1. Differentiate between the three types of staffing policies used by international companies. What are the advantages of each?

Description of Organization and Program

The Clarkstown Central School District’s (CCSD) Student Assistance Counselor Program consists of a social worker in each school within the district at the elementary, middle and high school levels.  Student Assistance Counselors (SACs) provide services that address the complex mental health needs of students and their families, in order to facilitate academic success.  Student Assistance Counselors help students with a wide range of problems such as coping with mental and physical illness; death of a family member or friend; managing changes due to separation, divorce and blended families; coping with difficulties in peer relationships, academics and school phobia; building resiliency to foster self-esteem and self‑confidence; and identifying students who are experiencing physical, sexual or emotional abuse (Clarkstown Central School District Website, 2015, p. 1).

As a social work intern from September until the end of May at Bardonia Elementary, an elementary school within the Clarkstown Central School District, I learned about the individual and group services provided through the Student Assistance Counselor Program.  The SAC Program within the Clarkstown Central School District offers, but is not limited to, two primary services: individual counseling and student counseling groups.  Individual counseling for students is offered on an as-needed basis, often initiated by a student’s parent(s) or legal guardian(s) in response to a traumatic or stressful event the student has experienced, or in response to a component of the student’s personality or area of development that is of concern.  Student counseling groups differ from school to school in terms of discussion content and duration.  For the purposes of this paper, I have focused on the student counseling group services provided by the SAC at Bardonia Elementary School.

The target population for Bardonia Elementary is kindergarten students and students in grades 1 through 5.  During the 2014-2015 academic year, Bardonia served approximately 400 students.  The school’s mission is “to motivate all children, encouraging interdependence between learning and teaching, in a nurturing, secure and challenging environment (Bardonia Elementary website, 2015).”

The group services provided by the Student Assistance Counselor at Bardonia exist as a social work component of the school; social work is not Bardonia Elementary’s primary focus or purpose.  The school provides academic classroom learning; “specials” such as art, music and physical education; English language learning for those students whose primary language is a language other than English; speech therapy, additional reading and math support services for students in need of them; school psychologist services for students with an individualized education plan (IEP); and student assistance counselor services for those students in need of social and/or emotional support (Bardonia Elementary website, 2015).  An organizational chart of Bardonia Elementary is provided in Appendix A, at the end of this paper.

Per discussion with the Student Assistance Counselor at Bardonia Elementary, who has provided social work services to students of the Clarkstown Central School District for 19 years, student groups at Bardonia were first implemented in 1989, when the first SAC was hired.  Groups were formed based on common social and emotional needs the first SAC had assessed from her student observations.  Some of the groups, such as “Meet and Eat” and “Changing Families” still exist at Bardonia today.  Funding for the individual student counseling services and student group counseling services at Bardonia, and all other CCSD public schools come from multiple sources, such as the Clarkstown Central School District budget, school tax within the district, Governor Cuomo, and organizations such as the New York State Office of Alcohol and Substance Abuse Services (OASIS).

From my experience as a social work intern, I learned that group counseling at Bardonia is typically offered to those students who may be experiencing social and/or emotional challenges that affect their ability to do their best in school.  However, groups are open to any child interested in participating and who have permission from a parent or legal guardian to do so.  Each child is limited to participation in one group per year, however.  At times, the Student Assistance Counselor will reach out to a student’s parent(s) or legal guardian(s) in order to refer the child for a group.  Other times, a parent or legal guardian will seek information from the SAC for an appropriate group for the child to join based on their concerns, and the SAC provides her recommendation(s).

According to Gitterman (1989), since group members have common experiences and problems, they are typically receptive to each other’s views, suggestions and challenges.  As members begin to feel supported by the group and a part of the group, they are more likely to share their concerns and experiences, ultimately accomplishing the purpose of the group (p. 92).  Groups can instill hope and encouragement, universalize experiences and break down isolation (as cited in Pack-Brown, Whittington-Clark and Parker, 1998).  Clients in group learn coping skills for life and experience healing through cohesion and mutuality (Hepworth, Larsen, Rooney, Rooney, & Strom-Gottfried, 2010, p. 273).

Program Goals

The overall goal of the SAC Group Program at Bardonia is to support the social and emotional well-being of students so that they have the ability to do their best in school.  Information from group members is used to help them problem solve and reduce stress both inside and outside of school.  The group services provided by the Student Assistance Counselor, myself and a fellow intern this year at Bardonia included lunch time gatherings called “Meet and Eat,” which aim to build social and friendship skills; “Creative Communications” groups that incorporate art therapy as a means of expression; a “Changing Families” group for children whose parents are going through divorce or who are divorced; and a “Sibling Group” for those children who have a brother or sister with a disability.  This year I also implemented “Bereavement Group” for those students having difficulty coping with the loss of a family member.  See Appendix B, for a logic model of the current SAC Group Program at Bardonia Elementary.

Group objectives vary from group to group at Bardonia.  “Meet and Eat” aims to build social and friendship skills and to help resolve conflicts members may be having with peers inside and outside of the school setting.  “Creative Communications” shares the same objectives, however art therapy is incorporated as a means of member expression.  According to Schirrmacher (1986), children’s art speaks for itself through its symbolism and does not need verbal language or storytelling; it is invaluable in itself.   It also provides adults with a better understanding of a child’s developmental status (p. 3-4).

The objectives for “Changing Families” are for students to share their experiences and feelings coming from a divorced or soon-to-be divorced family; connect to one another; and to normalize and reduce stress, worries or concerns associated with divorce.  Due to limited cognitive and verbal skills and dependence upon parents for structure and stability in their lives, elementary school aged children tend to have difficulties dealing with family separation (Abel, Broussard & Chung-Canine, 2013, p. 137).  Common reactions of elementary school-aged children who have been separated from a parent (as cited by Amato & Cheadle, 2008) include behavior problems, such as anger and conduct disorder; emotional concerns, such as depression, grief and self-blame; and academic concerns, such as the inability to focus and follow directions (Abel, Broussard & Chung-Canine, 2013, p. 137).   According to Coleman, Collins & Jordan (2010) however, trauma experienced in relation to divorce can be diminished by redefining divorce as normal and acceptable (p. 246).

“Sibling Group” shares the same objectives as “Changing Families,” however in respect to being a sibling to a brother or sister who has a disability.   According to Larkin (n.d.), the role of being a sibling to a brother or sister with a disability can be difficult.  Parents may expect these children to act as second parents and babysitters to the disabled sibling.  The extra care required for a son or daughter with a disability can overburden and emotionally exhaust parents, leaving them with minimal energy for their other children (p. 38).  A child who feels neglected, who has to give up a significant amount of parental attention can wind up angry, jealous and depressed.  Serious resentment can arise as well, if a child is asked to take on too much responsibility for his or her sibling (Larkin, n.d., p. 40).

“Bereavement Group,” shares similar objectives to “Changing Families” and “Sibling Group,” but in terms of coping with the loss of a family member.  According to Samide (2002), children’s functioning in school is one of the many areas which can be affected as a result of a death of a family member (p. 198).  Through mutual support, grief groups led by counselors in schools can be an effective way to alleviate the suffering of bereaved students.  These groups can also help facilitate healing so that children can function more effectively in the classroom and at home (Samide, 2002, p. 198).  Bereavement counseling and support groups (as cited in Davies, 2007; Mitchell et al., 2007) allow children to share their experiences with others while normalizing their feelings, thoughts and experiences (Swank, 2013, p. 236).

Program Interventions

According to Hepworth et. al (2010), interventions used in social work practice must be directed to the problem specified by the client, as well as the systems that are implicated in the problem.  The interventitive approach should match the problem and be able to facilitate change and goal attainment (p. 356).  For the SAC groups at Bardonia Elementary, the following interventions are used interchangeably by the group facilitator or co-facilitators, depending on the situation.  Ventilation, which consists of providing clients with opportunities to express their feelings about themselves, their life situation and experiences.  Sustainment, which consists of empathizing with the client by showing an understanding of what he or she is experiencing, and offering acknowledgement, validation, encouragement, and reassurance when appropriate.  Exploration, which consists of efforts to learn about clients’ problems, thoughts, feelings, behavior, current life situation, background, capacities, strengths, and external supports (Goldstein & Noonan, 1999, p. 112).  Modeling alternative ways for problem solving, thinking, feeling, and behaving, as well as helping group members to support and validate one another, are interventions also used in group work at Bardonia (Goldstein & Noonan, 1999, p. 282).  These techniques are all consistent with aspects of both the mediation social work group model, which emphasizes the role of group process and experience, and the remedial social work group model, which focuses on the individual within the group (Goldstein & Noonan, 1999, p. 278-9).

Current Evaluation Plan

According to Gumpert and Black (2008), social work with groups is a complex, multi‑leveled practice which requires assessment and intervention of interactions among group members, interactions between each group member and the worker, interactions between each member and the group as a whole, and interactions between the group and the worker (p. 62).  Current evaluation of the student counseling groups at Bardonia is based on the weekly observations made by the Student Assistance Counselor and interns throughout each academic year.

One of the established evaluation methods for the SAC groups at Bardonia Elementary consists of the facilitator or co‑facilitators of each group providing a summary at the end of the year of the observations he or she made during the duration of the group, and providing recommendations for forming groups the following year.  For example, have all members within a group expressed interest in participating in the program again the following year, and do all members want to remain together as a group, if possible?

The other established evaluation method for the SAC groups at Bardonia consists of a weekly, scheduled, hour and a half supervision time with the Student Assistance Counselor and her interns to discuss observations made while leading or co-leading their respective groups.  During this reserved time, interns can express their concerns, client achievements and overall feedback on the group.  In return, the Student Assistance Counselor provides her input and recommendations.

Proposed Modified Evaluation Plan

Purpose of the Evaluation Plan

Although I feel that the current evaluation plans in place for the SAC Groups Program are valid, reliable and effective, I cannot help but feel that the clients, the student members of the groups should be represented in the evaluation process more.  Who better to help the Student Assistance Counselor and interns determine if the program is meeting its goals and meeting the needs of the clients, than the clients themselves?

According to Padgett, Royce & Thyer (2010), routine client satisfaction studies allow managers to “keep a finger on the pulse of an agency” and to detect problems before they seem to get out of control.  Only after problem areas are identified, can remedies be proposed and implemented (p. 176).  Client satisfaction studies stem from the belief that clients are the best source of information on the quality and delivery of services they receive.  The use of client satisfaction as a form of evaluation indicates to clients that their experiences and observations are important.  Asking for feedback about client experiences also gives professional staff and management the opportunity to remove obstacles that may be preventing clients from having satisfying encounters with programs (Padgett, Royse & Thyer, 2010, p. 177).  Therefore, I suggest modifying the measurement tools used in the evaluation process of the SAC Groups Program at Bardonia Elementary by incorporating student feedback with methods appropriate to their corresponding grade and developmental levels.

Evaluation Design

According to Padgett, Royse & Thyer (2010), client feedback studies, such as the one I am proposing for the SAC Groups Program at Bardonia Elementary, often rely on homemade instruments with unknown reliability and validity (p. 184).  For my modified program evaluation plan, I propose that the facilitator or co‑facilitators of each SAC group (the Student Assistance Counselor and/or the social work interns) annually meet with group members individually one time only, towards the end of each academic year, to gather feedback on the students’ experiences in group.  Ideally, with this approach, no group member’s responses would be influenced by another group member’s responses.

Asking open-ended questions would be another method used in attempt for preventing responses from being influenced, as group members would not be provided with answer options.  Open-ended questions (as cited in Sanders et al., 1998) can provide information about the client’s perspective which may not have been collected with objective instruments (Padgett, Royse & Thyer, 2010, p. 183).

Data Collection Tools and Administration Schedule

Within my proposed, modified evaluation plan, the approach of the group facilitator or co‑facilitators (the Student Assistance Counselor and/or the social work interns) for collecting student feedback would slightly differ based on the individual student’s grade level and capabilities.  For example, among kindergarteners, first graders and second graders, having the SAC and/or interns verbally ask open‑ended, opinion questions may be less intimidating and more appropriate in terms of their development, as opposed to writing responses within a questionnaire.  Among third graders, fourth graders and fifth graders, having the SAC and/or interns provide a questionnaire with similar though slightly modified questions based on grade level, may be more appropriate and effective, as writing skills, communication skills and thinking skills are more developed at these grade levels.  However, these techniques would be considered by the SAC on a member to member basis in terms of which evaluation approach may be more appropriate for the individual child.  Client participation in surveys and interviews will also be voluntary.

According to Padgett, Royse & Thyer (2010), there are several factors that influence the choice of a measure, such as utility, is it easy to administer and interpret, and does it give useful information; suitability and acceptability, is it age appropriate, and does it work with the population in terms of vocabulary, reading level and sophistication; directness, can the instrument objectively capture the client’s behavior, emotional state, or attitudes; and appropriateness, will the clients find the instrument burdensome and is the instrument too complex or requires too much time (p. 302).  In taking all of these factors into consideration, I felt that my interview-style and questionnaire approaches were appropriate, given the client population and fit the purpose of modifying the program evaluation for the SAC groups at Bardonia Elementary.

Interview and survey questions for each group and each grade level will be created by the SAC and the social work interns and revised annually, if appropriate or necessary.  All questions suggested by interns the year that the plan is implemented and in future years, would require approval by the SAC.  All interview and survey questions would also need approval by the school principal annually, prior to being administered to students.

Questions for members of any group, “Creative Communications”, “Meet and Eat”, “Changing Families”, “Bereavement Group” and “Sibling Group” will include asking students to express how comfortable they felt contributing to group discussions; how helpful it may have been when other members shared similar experiences and feelings, or had suggestions for a problem the member was experiencing; and how it felt to participate in group activities.  All clients would also be directly asked about what they enjoyed most and disliked the most about the group.

In terms of group-specific evaluation questions, for members of “Meet and Eat,” a group aimed at building social skills, friendship skills and resolving conflicts members may be having with peers inside and outside of school, the group facilitator or co-facilitator (the Student Assistance Counselor and/or the social work interns) would ask how helpful, if to any extent, the group was for learning social skills, friendship skills and resolving any conflicts the group member had shared with the group.  The same questions could be asked to members of “Creative Communications,” a group with the same goals as “Meet and Eat,” but incorporates art therapy activities to help achieve these goals.

Since “Changing Families,” “Sibling Group” and “Bereavement Group” all intend for members to share their experiences; connect to one another; and normalize and reduce stress, worries or concerns associated with divorce, being a sibling to a brother or sister with a disability and coping with the loss of a family member, respectively, the group facilitator or co-facilitator would ask how easy or difficult it was for clients to share their experiences with the group; to connect to fellow group members; and how helpful, if at all, the group was in reducing stress, worries or concerns they may have had in relation to their particular familial situation.

The sources of data for, and results of the SAC Group Program client feedback portion of the evaluation plan would consist of the verbal responses from the kindergarteners, first graders and second graders, and the written responses from the third, fourth and fifth graders.  All data will be qualitative.  A record of the verbal responses among the younger group members would be recorded immediately post-individual interview by the facilitator or co-facilitators (SAC and/or interns) for that specific group.  Notes would not be taken during the interview, as the focus should be on the client and note taking make be a distraction or make the client nervous or anxious.  Responses to the questionnaires from the third, fourth and fifth grade group members would be collected by the Student Assistance Counselor and/or the social work interns, upon completion.

Analysis Plan

After member responses are collected, they would be provided to the Student Assistance counselor, by individual group.  The SAC would then review, categorize analyze and the results, per group.  Analysis of results would be performed once annually by the SAC at the end of each school year.

For each individual group member within a particular group, results would be coded as representing either a positive, neutral or negative experience in group.  Results will also be coded in terms of effectiveness:  did the client find the group helpful, neutral, or unhelpful?  The overall experience for each group will be determined by which categories had the most responses, in terms of positive experiences and effectiveness in helping students.  Based on each group’s experience, results would then be looked at overall for assessing the SAC Groups Program at Bardonia Elementary.

