will be rewarded. When the child gets into the habit of sitting on the potty, then only successful potty session will be rewarded with a sticker (however praise for trying when unsuccessful remains). When starting to do regularly this stickers might gradually become praise and sticker will be awarded if the child successfully asks for potty when they need it. Behaviourist approach to learning – Classical conditioning J. B. Watson (1878 – 1958) followed I. P. Pavlov? s work on classical conditioning with animals (dogs salivating when food arrived became then salivating even at the mere sight of the bowl; Pavlov took this further by conditioning completely unrelated food stimulus, such as bell or light, which after regular presence at the mealtimes would later on its own initiate the salivating response in dogs). Watson showed that classical conditioning is possible in humans as well (famous Little Albert experiment, where a baby was conditioned to have fear of rats). Classical conditioning is not really used in practice as a active way of teaching, however its theory can be used for observational purposes (e. g. recognising when sucking thumb signals hunger etc. ). Social pedagogy Social pedagogy is a discipline which brings together theory and practice in order to assure the best and holistic way of supporting children in their development and education. The overall aim of social pedagogy is to give children and young people the best possible chances for their future lives. In accordance with social pedagogy the Early Years Foundation Stage Framework (EYFS) has been devised to capture the development in early years and to help professionals to monitor, plan and support effectively individual development. For better and focused understanding the development has been divided into seven areas, out of which three are recognised as prime areas (Personal, Social and Emotional Development; Communication and Language; Physical Development) and four are described as specific areas of development (Literacy; Mathematics; Understanding the World; Expressive Arts and Design). The support the professionals can provide is differentiated into helpful advice in positive relationship and suggestions for enabling environments. In EYFS we can see influence of Piaget? s work in enabling environments where the focus is predominantly on individual? s own experience. We can also strongly identify the theory of ? zone of proximal development? by Vygotsky (cognitive development) in EYFS as we can easily identify where children are in their development, what is the next developmental stage for them and how we can support this next step. 023 Personal and external factors influencing development B3 Personal Factors: Give ONE explanation of a positive influence on the development of children and young people Health status: given by genetic predispositions as well as environmental factors, such as diet, pollution, stress, etc. If obesity is genetically passed on in the family than healthy diet together with developing positive attitude towards regular exercise will help the child to maintain a good health. Disability: Physical impairment, such as missing or underdeveloped limb Wheel chair together with barrier free environment (e. g. lifts, ramps, low sinks, etc. ) will help to support independence of an individual. Sensory impairment: visual impairments, hearing impairments, death-blindness, When working with individuals with visual impairment, we can use the other senses to compensate and provide necessary stimulation which helps the development, e. g. using special toys/ learning material which uses touch and sound as a mean of gaining information. However, if there is some vision left (which usually there is), the environment can be adjusted by using contrast colours, non-reflective material, good lighting, etc. Learning difficulties: Dyslexia, dyspraxia, dysgraphia, dysortographia, ADHD, ADD Children with ADHD benefit from having a regular routine. Activities needs to be short and well planned with simple and easy to follow instructions. Hands-on activities with regular physical exercise and lots of praise are essential. External Factors: Poverty and deprivation: poor diet, inadequate housing, lack of education, lack of access to play and leisure, low aspirations and expectations Good education can help the individual to break from the poverty and secure them a better brighter future. Family environment/background: neglecting parents, abusive parents, parents with alcohol or other drug-taking problems, ill parents who are not able to provide adequate environment for their children, etc. Parents who are ill and no longer able to fully provide for their children could be provided with carers who would help with the overall smooth running of the household, caring for needs of the disabled parent and the needs of the children, while keeping the family itself together. Personal choices: from certain age children/ young people make some decisions for themselves which can have effect on their development, e. g. taking drugs, changing their diet, etc. To help to prevent drug-taking it is important to support the development of a positive self-image and healthy self-esteem; education and raising awareness of dangers of drug-abuse is also a helpful preventative measure. Looked after/care status: children in residential care, in foster families, in their own family but having care status (they are the responsibility of local authorities). If children are being fostered it is beneficial if siblings can stay together. Education: Educational system, through family itself, through other groups (religious groups, sport groups, hobbies and interests, etc. ) Finding out strengths of an individual (which do not have to necessarily academic) and building upon those to build a healthy self-esteem and recognition of self-worth – this can help to compe with other weaker areas in a positive way. 023 Task C Report Produce a short report in the form of an induction pack for new staff at a setting, covering the following. a. Give two examples of assessment methods that could be used to monitor a child/young person’s development. (Ref 3. 