Reporting Schedule and Utilization Plan

If the majority (more than 50 percent) of client feedback were to express failure either in meeting the goals of an individual group and/or the program overall, the program and/or the respective group(s) would then be modified appropriately in further attempt to meet the goals, or the goals themselves may need to be modified, if concluded unattainable or an inappropriate fit.  Potential modifications to the SAC Group Program at Bardonia Elementary could potentially consist of making changes to group structure, for example, changes in the duration of each group session, the number of times a group meets per week, the time during the school day when the group meets, the size of the group, etc.  Interventions may need to be altered, new topics or activities may need to be incorporated, or new group rules may need to be incorporated as well.  See Appendix C, for a modified logic model of the SAC Group Program at Bardonia Elementary, which incorporates the proposed, modified evaluation plan.

REFERENCE LIST

Abel, E.M., Broussard, K. & Chung-Canine, U. (2013).  A Quasi-Experimental Evaluation of a      School-Based Intervention for Children Experiencing Family Disruption.  Journal of     Evidence‑Based Social Work, 10, 136–144.

Clarkstown Central School District. (2015). Student Assistance Counselors.

Collins, D., Jordan, C., & Coleman, H. (2012). An Introduction to Family Social Work (4th ed). Belmont, CA: Brooks/Cole.

Gitterman, A. (1989). Building mutual support in groups. Social Work with Groups, 12(2), 5-21

Goldstein, E. & Noonan, M. (1999).  Short-term Treatment and Social Work Practice: An        Integrative Perspective.  New York, NY: Free Press.

Gumpert, J. & Black, P. (2007). Ethical issues in group work: What are they?  How are they managed?  Social Work with Groups, 29, 61-74.

Hepworth, D. H., Larsen, J., Rooney, G.D., Rooney, R., & Strom-Gottfried, K. (2010). Direct social work practice: Theory and skills (8th Ed.). Chapters 4 & 8.  Belmont, CA: Brooks/Cole.

Larkin, D. (n.d.). Brotherly Love, Parenting Magazine, 38-40.

Royse, D., Thyer, B. A., & Padgett, D. K. (2010).  Program evaluation: An introduction (5^th Ed.). Belmont, CA: Cengage.

Samide, L.L. (2002).  Letting Go of Grief: Bereavement Groups for Children in the School             Setting.  Journal for Specialists in Group Work. 27 (2), 192-204.

Schirrmacher, R. (1986).  Talking to Young Children About Their Art.  Young Children. 41 (5)          3-7.

Swank, J.M. (2013).  Obstacles of Grief: The Experiences of Children Processing Grief on the Ropes Course.  Journal of Creativity in Mental Health, 8: 235–248

Case Summary:

A 61-year-old female (1.58m, 52kg) was admitted as an emergency with pleuritic chest pain and shortness of breath. On admission inflammatory markers (WCC and Neutrophils) were raised but bloods including troponin and D-dimer were otherwise unremarkable. A chest x-ray showed mild consolidation at the left base. She was diagnosed with an acute exacerbation of COPD according to the chest x-ray and blood gases test. The patient was initially treated with 28% oxygen, salbutamol 2.5mg nebulizer, clarithromycin 500mg tablet, symbicort 400/12 inhaler one puff, prednisolone 40mg tablet, ipratropium 500 microgram nebulizer as required and ondansetron 4 mg as required.

On discharge, the patient was instructed to continue clarithromycin and prednisolone according the great Glasgow and Clyde (GGC) guidelines. The patient was to continue to use the same drugs she was taking prior to her admission to the hospital, these are a symbicort inhaler one puff twice daily, a tiotropium inhaler once daily and a salbutamol inhaler as required.

History of presenting complaint:

The patient was admitted to the hospital, she has been complained of chest pain, shortness of breath (SOB), sore throat and fever since 1 day.

Past Medical History:

The patient past medical history including chronic obstructive pulmonary disease (COPD).

Social History:

The patient lives alone and can mobilize without aid.

Family History:

No relevant family history.

Medication History:

The patient had been using a symbicort inhaler one puff twice daily, a tiotropium inhaler once daily and a salbutamol inhaler as required.

Details from Examination:

The patient was experiencing shortness of breath, coughing and chest pain.

Further observations included:

• An oxygen saturation (SpO₂) level of 84% in air
• Respiration rate (RR) 28 breathes per minute
• Heart rate (HR) 110 beats per minute

Investigations:

1. A chest X-ray
2. Measuring the arterial blood gas tensions and recording the inspired oxygen concentration
3. Blood tests and cultures sent to laboratory
4. Throat swabs taken and sent to virology

Diagnosis:

The patient was diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). This diagnosis was reached using the patient’s past medical history and presenting respiratory and pain symptoms.

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is an episode in the usual period of the disease described by a variation in the patient’s baseline cough, shortness of breath, and/or sputum beyond the regular variability to the extent that it warrants a difference in control(1). Numerous clinical components must be considered while assessing patients with excoriations.These contain the history of past exacerbation, the severity of the COPD, and the existence of co-morbidity (2). Based on these clinical components the AECOPD may be classification into two major levels, of which the patient is classified as Level II (2):

• Level I: patient who can be treated at home.
• Level II: patient needs hospitalization if existence of co-morbidity. Therefor, increase short of breath, lack of appetite and sleep due to symptoms of hypoxaemia and inadequate home care, as for this patient.

Relevant clinical progress:

Day 1

The patient was initially treated with 1L/min of oxygen 28%. The patient was also receiving a number of different medicines on this first day: a 40mg oral dose of prednisolone once a day, a 2.5mg salbutamol nebuliser four times a day and 500mg of the antibiotic clarithromycin twice per day.

Day 2

The patient remained on the same combination of medicines as described under “Day 1”. Oxygen saturation for this patient was measured at 92% in air, which means without the use of an oxygen mask. It was found on this day that the patient had improved to the extent that an oxygen mask was no longer necessary. The blood pressure of the patient was 107/75. The respiratory rate for this patient was 20 and the heart rate was 90bpm.

Day 3

The patient was discharged on the third day, as there were considerable improvements to the patient’s condition. The patient was back to the patient COPD baseline. The patient was observed to have:

• HR: 92
• RR: 21
• Sp02: 93 % in air

The patient was discharged and advised to complete the remaining two days of clarithromycin and prednisolone. The patient was instructed to continue to use the same drugs they were taking before admission, which are: a salbutamol inhaler 100mcg 2 puff PRN; a symbicort inhaler 400/12 1puff and a tiotropium 18mcg 1 tablet inhaler.

Discussion

Acute exacerbation of chronic obstructive pulmonary disease management

The term “exacerbation” refers to a sustained worsening of a patient’s symptoms from their normal stable state (1). In terms of AECOPD, common reported symptoms include increasing breathlessness, wheezing, a cough, increased sputum production and changes in color of sputum.

Patients admitted into hospital with COPD will be treated through the AECOPD disease protocol. Initially, management for all patients admitted will involve Oxygen 28% until gases are checked(3,4). Then the oxygen will be titrated according to arterial blood gases, with the aim being between PaO₂ >7.5-10PKa. The bronchodilators given to patients will be: Salbutamol 5mg nebules four times daily (but can be given up to 2 hourly as needed), Ipratropium 0.5mg nebules four times daily (this will be added if there is a poor response to salbutamol); IV bronchodilators: Aminophylline may be considered if there is no response to nebuliser therapy(3,4).Corticosteroids, such as Prednisolone oral 30mg-50mgs should be taken each morning(1,3,4). Antibiotics should be used in the case of purulent sputum, raised inflammatory markers or focal radiological changes(1,3,4). They should be given orally unless there is a clinical reason for giving IV antibiotics.

From the patient’s initial examination, it was found that she was experiencing chest pain, she had a heart rate of 110 beats per minute and her respiration rate was at 28 breaths per minute. The patient therefore had her treatment adapted so that she would now receive oxygen 28% and nebuliser salbutamol, in accordance with the AECOPD protocol. Furthermore, patients who respond poorly to initial doses of beta2-agonists should then receive both nebuliser salbutamol and ipratropium bromide. After the patient has shown improvement, they should then begin to receive a salbutamol inhaler.

Oxygen therapy:

The national and local guidelines state that patients with an AECOPD should be treated with oxygen 28% via Venturi mask, then titrate the oxygen according to the arterial blood gases (ABGs) (4). During oxygen therapy the ABGs should be monitored for pO2, pCO2. The aim of oxygen therapy is to maintain pO2 >8 kPa or SpO2 between 88-92% in order to avoid tissue hypoxia on the other hand increase pO2 values more than 8kPa may rise danger of Co2 retention which lead to respiratory acidosis (2).

The patient has treated with oxygen therapy 28% on the day of admission. On the next day, the patient improved and became able to breathe without the need for oxygen and her SpO2 about 92%(4,3).

Bronchodilators:

The national institute for health and care excellence (NICE) guidelines recommend that patients with an AECOPD should be treated with short-acting bronchodilators nebulisers, hand-held inhalers or both can be used to manage inhaled treatment during acute exacerbations of COPD(3). Short-acting bronchodilators such as salbutamol 2.5mg as nebulisers are recommended and its may repeat up to four times daily and the dose may be increased to 5mg if needed(4,5). If the patient has poor response to salbutamol then using other short-acting bronchodilators like ipratropium 0.5mg nebules recommended four times a day by taking into account using moth-piece or close fitting mask to avoid risk of acute angle-closure glaucoma(4,6). Although long-acting B2-agonist (LABAs) and long-acting anti-muscarinic antagonist (LAMA) have been all shown decrease exacerbation percentages in patient with COPD by approximately 20%(7).

The patient has treated with salbutamol 2.5mg nebuliser four times daily for two days, then the patient back to salbutamol 100micrograms hand-held inhalers according to the NICE recommendation the patient should be switched to hand-held inhalers as soon as her condition has stabilized because preparing for the patient to leave the hospital(3). In addition, the patient on symbicort inhaler (LABAs+corticosteroids) one puff twice daily as per NICE guidelines (3).

Corticosteroids:

The local and national guidelines state that patients with an AECOPD should be on systemic corticosteroid in conjunction with other treatments. Oral corticosteroids (prednisone 30-40 mg) for 7-14 days should be used for moderate to severe periods of AECOPD (1).In case the patient cannot administer prednisone orally, instead of that intervenes hydrocortisone 100mg then 50-100mg three times a day if the patient needed for continuing the intervenes treatment(4).

The patient was treated with prednisone 40mg once a day for seven days as per in the NICE guideline(3).

Antibiotics:

The NICE guidelines state that antibiotic should be used in patients with AECOPD with a history of extra purulent sputum, those how without don’t need for an antibiotic (3). The NICE guidelines recommend a macrolide, aminopenicillin or tetracycline as first-line treatment, though participation from local microbiologist should be considered (3).

The patient had fever and the WBC was high and the chest x-ray highlighted a minor consolidation in the lung, which was likely caused by the current infection. Accordingly, the patient was treated with clarithromycin 500mg twice daily as per in the Great Glasgow and Clyde (GGC) chronic pulmonary disease Guideline (8). This was considered to be the most appropriate medicine for the patient, as she had an allergy to penicillin. Clarithromycin is an antibiotic which covers some of the most likely organisms causing this infection, including Pneumococcus, Haemophilus influenza and Moraxella catarrhalis (1,4).

Role of the pharmacist

1. Medicine reconciliation

As the patient was admitted, I carried out a medicine reconciliation. This is a vital procedure, as I can make sure that any important medication taken by the patient at home continues to be taken by them in hospital. I chose to confirm that the patient was taking no medication by using two sources: the patient herself and her electronic care summary.

1. Monitoring

The patient on clarithromycin and ondansetron (as needed for nausea and vomiting) both have been associated with QT prolongation, an ECG has been done and the QT didn’t prolonged and no further action indicated unless the patient has further regular ondansetron.

1. Counselling

I gave the patient counseling on inhaler technique and the advantages of taking the COPD medication correctly for the maximum benefit. A reason for counseling the patient on inhaler technique is that this will enhance the management of COPD and help to reduce any exacerbations.

The course of antibiotics being taken by the patient should be carried on until the end, as this can ward off a recurrence of symptoms, the strengthening of antimicrobial resistance. It is also important that the patient is counselled about the course of prednisolone, as this can reduce the likelihood of the recurrence of symptoms.

1. Discharge

The discharge prescription of the patient was checked against the relevant prescription and administration records, as well as her medication history, as this would make sure that the right medication was being given following her discharge from hospital.

Personality & Self- Concept

Effective leaders will always identify weakness and ensure that they turn into strengths. At a personal level, the following analysis defines my personality and areas of improvement. I believe learning is continuous, many of my conclusions are not based on rational thoughts as I only apply intuition to make the decisions, but always in a humble way. I always seek to meet people from all walks of life, without disregarding anyone as I hold the belief that everyone is equal and we ought to be given a platform to express ourselves. I am also optimistic coupled with the belief that detailed analysis and positive attitude will lead to better results. I aspire to change people’s lives in all aspects, not because I have all the solution through leadership, but in the application of humble consultations. I have a meticulous attention to detail, whilst observing scenarios while making effective solutions.

On the other side, I also have a number of weaknesses which am looking to change. Firstly, I am impulsive and demanding especially on the performance of new employees. To counter this, I have reduced the number of interactions with the new employees and as I have directed the pressure to supervisors who will, in turn, push the junior staff. Supervisors will usually have a leadership background and might understand my idea of being impulsive and demanding. On performance, I can be desperate to the extent that I forget body exercise needs. I can sit in the office for the entire day without moving if that’s the only way to go past a work challenge. As I look to reduce the weaknesses, I have made deliberate attempts to empower other people to give advice basing on experience in similar positions.

Medicare Access and CHIP Reauthorization Act

Introduction

            The Medicare Access and CHIP Reauthorization Act of 2015 abbreviated as MACRA is an American statute, which alters the payment systems used in compensating medical practitioners who treat patients under the Medicare program. MACRA alternatively known as Permanent Doc Fix revises the 1997 Balanced Budget Act (Daniel & Annelies, 2017). The law brings in large scale changes in the health sector, which are akin and next in scale to the changes initiated by the Affordable Care Act (‘Obamacare’) from 2010. MACRA was passed by Congress on 14^th April, 2015, and President Barrack Obama signed the act into law on 16^th April, 2015. This piece of legislation repealed the Sustainable Growth Rate (SGR) formula used to determine the payment of medical practitioners. SGR linked yearly medical practitioners’ payment updates to the gross domestic product (GDP) and the previous year’s spending. The act’s main objective was to replace the SGR formula with the Quality Payment Program (QPP) (AMA, 2018). The act contains the first major alterations to the way in which Medicare Part B physician reimbursement is done in nearly 20 years of SGR’s existence. The SGR formula has been used in reimbursing physicians under a fee-for-service (FFS) system since its creation in 1997 (AANA, 2018). The act has updates of the scheduled Physician Fee Schedule (PFS) and a new payment plan, which permits eligible medical practitioners to participate through two paths namely: the Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPs). The Alternative Payment Model creates a way for medical practitioners to get incentives for taking part in the new payment and care delivery models that have migrated from the fee-for-service model (AANA, 2018). On the other hand, the Merit-based Incentive Payment System (MIPS) still adheres to the FFS, but it differs because of its consolidation of the existent Medicare quality-related programs. This bipartisan act significantly supports the much-sought quality improvement in healthcare because it allows the migration from the present-day fee-for-service (FFS), volume-driven system of reimbursement, to a quality-based model, which rewards value and quality of health care delivery over the service volumes provided (Marron-Stearns, 2018). Regulations under MACRA Act also incentivize the process of using health information technology by all medical practitioners and other providers of care (Daniel & Annelies, 2017).

The Primary Provisions of MACRA

The basic provisions of the act bring about three major changes, which include:

• Increased funding
• Changes in the model of reimbursing medical practitioners through the repeal of SGR method
• Extension of the CHIP (Children’s Health Insurance Program) (Daniel & Annelies, 2017).

Implementation

            The implementation of the MIPS under MACRA act falls under the docket of the Department of Health and Human Services (DHHS) Secretary. The DHHS and the Government Accountability Office (GAO) are designated to help in the implementation of a countrywide electronic health records system (EHRS) (Marron-Stearns, 2018). Both DHHS and GAO help providers of care by comparing and recommending available EHR systems to providers. The full implementation plan for EHRS is set to begin on 31^st December 2018 as planned under act. Even though the main provisions of the act start in 2019, providers of healthcare services should be prepared before then because the 2017 data on performance will be used by Medicare to process 2019 payments (Daniel & Annelies, 2017).