1) b. Give three examples of why sometimes child/young person’s development does not follow the expected pattern. (Ref 3. 2) c. Give one explanation of how disability can impact and affect development. (Ref 3. 3) d. Give three examples of different types of intervention that could promote positive outcomes for the child/young person, where development is not following the expected pattern. (Ref 3. 4) a. In our setting we use several assessment methods to monitor our children? s development. The most used one is a short free description on sticky labels – these capture a specific short observation in a specific area of development (e. g. Physical Development); the date and the identified area/ areas get recorded on the label. This method of recording information is useful for gathering evidence of the progress of development in specific areas and building a developmental profile of an individual child. We also use specific observation sheets, on which we capture a more detailed and complex observation. In the next section on the sheet the observation is evaluated and areas of the development are identified (often more than one). In the last section we identify the next steps for the child and how we can help the child to achieve that. We have two types of observation sheets in our settings following this format – one is purely written observation, the other one is a photo observation sheet. This method of recording and evaluation allows us not only to add to the developmental profile of each child but also to plan effectively to further support the child? s development. b. There are many possible reason why at times the development might not follow the expected pattern. Apart from the most obvious ones, such as disabilities and special learning needs, the development can get affected by external factors, such as environmental reasons, cultural reasons, social reasons; and specific individual reasons, such as emotional reasons, physical reasons and communication difficulties. Environmental reasons: Among environmental reasons which may affect child? s development is for example where and in what conditions a child lives and what type of school they attend. Social reasons: There might be big differences between children in terms of wealth of their families, family status and family structure (big family with strong bonds in comparison to divorced parents with negative mutual relationship), education of parents as well as their ability to tune themselves to the needs of their children – all of these will affect the way children will be developing. Communication skills: Slower developing communication skills have got potential to negatively influence the development in other areas. The inability to effectively express themselves may result in frustrations in children and aggressive behaviour as well as consequently lower literacy skills. Similar effects can be observed in children whose families? language is not the dominant language of the country. If the dominant language is not fully acquired the child may significantly struggle once at school. c. Disability can affect more than one area of development as children can become frustrated and their self-esteem can be lowered. The attitudes of low expectations and stereotyping by others will also have a secondary negative impact on a child? s development. d. There are several ways how difficulties in development can be recognised, monitored and positively supported. Educational establishments will have appointed SENCO, a person who is responsible for identification and organising further support for children with special needs. If appropriate Educational psychologist will be contacted to make a full assessment and recommendations in how to support individuals in education (behavioural problems and learning difficulties). Suggested interventions may be discussed with parents and with learning support assistants and individual educational plan might be written up and followed. If there are any issues with speech and communication, Speech and language therapist will be consulted – the outcomes of the assessment will lead to a specific plan of action, often involving regular contact in which special exercises will be explained, practised and taught to children and their parents/carers/other professionals for them to be able to support the children outside the sessions. If a child? s physical development is affected, physiotherapist can provide help with special exercises and massages to aid the physical development, maximize the range of movement and develop the appropriate movement control. Task D Report Produce a report which explains the following: a. Why is early identification of speech, language or communication delay important for a child/young person’s well-being? (Ref 4. 1) b. What are the potential risks for the child/young person’s well-being if any speech, language or communication delay is not identified early? (Ref 4. 1) c. Analyse the importance of early identification of the potential risks of late recognition to speech, language and communication delays and disorders. (Ref 4. 1) d. Who might be involved in a multi-agency team to support a child/young person’s speech, language and communication development? (Ref 4. 2) e. How, when and why would a multi-agency approach be applied? (Ref 4. 3) f. Give four different examples of play opportunities and describe how you would put them into practice to support the development of a child/young person’s speech, language and communication. (Ref 4. 3) a. Early identification of the language and communication difficulties is important as it can support the development to prevent further (secondary) impact on other areas. Also, as the brains in young children have not finished their development, the earlier we can intervene, the better prospects of success we have. b. Problems in language and communication can have a negative effect on other areas of development, such as cognitive and social development. Children with language and communication difficulties are more likely to struggle at school in learning to read and write, which can have further negative impact not only on other subjects but more importantly on their self-esteem. Children with such problems can become gradually isolated. c. Early identification of the potential risks of late recognition to speech, language and communication delays and disorders is very important in terms of putting the most appropriate interventions in place to support the development and benefit the children? s needs. Well timed and well tailored intervention has got the potential to optimize the development and to minimize potential negative impact for other areas of development. d. In the multi-agency team to support the child with speech, language and communication there will be the child? s GP or a health visitor, who will make a referral to a speech and language specialist. If there is a suspicion that the communication difficulties are connected with learning difficulties Educational Psychologist will be consulted. When it is decided on the type of intervention needed, the parents, the educational setting professionals and the rest of the team should work together in order to implement the chosen intervention in order to meet the needs of the child. e. Multi-agency approach is used when parents and/ or other professionals (such as GP, early years settings, etc. ) have recognised that a child is in need of additional help to aid the development. Different professionals are involved in the assessment of the needs (e. g. GP to assess potential hearing or other impairments) and speech and language therapist devises the best possible individual support. Multi-agency approach brings together different fields of expertise to assure the best possible outcome for the child. f. There are many informal opportunities how children? s communication and language development can be supported. These might often be more effective than formal exercises as they naturally meet the child in they world of play, making it more motivating and fun. Nursery rhymes and songs – Children enjoy joining in nursery rhymes and songs. These are short and memorable and their rhythmical pattern make them perfect little exercises for developing language, pronunciation and fluency (good practice when dealing with stutter). Books are perfect for developing passive and active vocabulary, understanding meaning of words and learning correct sentence structure informally. Books are a wonderful way to spark children? s imagination as well as teaching them to express themselves about the world around them by providing the relevant vocabulary. Pictures in books make it possible for children from the earliest age to actively engage with the story as well as to engage in a dialogue with another person. Dressing up and role play again helps the child in an informal way to engage in talking and communication with others whilst enjoying the imaginative play. Puppets are a fantastic way how to involve children in communication through play. Children are fascinated by puppets and enjoy adults taking active part in their play, which again allows for an opportunity to develop language and communication in a fun way. 023 Task E Complete table Complete the table on the next page, showing how the different types of transitions can affect children and young people’s development and evaluate how having positive relationships during this period of transition would be of benefit. Additional Guidance Different types are: a. Emotional, affected by personal experience, e. g. bereavement, entering/leaving care. b. Physical, e. g. moving to a new educational establishment, a new home/locality, from one activity to another. c. Physiological e. g. puberty, long-term medical conditions. d. Intellectual, e. g. moving from pre-school to primary, to post-primary. (Ref 5. 1, 5. 2) Give ONE specific example of a transition Give ONE possible effect on children and young people’s development Evaluate the benefit of a positive relationship during this period of transition ~ provide ONE example Emotional: Bereavement Depression which may affect sleep pattern, children may become lethargic and less interested in engaging in any activities which may affect they social, emotional and cognitive development Positive relationship with open communication and listening skills allows for a child to ask difficult questions and share their worries and sadness, to talk over difficult memories and anxieties about the future. This may help with overcoming the past and the sadness. Physical: Moving home Moving home may effect the children social development as they may lose previous friends and find themselves unable to fit in new friendship groups. Some children might start having food issues, such as overeating to deal with anxieties. This can affect their emotional, social and physical development. Positive relation can provide a helping hand with dealing with the new situation while supporting the self-esteem and encouraging the confidence in a young person. Positive relationship can also act as model of skills of how to establish a new relationship. Physiological: Gaining a physical disability – e. g. lost limb Withdrawal – children may become very solitary, unable and unwilling to join in with their peers, which can affect their physical, emotional, social as well as cognitive development. Positive relationship will communicate acceptance and healthy support in dealing with a life-changing situation; this should help in dealing with difficulties as they come Intellectual: Moving from pre-school to primary school Lack of concentration and motivation as the child might feel overwhelmed by new routines and new demands which they might find very difficult – this may affect their natural cognitive development and they might regress into safer younger stage of development. Positive relationship will allow for a child to feel safe, valued and as achieving (in their own pace) by identifying the appropriate approach of working with the child with the sensitivity to their specific needs and pace of development.