MACRA’s Background

The need to create this legislation was elicited by the need of the Centers for Medicare and Medicaid Services (CMS) to improve the quality of care while controlling the high rise in the costs of healthcare. In order achieve this end, the CMS decided to eliminate the FFS traditional model of payment and replace it with a model that would factor in quality as a variable. The QPP path establishes a healthcare system that is patient-centered and able to deliver better care, sustainable expenditure, and better health outcomes among communities and people by pegging payments on value and quality instead of volume (AMA, 2018; AANA, 2018). MACRA creates a lot of incentives, which are intended to encourage medical care practitioners to re-design their delivery of care so as to offer more value. This is bound to happen because by 2019, 4% to 5% of medical care providers’ yearly Medicare reimbursements are supposed to be based on value. This percentage is expected to increase by 2022 to 5%-9%, and this implies that there will be more incentive to re-design care systems to deliver more value. The SGR model is known to have led to utilization growth and uncontrollable expenses (Daniel & Annelies, 2017). In order to bring healthcare expenditure under tight control and redirect healthcare funding to the efforts of delivering high-quality care the SGR formula had to be replaced by QPP through the passage of the MACRA act. The act’s incentives will drive providers handling Medicare clients to remodel their systems by modernizing care practices and adopting technology such as the EHRS. Virtually, all providers that take Part B payments from Medicare will be affected. However, for the sake of protecting independent and small providers, who serve less than 100 patients, exceptions will be made. Also, providers who submit charges that are below $30000 under part B of Medicare will be exempted from being part of the QPP (AMA, 2018). In spite of this exception, it is expected that an estimated 93% of Part B Medicare reimbursements will get under the QPP (AANA, 2018). Medical practitioners to be reimbursed under the new model will include physicians, certified nurse anesthetists, clinical nurse specialists, nurse practitioners, and physician assistants and other groups of providers in the years to come. QPP provides two paths to provider reimbursement. Firstly, eligible medical practitioners who take part in the alternative payment programs of CMS such as Comprehensive ESRD Care Models and Medicare Shared Savings Program, and Next Generation ACOs will receive their payments under APM. By 2018, an estimated 25% of eligible providers will be paid under APMs, whereas; the remaining percentage that will not participate will automatically get their payments under MIPS (Daniel & Annelies, 2017; Marron-Stearns, 2018).

Comparison of MIPS to APMs

            Projections show that MACRA may affect 90-95% of physicians in active practice and influence 93% of Part B Medicare reimbursements. To participate in QPP and comply with MACRA act providers take either the MIPS or Advanced APMs path. The Advanced AOM alternative rewards and creates incentives for medical providers that take part in value-based payment systems that have downside and upside risk such as the ACOs model (Accountable Care Organizations model). The second alternative is MIPs. This default alternative is for care providers who do not participate in programs that qualify for the first alternative. Notably, the MIPS alternative is not a final destination for practitioners. Instead, it is a path to Advanced APMs for practitioners who are new to value-based and risk-based contracting (Daniel & Annelies, 2017).

MIPS

By 2017, all practitioners unable to participate in the Advanced APM will by default get included in the MIPS path. However, there are some types of physicians who will be exempted from this program and these include: independent practice small-scale providers who do not meet the Medicare revenue or patient threshold, practitioners under the present Shared Savings Program Track Two, Health Centers that are federally qualified and rural health clinics (AANA, 2018). After eliminating these exempted units, it is expected that 500000 practitioners will be enrolled under MIPs by 2019. By 2019 MIPS will present a 4% opportunity or risk by either rewarding or penalizing practitioners under it based on the practitioners’ ability to deliver value as computed under the MIPS system of scoring. These incentives will continue rising each year: 2019 (4%), 2020 (5%), 2021 (7%) and 2022 (9%). Providers under MIPS are rated according to composite computed score and the top quartile gets positive adjustments on performance. The middle 50% of the clinicians get a neutral score, whereas; those in the last quartile get a negative score. In essence, this path presents a zero-sum game, where the win of one clinician means the loss to another one clinician. MIPS participants will be graded on four basic factors, which are weighted differently to get a composite score. The four areas to weigh include clinical practice improvement, resource use, advancing care information, and quality reporting (Daniel & Annelies, 2017).

Quality reporting

            Quality reporting is the most weighted factor and the incentive based on it is high because its accounts for 60% of the total score that a practitioner can get by 2017. The measurement of this element is computed using the Physician Quality Reporting System (PQRS). The practitioners are expected to report 6 measures of quality including outcomes of care for at least three months (Mullins, 2018). This factor thus involves elements of high-quality care delivery and the ability to accurately measure and report the statistics (Daniel & Annelies, 2017).

Advancing care information

            The next most weighted factor is advancing care information and this component’s score accounts for 25% of the total score in 2017. Providers will report five basic metrics for 90 days (Mullins, 2018). This factor often requires the practitioners to improve and invest in developing the interoperability and functionality of HER systems (Daniel & Annelies, 2017).

Improvement of clinical practice

            CMS reserves 15% of the composite score for attribution to initiatives aimed at improving actual clinical practice in 2017. The initiatives under this consideration include the use of telehealth, engaging the use of qualified and clinical data registry (QCDR) and maintenance of certification (MOC) assessments – just to mention, but a few (Daniel & Annelies, 2017).

Resource use

The resource measure factor was not considered in 2017, but by 2018 it will be considered because CMS will measure cost accountability using reimbursement claims data via the resource use programs (Mullins, 2018). Resource use may have a small effect on the composite score, but providers will have to work hard to score high on all four factors (Daniel & Annelies, 2017).

APMs

            APMs provide the second alternative of complying with MACRA and participating in the QPP. According to CMS approximately 70000 practitioners would be eligible for enrolment into the Advanced APMs by 2017, and these practitioners would be exempt from the MIPs. Participating medical practitioners in the Advanced APMs get automatic qualification for a yearly bonus of 5% in addition to bonuses, incentives, and rewards earned from other programs. Just like MIPs participants, Advanced APM s participants will also get 0.5% increases on payment updates annually. But by 2026 medical practitioners in the APMs will get updates of 0.75%, while those in the MIPS will get only 0.25% by that time (Daniel & Annelies, 2017). This reinforces the notion that MIPS as a program is not a final destination for practitioners, but rather a path to the destination, which is supposed to be the Advanced APMs. All medical practitioners that need to be in the Advanced APM model should choose one Advanced APM models and get engaged. CMS has ratified a number of APM models and some of these models include:

• Comprehensive ESRD Care Model
• Comprehensive Primary Care Plus (CPC+)
• Next-generation ACOs
• Medicare Shared Savings Program (MSSP) ACOs in Track 2 or 3

Other alternatives, which may qualify for the same category by 2018 as recommended by CMS include:

• Advanced Cardiac Care Coordination Bundled Payment model
• Comprehensive Care for Joint Replacement (CCJR) Bundled Payment models
• Voluntary bundled payment model
• ACO Track 1+

In addition to these programs, which meet CMS standards, the CMS has created a permissive path known as the ‘Design Your Own Advanced APM’ alternative that uses the Physician focused (PTAC) Payment Model Technical Advisory Committee to assess and review proposals for creation of new APM models, which are brought forth by other stakeholders including providers of care as well as payers of care services. If PTAC approves any model of APM, then the medical practitioners under the APM qualify for this second option of complying with MACRA. Examples of APM models, which may soon be approved by P.T.A.C., include the oncology care coordination risk-based models and the Vermont All-Payer Model (Daniel & Annelies, 2017).

There are three major components that are essential in the creation of APMs and they are a necessary inclusion in submissions made to PTAC. These components include downside and upside financial risk, quality metrics-based incentives, and the use of certified EHRS technology.

Incentives or pay based on quality metrics

According to CMS requirements, advanced APMS should have their measures on quality focused on improving and monitoring patient care. Advanced APMS, which have been presently allowed to operate such as MSSP ACO, have quality metrics, which have been integrated into their participation programs. The quality and reporting elements of these plans primarily target process metrics, instead of outcome-based measures.

Downside and upside financial risk

For medical practitioners to qualify for the APMS path, they ought to get some of their Medicare payments through a qualifying and approved APM with financial risk. Presently, the minimal qualifications to get into an APM model are based on the need for at least 25% of reimbursement claims and 20% of Medicare patients to get their payments for services received processed through an Advanced APM arrangement (AANA, 2018). Medical practitioners can also get partial APM status if 10% of the patients they serve get their reimbursements processed via an advanced APM program and 20% of such reimbursements go through such an Advanced APM. The downside and upside risk should be at least 30 percent, and any new models seeking PTAC approval should confirm that their presented model meets this 30% threshold (Daniel & Annelies, 2017).

Deployment of certified EHRs technology

            Lastly, APMS should demonstrate a considerable use of certified electronic health records systems. This should happen at or above the basic meaningful use mandate found under the MIPS program. This requirement is needed because analytics and IT capabilities are essential in monitoring quality metrics.

The Pros and Cons of MACRA

In April, the state released the 962-page notice document presenting MACRA. Health industry players have dug into the Notice of Proposed Rulemaking (NPRM) document to understand its details and plan for changes that would affect their models of practice as they try to comply with MACRA requirements before the set deadlines. Going through this large document is an intimidating task, but healthcare organizations needs to understand it and start implementation plans because the change process that it initiates is necessary. MACRA has initiated remarkable and significant changes to the manner in which Medicare providers carry out their operations and it is these significant changes that have attracted negative feedback because most people often fear change and dislike the tumults that come with it because they change their ‘normal’ routines of operation (Daniel & Annelies, 2017). In addition to the Obamacare changes, the MACRA-initiated changes have increased the pace of change in the healthcare industry and these numerous changes in the recent past have led to some kind of ‘change fatigue’ thus attracting negative feedback. The plans of the government to cut reimbursement costs through these changes is also another aspect of the change process that does not make the whole process appealing for providers in the health sector because it reduces their collections.

In spite of the negative feedback, MACRA and the implementation document (Notice of Proposed Rulemaking) that puts it into action are not entirely a negative force. In actual sense, there are a lot of positive outcomes that are expected to emerge from the act and its implementation, and here are some expected merits and demerits of the act and its implementation.

The Pros of MACRA

Regardless of the nature of the reception that MACRA gets the law is in actual sense nobly conceived and its intentions of enhancing the quality of care at reduced costs a course that is worth pursuing. Here is a brief highlight of some of the important merits of MACRA to the health sector.

Extension of CHIP and the Elimination of the Sustainable Growth Formula

 Many people agree that the previous SGR formula, which MACRA repealed, was a flawed system and its use destabilized the Medicare program and negatively affected access to healthcare. By enacting MACRA, the US Congress averted a 21% cut on payment for services delivered to Medicare patients and the law helps in ensuring that there is a greater availability of medical practitioners that are willing to deliver healthcare services in return for Medicare payment. By passing SGR in 1997, Congress aimed at controlling the increasing Medicare expenses (Michaels, 2016). SGR determined payment levels for practitioners based on the growth of the economy measured by the GDP. However, by 2002 the formula was failing to control the costs that were increasing faster than SGR. In this period the practitioners were facing an estimated 5% pay cut. Physicians accepting Medicare payments have been facing annual cut since the SGR failed to control the skyrocketing costs of care delivery and most healthcare practitioners have since then considered opting out of the Medicare program. This is part of the SGR-related problem that MACRA hopes to correct by improving the appeal of Medicare (McWilliams, 2018). MACRA also creates an extension on the funding dedicated to Children’s Health Insurance Program (CHIP). This is a program, which was developed in 1997 to provide health covers for children from moderate and low-income homes with income levels, which are too high to qualify their enrollment into Medicaid (Michaels, 2016).

It fosters the attainment of improved patient outcomes

MACRA aims at replacing the FFS payment model with the value-based payment system. Regardless of whether providers take the MIPS path or decide to take part in the Accountable Care Organization (ACO), which is part of the Advanced APMS, they all have a common overarching mandate, which is to improve patient care outcomes through adding value. Two out of the four factors under MIPS, which take 65% of the composite score, which is used to compute penalties and bonuses solely focus on the improvement of care and the attainment of improved patient outcomes (Michaels, 2016). In fact, quality accounts for 50% of the score and this covers mandates on reporting quality metrics linked to population health and positive healthcare outcomes. Clinical Practice Improvement Activities (CPIA) emphasizes the deployment of patient-centered models in the formulation of programs, which lead to healthier, smarter, and better care. This accounts for 15 percent of the aggregate score and it is determined from the measure of improvements made on 9 basic elements that include population management, practice assessment and patient safety, and coordination. CPIA and quality categories need significant reporting, and this perhaps the reason why most physicians may dislike the new changes, but such extensive reporting improves accountability (Michaels, 2016).

Emphasizes the introduction and use of technology

 It is arguably true that the improvement of healthcare quality and cost-cutting are aligned with the improvement of technology use in healthcare. Collection, analysis, and sharing of patient information are essential in improving patient outcomes and reducing general healthcare costs. One of the main hindrance to the seamless use of technology results from the lack of interoperability, which is the inability of systems to communicate with each other seamlessly (Michaels, 2016). The (ACI) Advancing Care Information category under MIPS is aimed at changing the status quo and fostering technology use by initiating the support for basic objectives of Meaningful Use and the HITECH Act. The program’s efforts also continue to promote progress on the important issues that support the creation of better healthcare delivery such as the advancement of patient engagement and health information exchange (HIE). The increase in the use of technology within the healthcare sector implies that there will be more available information (Michaels, 2016). Therefore, apart from using this information, organizations have to be concerned about its storage, security, and safety. This is the main reason why security is an essential element of the ACI. The protection of patient information question for providers is a yes or no query and if providers cannot answer yes, the provider or organization gets a zero score for the whole ACI category. This may happen even if the provider meets all the other required measures (McWilliams, 2018). ACI takes a whole 25% of the composite score and it includes most of the HER incentives and it is sufficiently replaces Meaningful Use (Michaels, 2016).

The Cons of MACRA

            In spite of being conceived with noble intentions in mind, MACRA laws and the NPRM directing its implementation present some challenges, which are often perceived by some providers as being more disadvantageous to their operations than being beneficial (McWilliams, 2018). Here are a few reasons why the law may be regarded as being disadvantageous.

MACRA may hurt Small Practices

            Based on the data presented within the Notice of Proposed Rulemaking the new laws may have a significant negative impact on approximately 100000 providers in small-scale practice in the entire nation.  The projections from CMS reveal that about 90% of solo practice providers will get affected by negative adjustments, which may reach a total of approximately $300 million USD by the time the reimbursement regulations start in 2019 (Michaels, 2016). Also, 70% of practices, which have 2 to 9 eligible medical practitioners, are expected to get hit by negative adjustments that could reach $279 million USD.  Additionally, another 18% of practices employing 100 or more eligible medical practitioners are also expected to be hit by negative adjustments totaling $57 million. This trend implies that smaller practices may be unable to sustain their operations and bigger practices may be encouraged to buy or assimilate smaller practices. As such, acquisitions and mergers may increase with the finalization of the implementation of the MACRA laws and regulations (Michaels, 2016).

Short Implementation Time-frame

Most of the providers who are not ready to move into the new system often state that the implementation of MACRA is unreasonably fast. This means that the process does not give providers ample time to prepare. In fact, some providers have made an objection that implementation of the new regulations only eight months after the release of the Notice of Proposed Rulemaking is unreasonable (Michaels, 2016). In a letter dated 24^th June, the Medical Group Management Association (MGMA) notably alerted the CMS that MIP system does not grant ample time to trading partners, practices, and physicians to make preparations for the proposed alterations to system, investment, and workflow requirements. MGMA agrees with the overall spirit of the new laws and regulations, but they categorically hold that there is insufficient time to fulfill the designated goals. Recent research findings have even shown that a considerable number of physicians are totally unaware of the MACRA laws and regulations (Finnegan, 2017). This implies that the many doctors who are unaware of these newly proposed changes to Medicare payment systems may throw most medical practitioners into confusion as they try to catch up and comply with the laws and regulations so as to remain operational when MACRA finally comes into effect (Michaels, 2016).

MACRA may be Overly Complex

The complexity of MACRA’s implementation is plainly evidenced by the high page count of the NPRM document that is MACRA’s implementation guideline. Healthcare is a complex business in the current world, but the NPRM takes this a wholly new level of complexity. For instance, the NPRM defines the 55 acronyms used throughout the document in a total of three pages, and the page after page “bureaucratese” is hard to follow for a first-time reader of the document (Michaels, 2016). In fact, it is complex and challenging for any ordinary provider to comprehend and dissect the whole NPRM document. This is perhaps the reason why AMA (the American Medical Association) has urged the CMS body to take time and reconsider the approach it has taken on this rather burdensome and complex implementation. In response, CMS has decided to provide an interim final rule in the coming fall so as to get more feedback (Michaels, 2016).

Conclusion

            MACRA is a law conceived with good intentions in mind, and its full implementation is expected to have positive outcomes, which may include marked improvements in the quality of healthcare delivered by providers under the Medicare Part B. In addition, the implementation of the related regulations and laws are expected to lead to a decline in healthcare expenses that go into reimbursements. But it is also arguably true that the law has a few flaws such as its overly aggressive implementation timeline, which does not give providers sufficient time to prepare and plan changes that are necessary for compliance. In spite of this fact, it is true that the law is not totally untenable. However, the government and the concerned healthcare industry players should try and work together in finding a way to reach the intended goals of MACRA without placing undue pressure on providers, which may compromise their daily operations in healthcare provision. So far none of the regulations or clauses of MACRA have proven to be adversely negative to practice. The expected negative adjustments are yet to be clearly determined once the law is in full effect. However, there is an actual concern that needs addressing and that is the short implementation time-frame. A little delay in the setting of the deadline should be considered by CMS so that more providers can get time to make the necessary preparations. In the end, the full implementation of MACRA will be significantly beneficial to all patients in the affected health sectors because targeted improvements on quality may improve the quality of healthcare that the patients receive. It is also expected that the reimbursement costs will decline in the long-term and this may lead to a decline in healthcare cover premiums, which is beneficial for all citizens.

References

American Association of Nurse Anesthetists (AANA) (2018),. Medicare Access & CHIP

Reauthorization Act (MACRA).

American Medical Association (AMA) (2018). Quality Payment Program (QPP) Specifics:

American Medical Association.

Daniel, K.M.J. and Annelies, O. (2017), Medicare Access and CHIP Reauthorization Act

(MACRA): An evolution in Medicare physician payment and care delivery. Earnest & Young Global Limited

Finnegan, J. (2017). Survey finds fewer than 1 in 4 doctors prepared for MACRA. Fierce Health,

Marron-Stearns, M (2018),. MACRA Strategies for 2018 and 2019: Journal of AHIMA, vol. 89

(2), pp.22-58

McWilliams, J.M. (2018). MACRA: Big Fix or Big Problem? Annals of Internal Medicine, Vol.

168 (3), pp. 235-236. ISSN: 1539-3704

Michaels, D. (2016). The Two Sides of MACRA: Examining the Pros and Cons. Hayes

Management Consulting.

Effects of globalization on social change

1. Introduction

• Globalization has created immense effects on various aspects of social change.
• For instance, dressing, eating, and religion have greatly been affected by globalization that has been enabled by technology.

1. Analyze how social practices have changed due to global connectedness

• Global connectedness has affected social practices in varied ways.
• One of the social practices involves lifestyles that seems copied from other nations, particularly developed ones where civilization is high.
• Young people from developing nations are copying dressing codes abandoning their culture.

1. Using the four lenses, explain how a topic that has been discussed in this course has or has not been influenced by global connectedness.

• The four lenses of viewing globalization include natural science, social science, history and humanities.
• From a natural science lens, globalization has created social changes that are considered to be concrete and orderly thus improving world order.
• From a social science lens, personal networks created through globalization has enabled social change to create an element of social reality in the world through affecting factors such as religion, education, and human interactions.
• From a historical lens, global connectedness has enabled people to learn the historical aspects about other communities and groups through watching, listening and reading such historical facts.
• From the lens of humanities, global connectedness has significantly affected the studies by enabling students to understand the social changes through studying various humanities.

1. Analyze how global society has influenced social change. In other words, how has a shift to a more global society brought about social change?

• Basically, globalization has brought about multiple social changes in most societies in the world.
• One of the social changes that have structured the world in a unified way is religion.
• Traditionally, every country had varied ways of worshipping that were based on ethnic groups or tribes.

1. Analyze how global connectedness has influenced the behaviors and operations of individuals in your discipline of study. In other words, look at the influence of global connectedness through the lens of your discipline

• In my area or discipline of study (I study business), globalization has introduced online shopping.
• Consumers from different parts of the world can acquire goods and services from any foreign country through the internet.

References

Anheier, H. K., & Juergensmeyer, M. (Eds.). (2012). Encyclopedia of global studies. Sage    Publications.

Ghemawat, P., & Altman, S. A. (2013). Strategies for global connectedness. (Strategy business.)

Local Problem

The problem at a high school in South Georgia is that it is not known the extent of impact teaching reading using silent reading and repeated reading has on reading skills of students with mild intellectual disabilities in Social Studies. Both methods used together have been shown to be effective at increasing reading skills (Kim, Wagner, & Foster, 2011). Students have reading requirements that need to be met before graduation. Students may not be able to graduate if they are not able to read the material that is required for high school (Williams, 2014). Time is important and can be saved by using methods that have already been shown to increase reading skills (Pfost, Hattie, Dorfler, & Artelt, 2014). Currently close to 60% of students who receive special education services are not graduating with the same reading skills as their same age peers (Lowndes County Schools, 2015; Ga Military College, 2016; Valdosta State University, 2016).

This problem impacts the students who receive special education services because the students have to take remedial courses to get into college and fall behind their same age peers (Ga Military College, 2016; Valdosta State University, 2016). Possible factors that could contribute to this problem involve a lack of training for teaching reading to this population, a lack of consistency of teaching methods used for reading, and a lack of consistently using researched methods to improve reading skills (Teacher Survey, 2015). There are a large number of students who receive special education services who struggle when it comes to reading (Rosenberg, Westling, & McLeskey, 2013). Those students also have a reading goal so special education teachers need to be able to teach reading (McLaughlin & DeVoogd, 2017). Special education teachers need to have the ability to teach students according to their IEP goals and cover the regular curriculum (Mitchell, 2014). ***Comment MJ3: Which statement are you using from the literature that states there is a need for your study or that your study fills a gap? The statement needs to be published five years ago or more recently. There are a large number of teachers who are not prepared to teach reading. Repeated reading and silent reading methods can be taught easily to teachers, so they can help students increase their reading skills with methods that have already been shown to increase reading skills (Williams, 2014). According to Escarpio and Barbetta (2015), stronger credibility of reading methods can be shown by future research on repeated reading and other reading methods that include participants of older ages, a variety of exceptionalities, and both genders.

This study will add to the current knowledge on teaching reading by using repeated reading and silent reading. Both reading methods have been proven to help increase reading skills (Reutzel, Petscher, & Spichtig, 2015). How to teach reading effectively to students is a problem affecting a large population of the high schools in this locality. Furthermore, there is a significant increase in the disparity between the reading rates of students without disabilities and students with disabilities as these students progress through high school (Lowndes County Schools, 2015). The poor academic performance risk, as well as the possible frustration which is associated with low reading skills in South Georgia high schools, is a major concern for the students and parents (Ardoin et al., 2016). However, it is evident that the affected students are mostly unable able to graduate because they cannot fluently read the material that is a requirement in high school (Zawoyski, Ardoin, & Binder, 2015; Pressley & Allington, 2014). The issue is a major concern for parents and other stakeholders because the majority of students in the United States graduate easily and with better reading skills than their same aged peers in South Georgia (Ardoin et al., 2016).

Students with mild intellectual disabilities have relatively low reading rates. The negative attitudes towards reading could also be the reason for low reading performance (Guthrie, Klauda, & Ho, 2013). There is evidence that recommends teaching with the strategies of repeated reading and silent reading to increase reading skills (Klingner, Vaughn, & Boardman, 2015). Teachers are given a significant role in addressing their students’ poor reading skills, reading rates, and attitudinal barriers. This can be accomplished by identifying the impacts of each factor and applying the most appropriate instructional strategies as well as technology tools (Nguyen et al., 2014; Heller, Pattillo, & Smith, 2004; Guthrie & Klauda, 2014). School systems need to work hard in order to solve teaching-related problems such as lack of training for teaching reading to this population and lack of consistency of the methods used to teach reading.

Rationale

The challenge of low reading skills among some group of students is a major problem in South Georgia and the United States in general. The most affected group is students with mild intellectual disabilities. Research on the extent to which silent reading and repeated reading impacts high school reading skills is important (Ng, & Muntaner, 2014). This research deals with mild intellectual disabilities in finding the type of effect these reading methods have on students. Statistics show that approximately 60% of students with such challenges who receive special education services graduate with better reading skills than their counterparts with similar problems who do not receive special education services (Hutchins, 1995; Lowndes County Schools, 2015; McCulley & Osman, 2015). It is also evident that these students show similar reading skills after receiving special education services. This study points out both student-and teacher-specific problems that lead to low reading skills in high schools. However, over 85% of the problems are teacher-related or from lack of know-how from the teacher and school in general (Reutzel, Petscher, & Spichtig, 2015; Vaughn et al., 2013). Most of the teachers fail in playing their part in enabling growth of reading skills among high school students. Students only contribute to little or none in the cause of this challenge (Pressley & Allington, 2014). However, research shows that corporation between the stakeholders would help curb this challenge to a larger extent.

This study is being conducted to assess the impact of teaching reading, using silent reading and repeated reading with high school reading skills. This study is focusing on students with mild intellectual disabilities and how they are affected when silent reading and repeated reading methods are used to teach reading (Guthrie & Klauda, 2014). The use of silent reading, along with repeated reading, has been shown to be effective at increasing reading skills (Kim, Wagner, & Foster, 2011). Additionally, the study contains figures and graphs showing the current trend in the high schools. This study is accompanied by specific interpretations for the information provided (Tracey, & Morrow, 2017). With the use of available data, the researcher will identify the important points on the extent at which reading skills are increased for students who have mild intellectual disabilities when silent reading and repeated reading methods are used in high school (Paige et al., 2014). Georgia and more specifically South Georgia is affected by high rates of reading problems and low graduation rates, and has a great need for using other methods to increase reading skills (Lowndes County Schools, 2015). .

This study will be an important tool in providing other states with the specific strategies in their pursuit in reading skill excellence for students with mild intellectual disabilities in high school. The strategies that this study will offer will also be applicable in curbing the same challenge in all high schools across the country and for other disabilities that may be affected by repeated reading and silent reading as well (Guthrie, & Klauda, 2014). This study could also be utilized by other first world countries and developing countries as a benchmark to solve their struggles with the reading skills inequality in high schools (Scammacca et al., 2015). This study stresses that teacher-specific solutions are the best strategies for improving the level of student reading skills. Thus, they should be regarded and adopted as the vital approaches. The main purpose of this study is to investigate and show the extent of impact on reading skills for students who have mild intellectual disabilities, when silent reading and repeated reading methods are used to teach reading in high school Social Studies.

Definition of Terms

Sustained silent reading: This refers to a reading activity that is completed in class. Students are given a certain amount of time to material silently. The material is chosen by the students for information or pleasure. This method helps students learn to read, just for the sake of reading. There is no pressure of assessments, monitoring, skills work, or instructions from the teacher (Brussee et al., 2015).

Independent Reading: This refers to increased collaboration among teachers and students. Teachers provide guidance in the selection of text by the students. Students are responsible for keeping track of their reading material. They are also responsible for reflecting on the content of their reading. This strategy uses a collaborative approach to participation in discussions and mini-lessons (Mano & Guerin, 2018).

Guided Repeated Oral Reading: This involves students participating in reading the material out loud. This is dome between three to five times. The students get feedback from their peers and the teachers. This method helps to give students confidence, since they begin the process slowly and increase their speed as they repeat the text (Spichtig et al., 2016).

Scaffolded Silent Reading: It refers to silent reading, which involves the use of independent-level texts that are selected from various subjects. Also involved is interaction with individual students, periodic monitoring, and accountability through response arguments. It was mainly designed to help in addressing the weaknesses identified in traditional sustained silent reading (Grapin et al., 2017).

Repeated Reading: This refers to a reading method that was proposed by Jay Samuels, which focuses on developing automatic decoding. This is specifically for struggling readers. Focus is on asking students to read short text passages out loud until they reach a certain level of success in speed and accuracy. The text usually consists of fifty to two hundred words (Ciuffo et al., 2017).

Reading Fluency: Reading fluency refers to using intellectual material to decode words. There should be challenges when reading (Honig, 2014). Reading fluency comprises of three main components, which include automaticity, accuracy, and prosody (Caldwell, 2014).

Curriculum-based measurement: This is designed to provide a reliable and quick indication of the general academic health of a student (Blonder et al., 2018). The design of the measure enables the assessment of a student in basic academic skills. An example includes the measurement of oral reading fluency using words per minute (Young et al., 2017).

Instructional Level: This is the use of learning material, which is considered to be at an appropriate level of challenge for the individual learner. A good instructional level has a balance in the challenge and is not too difficult or too easy. Normally, the instructional level targets a reasonable accuracy range of between 93% and 97% (Santi & Reed, 2015)

Repeated Reading with Pairs of Students: This term refers to an instructional management procedure where two students, who are at the same instructional level, take turns reading out loud. The other students time the reading and count any reading mistakes (Tucker, 2016).

Students at Risk for Reading Risks: Students who are a risk of reading failures are the students who score low on the measures of reading fluency. The level of scores can be determined by counting correct words per minute and whether the accuracy level falls below or above the recommended 93% to 97% reading accuracy (Cho et al., 2015).

Automaticity: This term refers to the ability of a reader to read the words from a text effortlessly and correctly, which needs to be done in a manner that allows the reader  to use cognitive resources towards attention to the meaning while reading. This concept comes with practice and is enhanced by different pedagogical techniques (Gellert, 2014).

Connected Texts: This is when unfamiliar passages are read by students repeatedly, This allows the student to achieve fluency. The choice of the passages should be dictated by the instructional level of each student. These texts are identified as the intervention or non-transfer passages (Jennings et al., 2014).

Transfer Passages: The passages are the new passages that students have not interacted with previously. The passages are called generalization passages since they are also used in the assessment of generalization of the skills that the students have attained throughout their learning. The two common types of transfer passages are near transfer and far transfer. Near transfer passages are those that contain words that highly overlap with the practiced passages. Far transfer passages are those that have numerous unstrained words in comparison to the practiced passages (Wagner & Espin, 2015).

Individual Intelligence Tests: The tests that are administered one on one to students. This type of test is normally a part of the assessment process (Robeck & Wallace, 2017). The two most common individual intelligence tests are the Stanford Binet Intelligence Scale and the Wechsler Intelligence Scale for Children. These tests can be used to determine the level of intelligence of students. They are also used to categorize the students with intellectual disabilities, in order to determine where the students can be best served (Urbanski, 2015).

Significance of Study

The current study will be an original contribution to the teachers at the high school on teaching reading, using methods that have been shown to be effective at increasing reading skills. Results from the study will show if the two methods used for reading material that is required for Social Studies provide increases in reading fluency and comprehension skills. One way to show stronger credibility of reading methods suggested by Escarpio and Barbetta (2015) is for future research on repeated reading and other reading methods to include participants of older ages, a variety of exceptionalities, and both genders. The study will use students who are in high school and have been identified as having a mild intellectual disability. The results will show the impact of teaching reading, using repeated reading and silent reading methods. The decision of whether to teach using repeated reading and silent reading methods will come from the results of the study. Educators spend a large amount of time trying to find the best ways to help students increase skills in reading. Teachers need to be able to teach, using the best practices that have previously been researched and proven to provide positive results (Klingner, Vaughn, & Boardman, 2015).