Citizen Kane Breakfast Montage Essay

Abstract: While it is evident to the viewer that Charles and Emily’s marriage is falling apart during Citizen Kane’s breakfast montage, the mise-en-scene and technical devices used to reinforce this idea are less recognizable. The variation of the actors’ demeanors and placement, the progression of costumes, and the use of lighting subtly support the presentation of a deteriorating marriage, and furthermore, of Kane’s inability to sustain a successful, lasting relationship due to his career. The mise-en-scene and technical devices used in the montage are by no means limited to this portion of the film. In fact, they are found in numerous scenes throughout the movie to reveal other relationships that have fallen apart as a result of Kane’s profession, such as his friendship with Jed Leland and romance with Susan Alexander. The actors’ attitudes in each sequence in the montage and their placement in relation to one another are each examples of the mise-en-scene portraying Charles and Emily’s feelings toward each other as time passes in their marriage. The introduction to the montage shows the viewer two individuals playfully flirting after a long night of parties. Charles even plays the role of a butler as he serves his wife. Emily on the other hand, giggles and smiles as she begs her husband to stay home with her a little longer before he goes to work. As each successive sequence passes, Emily becomes reprimanding as her husband begins to spend more time at work, scornful when he insists on putting Mr. Bernstein’s gift in the nursery and when he insults the president in his newspaper, and eventually sad as she sits at a silent breakfast table reading the rival newspaper of her husband’s. Charles tone of voice evolves from flirtatious in the opening sequence, to powerful and controlling as his paper starts to become more successful, to critical when his wife starts to question his authority and literary topics, to demanding as he tells Emily â€Å"people will think what I want them to think.† This last controlling statement reflects a later scene, where a drunk Jed Leland writes a truthful article about Susan Alexander’s terrible opera performance. Kane and Leland initially wrote a declaration of principles stating that the newspaper would always bring the people honest news. To advance his career, Kane stepped away from that principle and only showed the people what he wanted them to see. The difference between Leland wanting to be an honest reporter and Kane wanting to become a successful businessman, no matter what the cost, destroyed the men’s friendship. Not only do Charles and Emily’s tone of voice change with each successive sequence, but the length of conversations and the distance between the couple also change by becoming shorter and more distanced. The first sequence is a long, flirtatious banter consisting of talk about parties and Emily’s beauty with little talk of the newspaper between the married couple sitting next to each other. Each progressive breakfast has a shorter conversation dominated by talk of the newspaper as opposed to the couple’s relationship. After the first breakfast, Emily and Charles sit on opposite sides of the table, a physical demonstration of how the newspaper is creating distance between husband and wife. A similar example of evolved physical distance can be seen in the later romance between Charles and Susan Alexander. A prime illustration of this is the scene where Susan is putting together a puzzle on one side of the massive living room in Xanadu and Charles is standing at the other end. When Charles and Susan started seeing each other, they were more often than not close in proximity. Susan was an asset for the Inquirer during her opera career, where Kane would have great reviews written about her performances, despite the fact that they violated his â€Å"Declaration of Principles.† Huge audiences were brought to his newly built opera house, thus making his name more popular. However, once the second Mrs. Kane ended her career as an opera singer and was no longer useful to the newspaper, Charles began to separate himself from her. The progression of Emily and Charles’ physical appearance- from striking clothing, hair, and general upkeep to neither husband nor wife trying to impress their significant other with their physical presentation- is another example of mise-en-scene exhibi ting the failing of the relationship. Emily’s first outfit is a frilly, skin-exposing dress that was worn during an evening out. Her hair is in an intricate, pretty up do and her makeup lightly done, but her skin still youthful without blemishes or wrinkles. Each following sequence has Emily wearing a dress that shows less skin and is more proper, her hair worn increasingly more carelessly, and her face showing more wrinkles and looking less youthful with a sad expression. Charles follows a similar pattern in the way his dress evolves. He initially wears a suit meant for a party and looks handsome with his hair slicked back and almost no sign of age on his face. However, he starts wearing robes to breakfast with unkempt hair, not looking to impress his wife. A few sequences in, we start seeing Charles back in a suit, but with increased amounts of age lines visible on his face, indicating that he is spending more time and energy at work, and he is either coming home from work around breakfast time or leaving immediately after breakfast to tend to the Inquirer. While the clothing choices of each character reflects the decreasing effort to please each other, the wrinkles on each characters face shows how both the relationship and the newspaper are starting to perturb both husband and wife. Both key lighting and fill lighting contribute to the montage by depicting the time of each day and the presentation of the actors’ faces. The key light is a parallel in every sequence of the montage. It always comes from the back window and portrays that it is the same time of day in each sequence. The corresponding unvarying time of day paired with the evolving conversations and attire described earlier create a feeling that the act of having breakfast together has become routine and a burden as opposed to romantic for the couple. While the key light is unchanged throughout the montage, the fill light on each actors face changes in each sequence to assist in the idea that time is passing. A large amount of fill light is used at the outset of the montage, giving a youthful, blemish-less look to the faces of Charles and Emily. However, the fill light becomes less prominent in each successive sequence, giving Charles an intensifying harshness on his face with more age lines and Emily more dramatic shadows along her cheekbones and eyes, making her appear to be tired and sad. Acting, costumes, and lighting are all devices used throughout Citizen Kane to demonstrate failing relationships between Kane and some of the closest individuals in his life, including Emily, Jed Leland, and Susan Alexander. Nevertheless, the breakfast montage effectively applies both mise-en-scene and technical devices to display the first broken relationship caused by Charles Kane’s passion for the Inquirer.