This study will provide social change that is positive for students who have mild intellectual disabilities. The extent there is an impact on reading skills for students who have mild intellectual disabilities when silent reading and repeated reading methods are used to teach reading in high school Social Studies. The next environment will be impacted by increasing reading skills, by teaching with reading methods that have been shown to increase reading skills. The majority of high school students need help with reading when they move onto the more complex reading material that is required in high school. Less than half of all high school students have been shown to read on grade level. The inability to read on grade level causes a large amount of high school students to have trouble reading and understanding high school content (Hong-Nam, Leavell, & Maher, 2014). Teaching at the high school level focuses on content, not reading skills. Reading instruction needs to take place at all grade levels including high school (Capin & Vaughn, 2017). Students need reading skills in all future environments such as college, filling out forms for jobs and daily life, or reading directions (Job & Coleman, 2016). Reading is needed each day. If students are going to be successful in the future they need to learn to read (Basaran, 2013). Students who do not learn to read while going to school have been shown to have difficulties finding a job (Bulgren, 2013). This may lead to a lack of independence and a need for assistance from society (Job & Coleman, 2016).

Research Questions

The following research question guided this study:

***Comment MJ6- Why do Research Questions 2 & 3 repeat what Research Question 1 presents?***Can I have just 1 research question, or should I have the methods separate with 2 questions?

RQ1- To what extent does the teaching of reading using silent reading and repeated reading impact the reading skills of students with mild disabilities in high school Social Studies?

Review of the Literature

The Problem

The problem at a high school in South Georgia is that it is not known the extent of impact teaching reading using silent reading and repeated reading has on reading skills of students with mild intellectual disabilities in Social Studies. Currently, close to 60% of the students who receive special education services are not graduating with the same reading skills as their same age peers (Lowndes County Schools, 2015; Ga Military College, 2016; Valdosta State University, 2016). However, there is still a widening gap between students who can read well and students who struggle with reading (Pfost, Hattie, Dorfler, & Artelt, 2014). This problem impacts the students who receive special education services because the students have to take remedial courses to get into college and fall behind their same age peers (Ga Military College, 2016; Valdosta State University, 2016). There are several possible factors that have contributed to this problem. One factor is a lack of training for teaching reading to this population of students. A second factor is a lack of consistency of teaching methods used for reading with this population of students. A third factor is a lack of consistently using researched methods to teach reading with the current population of students (Teacher Survey, 2015). This is the problem affecting a larger population of the high schools in this locality. Furthermore, there is a significant increase in the disparity between the reading rates of students without disabilities and students with disabilities as these students progress through high school (Lowndes County Schools, 2015). This study will contribute to the current knowledge on repeated reading and silent reading which are both reading methods that have been proven to help increase reading skills (Reutzel, Petscher, & Spichtig, 2012). This study will contribute to the body of knowledge needed to address this problem by showing the extent of the impact on reading skills with students who have mild intellectual disabilities when silent reading and repeated reading are used in high school Social Studies to read the material.

The strength of reading skills has been shown to be important in current reading and future reading for all students (Basaran, 2013). Reading comprehension and reading fluency work together and are needed in order for students to be successful in school (Stevens, Walker, & Vaughn, 2016). Teachers need to know how to teach reading skills in order to help all students achieve the highest level of reading skills they can achieve (Tarkhanov & Fomin-Nilov, 2016). There are many reading methods that can be used to help students increase their reading skills (Lovett, Lacerenza, Steinbach, & DePalma, 2014). Previous studies have been carried out on different aspects of the effect of the implementation of reading methods on various groups of students (Bergen, Zuijen, Bishop, & Jong, 2017). There have also been studies carried out using the different reading methods in different environments (Freund, Kopak, & O’Brien, 2016). The size of the research groups have been different in many studies and may even be shown to contribute to the final results of the studies. According to Zhan and Kudua (2014) information theory has a strong focus on studying a specific area for the benefit of everyone, it will be important to see how this research can have effects for such a large group of students. The impact of these techniques on high school students with intellectual disabilities needs to be researched further (Bulgren, Graner, & Deshler, 2013). The current topic of silent reading and repeated reading has not been researched thoroughly (Klein, 2016). This literature review looks into the different research studies carried out by other researchers and their findings. Areas are also identified that need further research and what the current research will contribute to the current field of study.

The Importance of Reading Skills

The importance of proper reading habits cannot be overstated because this is what provides a foundation for all future reading. Studies have shown that being able to read fluently is directly related to reading comprehension (Basaran, 2013). Reading fluency is very important in order for students to become successful at reading (Guerin & Murphy, 2015). When children develop strong reading skills at a very young age, they have been shown to adapt faster in their places of work than children who did not develop strong early reading skills (Jamieson, 2013). Research further indicates that when parents show continued interest in the reading of their children, there are positive results (Basaran, 2013). Reading is so important in a child’s life because through reading, children discover new ways of solving problems Children are also exposed to new information and new ways to achieve their goals that would not have been possible without reading (Daniels, 2017). Through reading, children have been able to discover new hobbies and talents. Other children have even explored new areas that have ended up becoming the career of their life and succeeded in them (Linder, Mueller, Gibbs, Alper, & Freeman. 2017).

Exploration begins from understanding and reading (Ciuffo, Myers, Ingrassia, Milanese, Venuti, &Alquino, 2017). Through reading one begins to understand themselves better and even the environment that surrounds them. According to Lepola and Niemi (2016) books can be a student’s best friend and in a sense, a counselor. Knowledge is passed on through books therefore it would be unfortunate for students who cannot access information from books because they are unable to read. The basis of any reading is on understanding. It is through reading that people understand the rules of life in order for them to adapt in a society (Lepola & Niemi, 2016).Reading also builds confidence and enables people to plan better and memorize information. Therefore all of the reading skills that students learn enable them to develop a path that leads them to a better understanding of the future (Lepola & Niemi, 2016). One author noted how high school teachers are given the responsibility of teaching reading skills. The best way to do this is to use strategies that have already been proven to increase reading skills (Williams, 2014). This shows the need for understanding reading skills in students and studying the best ways to increase reading skills.

This study will investigate the benefits associated with using silent reading and repeated reading methods to teach reading skills to students, and to show an increase in reading skills. Intense reading instruction can be provided to high school students who receive special education services than to students who do not receive special education services. The current study is important for all students but especially students with mild intellectual disabilities. Research has shown that students who receive special education services graduate with better reading skills than students who do not receive special education services (McCulley & Osman, 2015). The methodology that teachers can implement to improve the reading ability of students is also very important. Teachers learn how to teach students during the instruction they receive in college and during student teaching (Tarkhanov & Fomin-Nilov, 2016). Ford-Connors et al. (2015) wrote how teachers know what they are meant to teach, but they have not been told how they are going to explain it. The issues that result in this problem are a lack of training for teaching reading to this population, a lack of consistency of teaching methods used for reading, and a lack of consistently using researched methods to improve reading skills. Technology has also been shown to be very important with any method that is used to teach or increase reading skills (Sen, 2016). Repeated reading and silent reading methods are the focus in the current study.

Target Groups under Research

Vaughn et al. (2013) conducted a study with a similar methodology to the current study, where participants were not randomly assigned to classes. Participants were of an older target group than the majority of other studies. Alharbi (2015) conducted a study using older students, specifically college level students, to show if using a silent reading strategy and an oral reading strategy helped strengthen reading skills. Participants were randomly assigned to either of the groups which is similar to the current study (Alharbi, 2015). Previous research has also been conducted on participants from a wide range of ages. Grabe and Stroller (2013) conducted their research on eighth grade students. Studies by Hawkins et al. (2013) were conducted on students in fourth grade. Price, Meisinger, Louwerse, and Mello (2015) carried out their study on students in 3rd grade. It is clear that these researchers put more emphasis on researching younger students. The current research intends to address the challenge of reading in an older group of students, those in high school. The importance of focusing on high school students for this research will be to show how repeated reading and silent reading techniques affect older students. Hawkins et al (2013) pointed out that there is not enough research on the current topic with older students. They suggested that future research needs to involve participants who are older than the majority of studies already conducted. Again, Hawkins et al (2015) suggested in their later studies that future research should include older students. According to Sénéchal, (2017) good decisions are made through reading information. Students in high school are in the stage of making choices about their lives. They are also in the stage of exploration, for instance they want to try out how to prepare a meal or read a manual on a new gadget. It is therefore important for this study to pay special attention on them and understand their reading habits.

A huge factor that affects the ability of students to learn how to read is the presence of disabilities (O’Brien, Hausmann, Wallot, & Kloos, 2013). Repeated reading and silent reading have been shown to greatly improve the fluency with which students carry out their reading. Previous studies compared cases that involved students with disabilities and those without disabilities. Studies by Erickson, Derby McLaughlin, & Fuebrer, (2015) and Savaiano & Hatton (2013) showed that repeated reading greatly improved the reading fluency of students with different disabilities, even including visual impairments.

Size of Research Groups

A key difference in the studies that different researchers have carried out is in the different sizes of groups that were used. Some researchers opted for small groups. Escarpio and Barbetta (2015) carried out their research on four students. Only two boys and one girl participated in the study conducted by Erickson, Derby, McLaughlin, & Fuebrer, (2015). A study conducted by Hawkins, et al. (2013) only used 4 students. Chang (2012) conducted a study on silent reading and oral reading that used 35 students. Chang and Millet (2014) conducted a similar study using 26 participants. A study conducted by Gibson, Cartledge, Keyes, & Yawn (2014) used only 8 students from first grade. A study conducted by Guerin & Murphy (2015) used only 3 students. The current research will target 80-96 students from eight different special education resource classes. The participants will come from the courses that have End of Course Tests so assessments will measure the same skills for all of the students in the study. The courses will be the Special Education resource classes of U. S. History courses and the Economic courses. There are approximately 13 to 16 students in each of the 6 classes that are being used for the study. This higher number of students will enable this research to be more credible in terms of analysis made on the students. One of the few available studies showed that using a higher number of participants showed a higher level of credibility than studies where smaller numbers of participants were used (Case, Speece, Silverman, Schatschneider, Montanaro, & Ritchey, 2014). A large amount of studies conducted in the past used a small amount of participants. More dynamics will be considered in these students, in particular their reading habits as opposed to the four students considered in the earlier research.

Results From Previous Research Studies

The current research aims at investigating if the same results occur from groups of high school students with mild intellectual disabilities as the different groups that have already been studied. Previous research has identified the different reading techniques to be effective with a wide range of different students (Lepola & Niemi, 2016). Research by Cuevas et al. (2014) showed that silent reading increased reading skills. Reading comprehension also increased significantly. Another study showed the importance of using silent reading to increase reading skills (Reutzel & Juth, 2014). A study by Chang and Millett (2103) showed that reading comprehension skills increased when repeated reading methods were used with university students. A study conducted with elementary school students showed that the use of repeated reading increased reading skills, specifically reading fluency and reading comprehension, in students who had learning disabilities (Strickland, Boon, & Spencer, 2013). Silent reading has been shown to be similar to oral reading, and the majority of research has focused on oral reading methods (Vanden Boer, VanBergen, DeJong (2014). Repeated reading and silent reading have shown to have comparable positive results in all areas of reading skills (Schimmel & Ness, 2017). A study conducted by Alharbi (2015) showed an increase in reading skills after the reading strategies were used but did not show one strategy to be significantly better than the other strategy. Gibson, Cartledge, Hayes, & Yawn (2014) also showed that the use of repeated reading caused increases in reading skills. One study actually showed that silent reading at the middle school level produced results that it did not increase reading skills as well as other methods (Dickens & Meisinger, 2016). This shows a need for the current study, to show that repeated reading and silent reading help increase reading skills.

Theoretical Basis

Comment MJ8- Your selection of theories needs to be convincing and justified to your study

Information theory has a strong focus on continuing to study a specific area for the benefit of everyone (Zhan & Kudua, 2014). The use of reading methods that have already been researched is economical. Reading affects society as a whole. Students and society benefit when students graduate with strong reading skills. The students are receiving the benefits of increased reading skills (Park, 2016).

***Start Here***There have been studies conducted in the area of reading that have followed Information Theory. (add information from 4 studies that followed information theory).

Comment MJ9-A convincing argument is needed that Scientific Realism supports and affirms your study

The conceptual framework chosen for this study is Scientific Realism (Creswell, 2012).  Silent reading and repeated reading methods are being studied to show if the two reading methods are effective enough to show increases in the area of reading skills (Sankey, 2014). Silent reading is being used since reading skills are needed in every area of life for all people.

***Start Here***Scientific Realism has played a role in several studies conducted on reading methods (add information from 4 studies that had something to do with scientific realism).

Research Methodology and Design

Comment MJ10- A convincing rationale for your selection of your research methodology needs to be presented

Quasi-experimental research is the method being used for the study. The focus of the study is a quantitative approach. The main reason for choosing a quasi-experimental design has to do with studying what effect a teaching method has on reading skills. There is an independent variable and a dependent variable (Kizkapan & Bektas, 2017). Another reason A quasi-experimental design was chosen is because some of the factors are not able to be controlled. Even though the study is an experiment, the participants are not being randomly selected.

Quantitative research is being used to show the relationship between two reading methods and reading skills (Sukamolson, 2012). Quantitative research has been used in the past to study the effectiveness of reading interventions and to compare interventions to each other (McCulley & Osman, 2015).

***Start Here***Quasi-experimental and a quantitative approach have been used in several previous studies conducted on reading methods (add information from 4 studies that used a Quasi-experimental and a quantitative approach).

Summary

Overall, this chapter discussed and outlined the key themes that are within the research literature. Different researchers have often suggested that research using different exceptionalities, other grades, and different subjects are needed (Strickland et al., 2013). Bulgren (2013) stressed that all students with learning disabilities can achieve success if teachers use interventions that have already been studied and shown to increase reading skills. The author also pointed out that more research on this topic should be conducted with students who have learning disabilities and other disabilities. Hawkins, et al. (2013) made it a point to inform the readers that future studies need to be conducted using participants of different ages, gender, and disabilities. According to Strickland et al. (2013) research using different exceptionalities, other grades, and different subjects is needed. Cuevas et al. (2014) suggested conducting future research with more diverse groups of participants. According to Hawkins et al. (2015) more research needs to be conducted using older students than the majority of current research uses.

The current study will focus on older students who have mild intellectual disabilities. It will look at the reading fluency and reading comprehension with a larger participant group of between 80-96 students (Merga, 2013). Different studies have indicated that experience is gained from other people and reading is one of the methods of gaining experience because you read what other people have gone through Reading connects to the brain and it is in silent reading that concentration and focus is better in high school students (Ciuffo&Alquino, 2017). If the current study shows increases in reading skills, both of the methods will be used at the high school to help increase reading skills throughout the school.

Specific issues addressed include:

• The different groups of students studied by the various researchers
  • The different age groups will show how silent reading and repeated reading affect different aged students. This will show if the two reading methods work the same will all age groups.
• The methods that these researchers used to carry out their research.
  • The different methods used to carry out different research studies will show which method or methods prove to be the best. This will allow for only the best type of methods to be used in the future.
• The results that these previous research papers came up with.
  • The results from all of the previous research papers will show which studies to follow in the future. This will allow for less time to be wasted on research that has already been conducted and shown to be invaluable.
• The need for teachers to learn what they will teach the students.
  • Teachers have to know how to teach, using the methods that have already been proven to work. Teachers do not already have the knowledge of how to use all of the reading methods that have been proven to be effective.

In spite of the intensive research that has been carried out in this field of improving the reading skills of different students, limited analysis has been carried out on students in high school with mild intellectual disabilities. This study aims at investigating how silent reading and repeated reading techniques will improve the reading ability of these students. According to Daniels (2017) the best discoveries have been made in silence because this is when you learn and grow and see the point of the author in a clear vivid manner.

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Constant change and the strategic role of communication

Abstract

Purpose

Libraries have been experiencing relentless change and uncertainty in their environment. The literature on corporate communications, strategic management and planning, marketing and public relations more recently, has been recommending using communications as a strategy to coherently and proactively handle and foresee change. Planning and using an overall communications strategy will bring integrity and adherence to the library’s goals and direction while reducing the discomfort of change. This selected bibliography is a quick starting point for understanding the significance of an overall communication strategy and its use for managing conflicts and changes in the library’s environment strategically. Design/methodology/approach – This article covers books and articles from mid-1980s to 2004, published around the world. The sources are listed alphabetically by author and then chronologically for different sources by the same author, providing brief but useful information about the content covered for each source. Findings – This bibliography illustrates a variety of research from corporate communications, strategic planning, communications management, marketing and public relations literature that emphasize the role of communication in strategic management. Research limitations/implications – It records a comprehensive list of publications covering international perspectives as well as publications about communication strategy. Practical implications – This selected bibliography is primarily intended for librarians, library planners, managers or administrators, but is also relevant to corporate and business professionals, planners and administrators. Further, it would also be a useful resource for students, faculty and researchers of communication. Originality/value – This bibliography presents a much needed resource list for gathering insights into the strategic role of communication for organizations such as the library that are in a state of constant change. Keywords Change management, Organizational change, Communication, Strategic management

Paper type Literature review

Introduction

In an environment of accelerating change, increasing competition, and effects of the worldwide information revolution, libraries are constantly managing programs and resources to accommodate changing needs. Change by its very nature tends to be uncomfortable, disruptive and even painful. Libraries have to manage this stress and uncertainty to be effective organizations. They have to counter their dynamic environment and competently convert threats and weaknesses from their internal and external environments into opportunities and strengths. As Pugh (2000, p. 2) points out: “…it is not a case of managing [emphasis added] change. It is more a matter of organizing ourselves to cope with anything that might come along.” Also, as Van der Waldt (2004, p. 135) asserts “the sooner organisations practise the routine of change, the greater the chances of organisational survival and sustainability. The management challenge today is not so much to plan for change, but to learn to live with it, anticipate it and to capitalise on it.” In order to be proactive and foresee change, libraries have to be strategic in their approach (Pugh, 2000). Such a path needs to be supported by a library’s structural and cultural orientation for planning and communicating, especially to the internal as well as external stakeholders. Communicating a library’s strategic plan and directions will instill stronger confidence in its constituencies about its programs, decisions and activities, as well as about the library’s sustainability and capability for handling chaos in its environment. “[C]ommunication can ease the pain of change for organisations” (Waldt 2004, p. 134). It not only informs, but also empowers stakeholders to understand the directions of change and transformation organizations are undergoing. In fact, the more stakeholders hear and learn about why and how an organization is moving in a particular direction, the lesser conflicts there will be between stakeholders and the organization’s understanding of programs and priorities. Similarly, the more an organization listens and learns from its stakeholders, the more its decisions will cater to the needs and interests of its constituencies (Kinnell, 1989; Da Saez, 2002). The success of library’s adjustment to change therefore, depends heavily on the effectiveness of its communication to all its constituencies. Communication helps libraries gain stakeholder support as well as reduce the library’s struggle to manage conflicts and change. A library’s communication plans typically comprise a layout of steps to inform all concerned about its products andservices (Weingard, 1999; Vikki Ford, 1985; Marshall, 2001). For instance, plans drawn up to communicate via newsletters, e-mails, announcements on the web site, departmental liaison’s messages, and so on are largely created for specific purposes of publicizing or marketing the new product or activity. Such communication plans typically tend to be ad-hoc and reactive. Although useful, they are fragmentary and do not present a coherent picture of a library’s strategic direction or path for handling changes in the environment (Weingard, 1998). There is growing evidence from the literature on organizational and corporate communications, communications management, marketing and public relations that “piecemeal, reactive communications” are not helpful for managing change or for making organizations more effective (Ferguson, 1999, p. 44; Waldt, 2004; Grunig, 2002). Creating an overall communications strategy can help bring coherence to all the various communication plans of libraries. Such a strategy “provides focus and direction for an organisation’s communication, building relationships with strategic stakeholders…[and] provides the framework for the communication plans necessary to carry out the strategy” (Steyn, 2000, p. 179). With such a strategy libraries can reconcile goals and activities with the expectations and needs of its constituencies. Libraries can engage in proactive, well-coordinated and useful communications by drawing up a communication strategy at the strategic planning level. A communications strategy is at the core of a library’s ability to do its work efficiently and competitively. By anticipating and detecting problems ahead of crisis situations, it can gain competitive advantage and handle issues more efficiently. Such a strategic role of communication will ensure excellence in the quality of information shared, while streamlining and prioritizing communication to help achieve an organization’s objectives effectively (Steyn, 2004). An overall communications strategy therefore is quintessential for libraries to manage changes in their environment, especially their stakeholder needs more efficiently and proactively. The need for greater attention to the strategic role of communication for organizations has been emphasized in several recent monographs and research studies including Excellent Public Relations and Effective Organizations: A Study of Communication Management in Three Countries edited by Grunig et al. (2002); The Communicating Leader by Puth (2002); Strategic Public Relations Management: Planning and Managing Effective Communication Programs by Austin and Pinkleton (2001); Corporate Communication Strategy by Steyn and Puth (2000). The purpose of this bibliography is to provide informative sources that highlight the significance as well as application of an overall communication strategy. These sources will help libraries gain a better understanding of the issues surrounding the strategic role, creation and use of communication strategy as a management tool for handling constant change. This bibliography illustrates a variety of research from corporate communications, strategic planning, communications management, marketing and public relations literature that emphasize the role of communication in strategic management. Key publications published approximately from the mid-1980s to 2004 are included in this bibliography. The topic is comprehensively covered in terms of including selections on theoretical analysis, literature reviews, case studies, descriptive analysis, and practical workbooks. Although several publications were printed or published in the USA, a majority of the authors included here provide an international or global perspective as well as background for the topic of communication strategy. The bibliography comprising mainly of books and journal articles, is arranged alphabetically by author, and for more than one citation by the same author, the annotations are listed chronologically in ascending order for easy reference. Cross references to related publications that maybe of interest to the reader are listed at the end of the annotation. This selective annotated bibliography is intended to provide a quick and brief, but useful starting point for library planners, managers or administrators and librarians involved in strategic planning, communications, marketing and public relations activities in libraries.

Annotated bibliography

Andreasen, A.R. and Kotler, P. (2003), Strategic Marketing for Nonprofit

Organizations, Prentice Hall, Upper Saddle River, NJ

In this book, Andreasen and Kotler suggest that in order for an organization to accomplish its mission, marketing and communication goals must be planned at the top management level. Relating specifically to the importance of communication for nonprofits, this book presents a thorough grounding in marketing including planning strategically, targeting and positioning messages, evaluating programs, and so on. It discusses these issues in five parts: “Developing a customer orientation”; “Strategic planning and organization”; “Developing and organizing resources”; “Designing the marketing mix”; and “Controlling the marketing strategies”. For information in the educational institutions context, see Kotler and Fox (1985). Although dated, this publication provides insightful approaches for educational organizations.

Austin, E.W. and Pinkleton, B.E. (2001), Strategic Public Relations Management: Planning and Managing Effective Communication Programs, Lawrence Erlbaum Associates Publishers, Mahwah, NJ Presenting a very practical approach to plan communications or public relations activities, this book shows how measurable outcomes for strategy can be planned. It distinguishes between strategic and tactical approaches to communication as the main path to successful communication plans. Using their academic and applied experiences, the authors have described in 16 chapters how to take stock of overall mission and strategic goals of an organization, determine research needs, collect data for strategic guidance, use a theoretical framework for guiding such research and finally pitch the message successfully and follow through. They recommend using a strategic approach to communication planning, skillful research methods and key principles from communication theories to increase credibility of measures used for such programs.

Bonk, K., Griggs, H. and Tynes, E. (1999), The Jossey-Bass Guide to Strategic Communications for Nonprofits, Jossey-Bass publishers, San Francisco, CA In this practical workbook style toolkit, the authors present information for nonprofit organizations to build a communications strategy so as to manage change and achieve the organization’s mission. The importance of building such a plan especially for nonprofit organizations is emphasized, for whom concrete outcomes are sometimes harder to measure. The first three chapters discuss about researching for information and trends from news and media as the communication plan is being developed. Chapter four details the needs for developing a communication plan and the various steps it involves such as identification of target audience, researching media coverage, public opinions and facts, message development, producing high quality public relations materials, assessment and development of a work plan. The rest of the chapters discuss details of the points mentioned in chapter four for building the communication plan.

Bryson, J.M. (1995), Strategic Planning for Public and Nonprofit Organizations: A Guide to Strengthening and Sustaining Organizational Achievement, 3rd ed., Jossey-Bass Publishers, San Francisco, CA Bryson presents a thorough study of the thought process and steps involved in strategic planning. Part one, “Understanding the dynamics of strategic planning” provides change management as the basic need for strategic planning in public and nonprofit organizations. Part two contains the main bulk of the book discussing topics such as the planning process, the need to clarify mandates and mission of the organization, assess the environment, identify strategic issues, formulate plans, establish vision, implement strategies successfully, and revisit and reassess plans and strategies. The process guidelines section in each chapter is a very helpful section presenting practical approaches for organizations to use. Through out the book, Bryson emphasizes the need for organizations to think and act strategically. The last part presents a discussion about the role of leadership in the strategic planning process and the steps to get started with the planning process. This book has become a popular reference handbook for strategic planning. In 2004, a third edition to this book with several updates was published. Much of the updates related to new material such as balanced scorecards, stakeholders analysis, collaboration and partnerships, and so on along with new examples from various types of public and nonprofit organizations. Also see for a practical application of strategic planning the publication listed below by the same author: Creating and Implementing Your Strategic Plan: A Workbook for Public and Nonprofit Organizations.

Bryson, J.M. (1997), Managing Information Services: An Integrated Approach, Gower Publications, Brookfield, VT More directly related to Library and Information services type of organizations, this book by Bryson is important for library managers to gain an understanding of the subject as well as to use methods for their strategic planning activities. The influence of information technology and telecommunications in the work of information organizations like the libraries is described. Information about strategic planning for managing and adjusting to the changing nature of the library business is presented in its coverage of subjects such as role of library managers, delivery of services, technological changes, conflict management, making policies, and communicating during times of change. Published in 1997, this book presents ideas for library and information service organizations for planning and change management.

Bryson, J.M and Farnum, K.A. (2004), Creating and Implementing Your Strategic Plan: A Workbook for Public and Nonprofit Organizations, Jossey-Bass Publishers, San Francisco, CA This workbook is a must for managers that are entrusted with the task of planning strategically for the library. It is a step-by-step introduction to all the work that needs to go into mission, vision and goals creation for an organization. A list of activities required to create, review, adopt and assess an organization’s strategic plan is presented in this book. This workbook can be used by itself or in conjunction with the comprehensive book by the same author published originally in 1995, with a new edition in 2004.

Clampitt, P.G., DeKoch, R.J. and Cashman, T. (2000), “A strategy for communicating about uncertainty”, Academy of Management Executive, Vol.14, No. 4, pp. 41-57 The authors present a background of how managers make choices and communicate change within organizations. This article discusses what strategy constitutes as compared to tactics, and how executives can choose among alternative strategies. It presents sections that explain what to expect from strategy, how to communicate strategy, what makes communicating a strategy effective and how to evaluate strategy that would be particularly interesting to library managers.

Cushman, D.P. and King, S.S. (Eds.) (2001), Excellence in Communicating Organizational Strategy, State University of New York Press, Albany, NY This book presents the significance of communicating strategically for organizations to be able to achieve goals. It takes into account the need for organizations to communicate to their stakeholders so that the structures or initiatives planned are understood as intended. The purpose of this book according to the editors is to “explore in some detail the theoretic, strategic, and practical linkages for creating excellence in communicating a firm’s strategy”. With the help of several case studies of

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corporations, the book presents via 14 chapters, a wide variety of corporate practices that are involved in managing change and crises, competition, leadership and so on. The final chapter summarizes all the issues raised in each of the 13 chapters and presents the lessons learnt and implications for organizations to achieve excellent communications.

D’Aprix, R. (1996), Communicating for Change: Connecting the Workplace with the Marketplace, Jossey-Bass Publishers, San Francisco, CA D’Aprix’s core argument in this book is to use communications strategically based on information from the “marketplace”. According to him, “communication is an essential tool for accomplishing change…and the only argument powerful enough to encourage people to embrace change is one that is rooted in the marketplace.” He recommends that an organization’s mission, vision and goals need to be connected to the marketplace activities and this needs to be done via strategic communication. In eight chapters, he pulls together a resource for organizations to understand what is the actual push behind change and how to embrace adjustments and threats through communication. Chapter one and two discuss the environment of change, especially for the worker. Chapter three describes the problems of reactive form of communication during change management. Chapter four presents the thesis of the book – the market based strategic communication model. Chapters five and six discuss the critical role of communication and the role of the leaders involved in communicating. In chapter eight the author summarizes the problems of horizontal communications in organizations. The main idea of the book is summarized in chapter nine with more analysis about communication based on the study of marketplace, customer demands or needs.

Deetz, S.A., Tracy, S.J. and Simpson, J.L. (2000), Leading Organizations through Transition: Communication and Cultural Change, Sage Publications. Thousand Oaks, CA This book is written more in a textbook format where every chapter begins with an overview, objectives and questions for further discussion. Through its ten chapters, this book covers the importance of culture to manage change, role of leadership in managing transition and change, role and impact of technological changes on organizations, role of language for communication about change by leadership, role of communication as a process as well as content for communicating change, and managing change in multinational organizations. The final chapter provides a review of all the material discussed in the book along with a practical case for organizations to apply their situation. This book will be interesting for library managers looking to understand the role of culture and effective communication in change management programs.

Dozier, D.M., Grunig, L.A. and Grunig, J.E. (1995), Manager’s Guide to Excellence in Public Relations and Communication Management, Lawrence Erlbaum Associates Publishers, Mahwah, NJ This is the second book from International Association of Business Communicators (IABC) funded research on excellent communication management. It presents a lucid and practical account of the results of the basic theory of public relations mainly for the practitioners of public relations and communication in organizations. It describes the

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characteristics of excellence in three broad aspects: communication within the organization, ideas and expectations from hierarchically placed upper level communicators, and finally organizational culture. Interested readers can see other books by Grunig et al. listed below that discuss research findings from the IABC excellence project.

Ferguson, S.D. (1999), Communication Planning: An Integrated Approach, Sage Publications, Thousand Oaks, CA Designed to reach an array of readers such as students, researchers, practitioners, and consultants, this book presents an excellent discussion (in four parts) of the integration of communications from public relations, marketing, advertising and corporate strategic planning. Strategic planning cultures and the role of communication is presented in part one. In part two the practical aspects of planning integrated communications and writing communication plans for overall communication strategies; operational plans for implementation; work plans for assigning responsibilities, evaluation and budgets; support plans for public relations, advertising, marketing campaigns; and finally communication plans for handling crisis are covered. Theoretical foundations for communications planning such as learning, persuasion, influence, psychology of audience theories comprise part three. Part four provides information about strategic approaches for management of collaborative and partnership type of activities. The book has practical advice and examples of communication plans for use by readers. Each chapter ends with a convenient conclusion that summarizes the purpose and main points discussed. Although primarily written for business audiences, this book will be very pertinent for librarians and managers seeking basis for library communication plans.

Grunig, J.A. et al. (Eds) (1992), Excellence in Public Relations and Communication Management, Lawrence Erlbaum Associates Publishers, Mahwah, NJ This is the first publication from the work of a research project funded by International Association of Business Communicators (IABC), which editor James Grunig claims was the largest research project ever funded for public relations. A general theory of public relations as a theory of communications management is proposed here based on extensive multi-disciplinary literature review of all research relating to public relations. In the first part, the basic theory of public relations from various viewpoints, definition and description of effective organization, public relations and management decision-making and application of excellence and effectiveness by communication managers is discussed. The second part develops the program level planning of communication. This includes discussions of strategic management, publics, evaluation of public relations programs and practices and informs how effective public relations programs are managed. The third part presents department level characteristics of public relations for excellence. It attempts to explain how research on the environment and organizational issues helps bring about excellent public relations. This part includes chapters on excellence in management, models of public relations and communications, organizational role in communications, and public relations function. The fourth part of the book covers organizational level conditions that allow for excellence in public relations. Topics in this section include structure and environment of organizations, power, activism, two way communication, culture, and

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so on. In the fifth and concluding part, bottom line advantages of effective and excellent communication and public relations programs are discussed.

Grunig, A.L., Grunig, J.E. and Dozier, D.M. (2002), Excellent Public Relations and Effective Organizations: A Study of Communication Management in Three Countries, Lawrence Erlbaum Associates Publishers, Mahwah, NJ This is the most recent book of the 15-year study funded by International Association of Business Communicators (IABC) of over 300 organizations in the US, Canada, and UK that began in 1985. It continues to develop the issue of how communication (as public relations) brings about organizational effectiveness and excellence. Results of both quantitative and qualitative analysis with details on methods, data and observations are presented. In chapter one, the authors present an overall theory developed from the literature, theoretical logic and data for public relations as communication management. In chapter two, the methodology of the excellence study is described with details of sample, measures of concepts and quantitative and qualitative methods used. In chapter three, the excellent characteristics of communication for organizations are presented. Chapter four, five and six discuss the value of public relations, empowerment of public relations function, and communicator roles. Chapter seven details the role of the communication function within an organization and its relationship to other functions of the organization. Four models of public relations – press agentry, public information, two-way asymmetrical and symmetrical model are presented here. In chapter eight three dimensions of these four models, namely, one-way and two-way; symmetry and asymmetry; and mediated and interpersonal techniques are explained. Chapter nine presents strategic communication programs as an excellence criteria for organizations. Another excellence characteristic discussed in chapter ten relates to activism of the organization. The authors found that organizations that are in a changing, unfriendly environment can move towards excellence better than those that are relatively stable. Chapter 11 presents the need for organizations to have an organic structure, a participative culture and a two-way communication system to build successful communication programs. Further, research questions related to globalization of public relations, strategic management and nature of relationships, ethics and the role of public relations in change management are discussed in chapter 12. Overall, this book is considered ground-breaking research on the role of public relations and informs readers about how and why communications should be considered as a critical management function for success of the organization.

Johnston, J. and Zawawi, C. (Eds) (2004), Public Relations: Theory and Practice, 2nd ed., Allen & Unwin, St. Leonards, NSW Public Relations: Theory and Practice presents readings on a range of topics in public relations with cases and examples from Australia and New Zealand. The goal of this book as the editors claim is to provide “insights into organizations at a range of levels – corporate, political and NGO’s- as they interface with the publics”. The reader is led from a thorough grounding in public relations theory to the processes and application of the practice of public relations. Structured in five parts – Theory; The legal and ethical framework; Process and application; Public relations in action; and Public Relations Practice, this introductory book presents the nature, history, law, ethics, management and practice of public relations.

Kitchen, P.J. and Schultz, D.E. (Eds) (2001), Raising the Corporate Umbrella: Corporate Communication in the 21st Century, Palgrave, New York, NY Kitchen and Schultz present an “overarching corporate perspective” for corporate communication. They conceptualize a “corporate umbrella” that nurtures, protects and provides the firm support and means to integrate many different communications within the organization. The first chapter presents the logic and structure of the book. The role of the leadership to communicate with stakeholders, corporate identity and responsible managerial practices are the topics of chapters 2-4. Chapters 5-10 discuss integrated corporate communications; branding and advertising; global communications, marketing public relations, crisis communications and threats and opportunities. The final chapters, 11-13, of the book present nature of the corporation “as engines for prosperity and growth”; “vision, values, intellectual property and assets”; and the “value of the corporate brand. The editors conclude with a summary of the need for corporations to “raise the corporate umbrella” where “interaction and integration between these (corporate and marketing) two vital strands of communication lead to synergistic outcomes.” Illustrations of concepts, models and figures as well as examples from corporations interspersed throughout the book make the reading smooth.

Moorcroft, D. (2003), “Linking communication strategy with organizational goals”, Strategic Communication Management, Vol. 7, No. 6, October/November In this article, Moorcroft asserts that communication strategy should be simple and easy to think about and implement. Writing about experiences in Royal Bank of Canada, he presents steps for communication planners to follow so that the organization can achieve strategic alignment of its communication plans with organizational goals. The article is divided in to sections as follows: defining what strategy means, different types of strategy, getting information to build your plan, essentials of a strategic plan, placemat plan, operating plan, providing the link to business targets, links to overall communication objectives, Moorcroft takes the reader through various steps of successfully creating and implementing a communications strategy. This process of planning a communications strategy seems to have succeeded, since the author reports that Royal Bank of Canada has won more than 30 communication awards and was “benchmarked as a best practice communications company by many organizations and journals”.

Moore, J.I. (2001), Writers on Strategy and Strategic Management: Theory and Practice at Enterprise, Corporate, Business and Functional Levels, Penguin Books Ltd, London This paperback is excellent for getting an overview of writings on the subject of strategic management. Moore skillfully summarizes each of the writers main contributions in corporate strategy through six parts: The Shapers and Movers; The Consultants; The Scholars and Researchers; The Developers and Teachers; The Incrementalists; Strategies for Decline: Endgames and Turnaround. Each part includes an introductory preface and covers a number of works by different authors. The

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Shapers and Movers included are Kenneth R. Andrews; H. Igor Ansoff; Alfred D. Chandler Jr; Michael E. Porter; Henry Mintzberg. The Consultants are: Robert D. Buzzell and Bradley T. Gale; Bruce D. Henderson; Benjamin B. Tredgoe and John W. Zimmerman; and Kenichi Ohmae. Derek F. Abell; Joseph L. Bower; Richard G. Hamermesh; Henry Mintzberg; Richard P. Rumelt; Malcolm S. Salter and Wolf A. Weinhold; Oliver E. Williamson; Robert A. Burgelman and Leonard R. Sayles comprise the Scholars and Researchers. Lester A. Digman; Jay R. Galbraith and Robert K. Kazanjian; Charles W. Hofer and Dan Schendel; John A. Pearce II and Richard B. Robinson Jr; Arthur A. Thompson Jr and A. J. Strickland III, and Gerry Johnson and Kevan Scholes are the Developers and Teachers. James Brian Quinn; Charles E. Lindblom and Gray Hamel and C.K. Prahalad are the incrementalists. Finally, the Analysts of Decline are Kathryn Rudie Harrigan; Stuart St. P. Slatter and David Lovett. There is a subject as well as author and authorities index at the end of the book. This book presents key ideas from eminent and effective writers in the field of corporate strategy and strategic management.

Moss, D. and Warnaby, G. (1998), “Communications strategy? Strategy communication? Integrating different perspectives”, Journal of Marketing Communications, No. 4. pp. 131-140 Moss and Warnaby present an integrated model for the strategic role of communication by putting together concepts from the strategy literature with that of public relations and communications literature. Through a survey of the literature they show that the role of communication has been neglected in the corporate strategy literature but emphasized in the communications management and public relations perspective. Bringing together these two perspectives “strategy communication” and “communications strategy”, into the strategy making modes model put forth by S.L. Hart, the authors present a unique perspective for organizations to achieve a competitive edge as well as more effectiveness. The authors propose “communications styles” that present the focus for communication during the development of strategy: Directional, Inspirational, Informational, Enabling and Motivational. Further, they propose “communication orientation” for each of the styles that indicates the importance given to communication in terms of internal and external stakeholders. With their integrated typology the authors succeed in providing a starting point for organizations to understand the role of communications in organizational strategy.

Moss, D. and DeSanto, B. (2002), Public Relations Cases: International Perspectives, Routledge, London This book begins with an introduction to the changing role of public relations practice and the need for practitioners and students to understand that “to operate successfully on a global scale …. an acute sensitivity to cultural diversity” is required. The goal of the book is to “contribute to a better understanding of how public relations is being practiced in different countries around the world.” This collection of case studies illustrates how global public relations has become and provides the readers with insight into best practices and examples from various parts of the world. A total of 20 case studies from across various corporations, nonprofit and governmental organizations are included: Shell, Commission for Racial Equality, BBC America, Perkin Foods, Clarica, Barloworld, PriceWaterhouseCoopers, Norwegian Dairies,

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Oklahoma City and Kerr-McGee; Swedish crises, UK BSE crisis, fundraising in Spain, Worldcom, Marks and Spencer and so on. Moss and DeSanto emphasize the importance of research for understanding situations, assessing perception, beliefs and values to understand publics. They predict that effective practitioners of public relations develop strategic plans grounded on such research and communicate “according to a well-thought-out plan, rather than a haphazard, ad hoc reaction to outside events”.

Oliver, S. (Ed.) (2004), A Handbook of Corporate Communication and Public Relations: Pure and Applied, Routledge, London In this book, Sandra Oliver pulls together a generalist approach to corporate communications and public relations including both pure and applied research. In part one – Corporate Communication at the National Level, articles include diversity programs, change communication program, knowledge management, corporate and government, corporate and public service and so on. Part two presents articles on corporate communication at the international level: Communication audits, framework for international public relations, facets of global corporate brand, differing corporate communication practice in successful and unsuccessful companies, communicating in china, corporate communication function, integrated corporate communication and the changing face of corporate communication. Part three – Managing Image, Identity and Reputation covers chapters on reputation and leadership; corporate reputation, communicating continuity plans, crisis management in the internet mediated era, terrorist attacks and impact on corporate public relations and public relations and democracy. Part four, the concluding section is titled – The future is now. This section presents articles on visualizing the message, methodological issues, creative thinking, using language, ethics and the final chapter on the new frontier for public relations. This book provides a useful synthesis of theory and best practices with case studies in corporate communications both at the national and international levels.

Oliver, S. (2001), Public Relations Strategy, The Institute of Public Relations, Kogan Page, London In this book of about 130 pages, Sandra Oliver succinctly presents the changing role of public relations, especially in “developing and supporting management strategy.” Writing for mainly public relations practitioners, she recommends that they should be looking beyond the “tactical requirements” of their jobs to connect to the overall role and policies of an organization. She begins with a description of strategy and the strategic role of public relations. The third chapter is a discussion of image and identity – “how organizations obtain and maintain their reputations, and how substance must underpin all public relations activity”. The fourth chapter is devoted to how public relations and communication (internal and external) is helpful for the human resources perspective. Chapter five discusses the differences, similarities and overlap between public relations and marketing. Finally, she presents the changing nature of communication with the effects from Internet and new communication media. This book discusses models and theories of public relations as a strategic function of management as well as presents several international case study examples to illustrate the trends in public relations.

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Potter, L. (2001), The Communication Plan: The Heart of Strategic Communication, International Association of Business Communicators (IABC), San Francisco, CA (spiral bound) Designed to serve as a practitioner’s guide, this manual steps through all aspects of managing communication strategically. It presents the “real stuff, the solid knowledge of what strategic communication really is and how to practice it.” This book (a loose leaf binder) begins with a study of strategic planning considered crucial to the communication planning process. Then it presents a ten-step strategic communication plan. The plan takes the readers step by step to show the process of aligning communications with the overall strategic plans of an organization. There are several examples of case studies included within the chapters as well as sample strategic plans at the end of the book. This is an excellent source for library managers or communicators to develop an understanding in a simple and easy way of the process of designing and implementing a communications strategy that is based on the strategic plans of the library.

Puth, G. (2002), The Communicating Leader. The Key to Strategic Alignment, 2nd ed., Van Schaik Publishers, Pretoria First published in 1994, the popularity of this book is indicated from the fact that it was reprinted twice (1996 and 2001) and a second edition appeared in 2002. With the second edition the title changed from “The Communicating Manager” to “ The Communicating Leader: the Key to Strategic Alignment” indicating the transition in emphasis of the topic. Organizations are shifting from using strategies mainly to compete with other organizations using them to align the workplace and external stakeholders to the strategic intent and vision of the organization. This book is mainly about strategic communications by leadership of organizations. Written in a conversational style with a summary at the end of each chapter and illustrations, this book covers communication by leadership of an organization in three aspects: Fundamentals of leadership communication, contexts for leadership communication and basis for strategic leadership. Though the coverage in this book is mainly for the leadership of an organization, the last part about strategic contexts with sections on “formulating strategy” and “communication for strategic alignment” is very useful for understanding and applying an overall communication strategy within the organization.

Quirke, B. (1996), Communicating Corporate Change: A Practical Guide to Communication and Corporate Strategy, McGraw-Hill, London and New York, NY Written more from the perspective of internal communications for organizations, this book provides a comprehensive practical view for realizing effective communications. The first two chapters in this book provide an overall review of how change affects organizations, need for cultural and attitudinal changes and the role of communication strategy in handling such change. These chapters are especially useful for the reader who is looking for developing a more strategic role for communications within their organizations. Chapter three covers “ Structure, identity and values” indicating the significance of sharing values to create a common understanding of the identity and image of the organization. The fourth chapter covers the main content of the book where the communication of corporate strategy is discussed among numerous other

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aspects of communication. The other practical aspects of the book include “Communicating in teams”, and “Orchestrating communication” that provide readers with advice of how to work in and with teams, and offer a variety of communication approaches needed to understand and implement communication plans is described with help of a model. Although it uses examples of corporations, this book would be useful for library managers seeking diversity in approaches of internal communication.

Van Riel, C.B.M. (1995), Principles of Corporate Communication. [Identiteit en imago. English]. Translation, Chris Blackburn (Ed.), Prentice Hall, London Van Riel defines corporate communications as “a framework in which all communication specialists (marketing, organizational and management communication) integrate the totality of the organizational message, thereby helping to define the corporate image as a means to improving corporate performance”. The main issues of corporate communications are explained through six chapters. A lengthy introduction describes Van Riel’s explanation of corporate communications along with the discussion of Identity and Image as core concepts for organizations. The second and third chapters discuss details of corporate identity and image. The fourth and fifth chapters present “an effective corporate identity programme” and the processes involved in organizing corporate communications. The final chapter is a presentation of four case histories as examples. Each chapter provides a conclusion except for the last one. The corporate communications analysis in this book presents a theoretical and academic background as well as a clear practical perspective for using communications for the effectiveness of organizations.

Van Riel, C.B.M. (2000), Strategic Corporate Communication: A Selection of Articles by Belgian and Dutch Authors in Leading International Journals, Alphen aan den Rijn, Samsom In this collection of articles, Riel presents papers written by several Belgian and Dutch writers (cross-discipline) to summarize their thoughts about corporate communication strategy and reputation. All the articles are in English except for one, which is in German. The main subject areas this book covers are communication in management, marketing and culture. Divided in four parts: Strategy and communication; Marketing and communication; Corporate communication and management; and Language culture and communication, this book presents “communication as a management tool to solve organizational problems”. Some of the topics covered include: strategic business communication; types of journals that maybe useful for those interested in strategic communication; crisis communication: the Brent Spar case – superbrands: myth or reality?; Measuring corporate images; interactive communication: consumer power and initiative; the reputation landscape: a vision on reputation management rooted in five areas of functional management; and trade show effectiveness: a cross-national comparison.

Ristino, R.J. (2001), “Integrated strategic communication”, Strategic Communication Management, April/May, pp. 32-35 Ristino advocates the use of Integrated Strategic Communication (ISC) as a path to bring together all communications of the organization to support the overall strategies

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and objectives of the organization. ISC’s “aim is to optimize the impact of persuasive communication on key constituencies”. The critical first step identifies the core constituencies of the organization since they control the reasons for a strategy to succeed or fail. The author presents ISC in a ten-step process in terms of integrated strategic marketing communications. According to the author, most organizations “fail to use communication strategically to build the long-term relationships necessary to nurture grassroots support for corporate initiatives”. Information gathering and two-way communication is recommended with organizational leadership (or strategy coordinating group) managing the communication coordination and process. The message, as Ristino asserts, should be coherent as well as consistent. Communication work groups are assigned day-to-day communication activities by the leadership. The author recommends a communications strategy that basically builds “mutual understanding between the organization and its constituencies” and communicates how the initiatives would be helpful to them. Message strategy, segmentation, feedback loops, selection of channel or media are essential to move communications to the next stage of implementation. The message is implemented with an initial phase and a repetition phase. Monitoring and evaluating communications campaign is considered crucial to determine the effectiveness of the communication strategy. Written in a lucid style with examples from corporations, this article discusses the integrated strategic communication campaign.

Van Ruler, B. and Vercic, D. (Eds.) (2004), Public Relations and Communication Management in Europe: A Nation-by-Nation Introduction to Public Relations Theory and Practice, Mouton de Grouter, Berlin This book begins with an overview of public relations and communication management in Europe. As the editors state, it was brought together from the results of two projects: European Public Relations Body of Knowledge and The Public Relations in Europe project. The book is arranged in 29 chapters covering Austria, Belgium, Bosnia-Herzegovina, Bulgaria, Croatia, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Malta, The Netherlands, Norway, Poland, Portugal, Russia, Serbia and Montenegro, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey, and the UK. It presents contributions with an insider’s point-of-view along with background and history, facts, figures and qualitative research results. In between the 29 chapters, conceptual statements that described different approaches by well-known scholars and professionals in public relations are included: constructivist approach, reflective approach, transitional approach, public sphere approach, civil society approach, and dialogue approach. The book is unique in that it overcame language and cultural barriers to bring together public relations perspectives in Europe.

Sriramesh, K. and Vercic, D. (Eds.) (2003), The Global Public Relations Handbook: Theory, Research, and Practice, Lawrence Erlbaum, Mahwah, NJ This book won the PRIDE Award from National Communication Association, Washington, DC, USA, for the best book on public relations published during the year 2003. Sriramesh and Vercic bring together an excellent collection of international information for public relations students, researchers and practitioners. The wide range of articles are arranged by continents including content on public relations

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history, development and current practices within each country. The introduction to the volume discusses the trends of globalization of public relations practice. Sriramesh states that “…every public relations professional must have a multicultural and global perspective in order to be effective, and such an outlook should not be considered the domain only of international public relations specialists anymore. The contributors to this handbook were asked to follow a framework set out in the first chapter of this book – A Theoretical framework for Global Public Relations Research and Practice. This chapter also presents to the readers an overall pattern for understanding public relations across the globe. Part one – Asia and Australasia covers China, UAE, Japan, Singapore, South Korea Australia and New Zealand. The African continent is represented by Egypt and South Africa. Part three – Europe includes information from Germany, The Netherlands, Sweden, Poland, Slovenia, and Russia. United States, Brazil and Chile comprise the fourth part – The Americas. Part five provides a discussion of non-governmental and global organizations – foreign governments, UNESCO, Transnational corporations and so on. An epilogue provides the rationale for connecting multiculturalism and public relations in the education of public relations. Sriramesh hopes that this “will pave the way for the public relations profession around the world to become truly strategic as a result of becoming more multicultural”. Also, refer to a separate publication by the same author on Asia: Sriramesh (2004).

Steyn, B. (2003), “From strategy to corporate communication strategy: a conceptualisation”, Journal of Communication Management, Vol. 8 No. 2, pp. 168-183 In this article, Steyn discusses the concept of strategy and its role in the corporate communication context. She builds the idea of a corporate communication strategy as a “functional strategy” that provides “focus and direction to the corporate communication function”. Steyn provides a comprehensive analysis of literature in presenting a theoretical approach through strategic management and public relations. According to her, a corporate communication strategy uses the “enterprise level strategy” rather than the “corporate level” or “business level” strategies to draw the framework for the organization’s communication plans. The analysis and assessment of external environment and building stakeholder relations is essential for setting up such a strategy, even though it is created internally by the communication leaders of the organization. Corporate communication strategy as imagined by Steyn, has a non-linear development and takes into account changes and trends in the environment and stakeholders needs. “It is regarded as an emergent rather than deliberate strategy” since primary strategic issues are derived from the strategy before communication goals are defined. Steyn summarizes how this conceptualization of corporate communication strategy can be operationalized via a model she developed, which was presented at the 11th International Public Relations Research Symposium, held at Lake Bled from 2-4 July 2004. for further readings about this perspective see: Steyn and Puth (2000); Tibble (1997) and Verwey (2003) in the list of references.

Stroh, U. and Miia, J. (2001), “New approaches to communication management for transformation and change in organisations”, Journal of Communication Management, Vol. 6 No. 2, pp. 148-165 This article presents an approach to change management by organizations using communications. Using implications from chaos, postmodern, complexity and

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contingency theories it describes the need for a communication approach. The authors emphasize the strategic approach, stakeholder importance and customer-oriented communications for managing change in organizations. The beginning of the article defines the concepts of change management, transformation and organizational development. In addition, it discusses via a comprehensive literature review the changing paradigm of organizational communications as they move from single subject to multi-disciplinary approaches. The article concludes that a “[w]ell-developed organisation change should be a strategically managed process but take into consideration all the possibilities of change that could occur in the environment.”

Tilson, D.J. and Alozie, E. (Eds.) (2004), Toward the Common Good: Perspectives in International Public Relations, Pearson Education Inc., Allyn and Bacon, Boston, MA This book presents a global perspective including a theoretical as well as practical approach to public relations. The editors Tilson and Alozie skillfully present readings that cover a wide variety of international settings. This is especially helpful for students to prepare for a global career in public relations. “A broad range of public relations practices and institutions – governments, public relations firms, corporations – are examined within a discussion of history, politics, economics, culture and communication.” Part one covers the historical perspective of public opinion and its relationship to public relations as a profession. Part two through part five are divided into articles by continents – Latin America, Europe, Africa, and Asia. Some chapters present overviews of relevant information specific to the country, while other provide case studies from different countries. One of the goals of the book is to bring together “thoughtful analysis and commentary from leading scholars” to explain the emerging field of global public relations and the local and global roles of public relation professionals.

Van der Waldt, De la Rey (2004), “Towards corporate communication excellence in a changing environment”, Problems and Perspectives in Management, Vol. 3, pp. 134-143 In this article, Waldt presents a discussion of corporate communications and change management. The main point of this article is that “communication eases the pain of change for organizations”. Proper communication to both internal and external stakeholders makes the management of change easier, which leads to an effective organization. The article discusses (with an extensive literature review) the conceptualization of communications as a solution for managing change and the application of strategic management of communication in organizations. The ten-step communication strategy process presented by the author are: Analyzing the internal environment, Identifying strategic stakeholders and networks, Identifying and prioritizing strategic issues, Identifying implications of strategic issues for stakeholders, Deciding on the corporate communication strategy, Setting communication goals and policy, Determining a budget, Discussing the draft strategy with top leadership, Conducting an analysis to choose the right channel of communication and Developing a strategic communication plan. The final step gives the organization a framework within which all its communication takes place.

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White, J. and Mazur, L. (1995), Strategic Communications Management: Making Public Relations Work, EIU Series. Addison-Wesley Publishers Ltd. Addison-Wesley Publishing Co. Inc. and Economic Intelligence Unit, Cambridge This book presents details of using “good communication” for an organization’s strategic planning and decision-making. It shows through research and in depth analysis how public relations can be used as strategic communication to achieve an organization’s goals. The first part of the book – Public relations and communications management describes strategic contributions of public relations, management, human resources, budgeting, control and evaluation aspects. The second part of the book discusses various types of communication such as media relations, marketing, internal, public affairs and crisis management. Part three presents information about managing relationships with stakeholders. Ethical and legal issues and the future of public relations are the topics of discussion in the final fourth part. This book is useful for understanding and applying communications as a strategy to aid implementation of an organization’s initiatives.

References

Austin, E.W. and Pinkleton, B.E. (2001), Strategic Public Relations Management: Planning and Managing Effective Communication Programs, Lawrence Erlbaum Associates, Mahwah, NJ.

De Saez, E.E. (2002), Marketing Concepts for Libraries and Information Services, 2nd ed., Facet Publications, London.

Ferguson, S.D. (1999), Communication Planning: An Integrated Approach, Sage Publications, Thousand Oaks, CA.

Grunig, L.A., James, E.G. and David, M.D. (2002), Excellent Public Relations and Effective Organizations: A Study of Communication Management in Three Countries, Lawrence Erbaum Associates, Mahwah, NJ.

Kinnell, M. (1989), Planned Public Relations for Libraries, Taylor Graham, London.

Kotler, P. and Fox, K. (1985), Strategic Marketing for Educational Instituttions, Prentice-Hall, Englewood Cliffs, NJ.

Krishnamurthy, K. (Ed.) (2004), Public Relations in Asia: An Anthology, Thomson, Singapore. Marshall, N. (2001), “Public relations in academic libraries: a descriptive analysis”, The Journal of Academic Librarianship,, Vol. 27 No. 2, pp. 116-21.

Pugh, L. (2000), Change Management in Information Services, Gower Publications Limited, Brookfield, VT.

Steyn, B. and Puth, G. (2000), Corporate Communication Strategy, Heinemann Publishers, Sandown, South Africa.

Steyn, B. and Bu ¨tschi, G. (2004), “A model for developing corporate communication/public relations strategy – an online application (http://www.digitalmgmt.com/htm/demo/ dmsUserWeb)”, paper submitted to the 11th International Public Relations Research Symposium, held at Lake Bled, Slovenia from 2-4 July 2004. p. 28,

Tibble, S. (1997), “Developing communications strategy”, Journal of Communication Management, Vol. 1 No. 4, pp. 356-61.

TUBERCULOSIS CASE STUDY

Patient

The patient was a 46 year old male who was diagnosed following admission to hospital with active respiratory tuberculosis (TB).

History of presenting complaint

In the 6 week period prior to admission, the patient had experienced a worsening dry cough which was unrelieved by over-the-counter (OTC) cough medicines.  He presented to A&E when his cough became productive and purulent, and he had experienced two episodes of haemoptysis.  He had also been experiencing night sweats, and was aware of having lost some weight, although he was unsure of how much.

Past medical history

The patient reported no previous illnesses or medical treatment.

Social history

The patient was born in China, and had arrived in the country approximately 6 months prior to his admission to hospital.  He was staying with a friend and was working on a casual basis in a factory.  He had just begun to apply for the right to remain in the UK.  He did not smoke or drink alcohol.  He was unaware of any family medical history.

Drug history

The patient’s drug history was confirmed by speaking to him (with the assistance of an interpreter).  He was not registered with a GP in the UK, and took no regular medicines.  He had bought some OTC cough medicines in the last few weeks; he could not remember their names and, as they had not been effective, he had stopped taking them over a week previously.

Examination details

Chest examination: Trachea central; expansion right = left.  Dull to percussion on both right and left apices.  Slight expiratory wheeze.

Chest X-ray: Shadowing in upper lobe of both lungs

Sputum samples: Smear positive for acid-fast bacillus.  Culture: mycobacterium tuberculosis

In addition, blood tests including full blood count, urea and electrolytes and liver function tests were completed.  Blood borne virus testing was completed with the informed consent of the patient.  The patient’s weight was checked, and his temperature was regularly monitored and documented.

Diagnosis

The results of the investigations above, together with a thorough clinical assessment of the patient, led to a diagnosis of active respiratory tuberculosis.

Clinical progress

Day 1:  The patient was admitted via A&E, where his presenting symptoms led to his case being discussed quickly with an infectious disease specialist.  As it was suspected that he might have active respiratory TB, and would therefore be considered an infection risk, arrangements were made for rapid transfer to a ward with a negative pressure isolator room.  On arrival, he was commenced on empirical TB treatment, his admission bloods having shown no renal or hepatic impairment, and satisfactory visual field testing having been completed.  The clinical pharmacist confirmed his medication history and documented it in his notes, and counselled him on the medication he was to receive.   The patient was also prescribed paracetamol for pyrexia.  Two induced sputum samples were obtained and sent for culture.

Day 2:  A further induced sputum sample, obtained in the early morning, was sent for culture.  The patient met the TB liaison nurse for the first time.

Day 4: The patient was tolerating his TB medication well, and reported no adverse effects, although he had noticed that his urine was red.  His liver enzymes were slightly elevated, although still within laboratory reference range.  His other blood results were also within laboratory reference range.  He was still occasionally pyrexial.  He reported that his appetite had improved a little.  All blood borne virus tests had returned negative.

Day 8:  Culture results confirmed the initial diagnosis of active respiratory TB. No other organism was grown in the cultures. The patient continued to feel better and was no longer pyrexial.  All blood tests remained within laboratory reference range, and his liver enzymes had returned to close to pre-treatment levels.

Day 15: The patient’s weight was checked, and was found to have increased to 66.3kg (from 63.6kg at admission).  His medication was reviewed and amended to take account of this.

Day 17: The patient’s blood tests (urea and electrolytes, liver function tests) confirmed no adverse effect of amending his medication two days previously.

Day 18:  Preliminary discharge planning was commenced: as Directly Observed Therapy (DOT) was being considered, the clinical pharmacist was asked to calculate a 3 times weekly dose regimen for the patient.  This was documented in the patient’s notes.

Day 20: Having completed over two weeks of treatment, the patient’s health had improved sufficiently for him to be considered well enough to go home.  Plans had been made for a more permanent residence for him.  Following a discussion with the patient, medical staff, the TB liaison nurse and the clinical pharmacist, it was decided that he did not require DOT, but would instead remain on daily medication which would be supplied in a weekly blister pack (prepared by the hospital pharmacy), and would be supported in the community by the TB liaison nurse.  He was counselled on all of his medicines and on the use of the blister pack by the clinical pharmacist, with the assistance of an interpreter.  He was to be followed up at clinic in one month’s time.

Discussion

Tuberculosis (TB) is an infectious disease caused by the mycobacterium tuberculosis complex.  It is a notifiable disease.  Although it continues to be a leading cause of mortality in low and middle income countries, public perception in the UK has until recently assumed that TB is no longer an issue here, due to the mass screening campaign in the first part of the 20^th century, and the availability of the Bacillus Calmette-Guérin (BCG) vaccine.

However, the number of cases reported in the UK has risen steadily in the first decade of the 21^st century, with 8963 cases reported in 2011.  The majority of patients were born outside the UK, with coming from south Asia and sub-Saharan Africa. ⁽¹⁾

Of particular concern is the emergence of multi-drug resistant TB (MDRTB) – where there is resistance to at least rifampicin and isoniazid, two of the mainstays of standard TB therapy.  If these cannot be used, second-line treatment can involve the use of medications for which there is less evidence of benefit and which may have more harmful side effects.  There may also be implications for cost, given that some of the medications used, (for example, amikacin), can only be given by the intravenous route, necessitating hospitalisation.  Patients in low income countries may not have access to either the facilities or the funds to obtain adequate treatment.  It is of vital importance to quickly identify everyone who is infected, and to ensure that they are treated effectively with the correct medicines, at the correct dosage, for the correct length of time. ⁽²⁾

TB is usually spread by the inhalation of airborne droplets which are expelled by infectious people whilst sneezing or coughing.  Once inhaled, the body’s immune system is activated, and in approximately 80% of people, the bacteria are killed.  In the remainder, the bacteria may remain dormant within granulomas formed during the immune response; the patient is said to have latent TB.  About 5-10% of patients with latent TB will go on to develop active TB later in life.

Where the body’s immune system fails to destroy or to control the bacteria, they will begin to divide and spread; the patient is then said to have active TB.  As the main route of infection is via the lungs, it is unsurprising that the most commonly recognised form is respiratory TB.  Characteristic symptoms include cough (initially dry, becoming productive and purulent), night sweats, weight loss and fatigue.  Other recognised variants include:

• Central Nervous System (CNS) TB – patient presents with non-specific symptoms such as anorexia, malaise, headache and vomiting, and then develops meningeal inflammation and focal neurological symptoms.
• Bone and joint TB – associated with, amongst other symptoms, back pain and kyphosis.
• Lymph node TB – most commonly seen in the cervical lymph nodes, which become enlarged but which may become asymmetrical.
• Disseminated TB – bacilli spread throughout the bloodstream, causing malaise, fever, anorexia and weight loss.
• Pericardial TB – may be associated with pericardial effusion.

Treatment for all forms except CNS TB usually lasts for six months; CNS TB is normally treated for at least nine months. ^{(3, 4)}

Positive diagnosis is made in a number of ways depending on the variant involved.

• Active non-respiratory TB – A biopsy is taken from the affected site and is sent for culture.
• Active respiratory TB – Shadowing on the patient’s chest X-ray may suggest TB – this is normally apical in TB, as opposed to basal in pneumonia. Sputum smear microscopy is then used, where the sputum sample is checked for the presence of acid-fast bacilli.  However, this does not discriminate between Mycobacterium tuberculosis and other mycobacteria, so it is necessary to send sputum samples for culture to confirm the diagnosis.  This technique has the added advantage of allowing for drug resistance testing to be carried out at the same time.
• Latent TB – The tuberculin skin test (Mantoux test) is commonly used – a small amount of PPD tuberculin is injected into the forearm. If a reaction is seen when the test is “read” 48 – 72 hours later, this is a sign that the patient has either latent TB or has received the BCG vaccine, or has been exposed to non-tuberculous bacteria.  A positive result therefore warrants further investigation.  It should also be noted that false-negative results can be seen in patients who are immunosuppressed.

IMMEDIATE MANAGEMENT

As the patient was suspected to have active respiratory TB, the priority was to ensure prompt, appropriate and effective treatment for the patient.  It was also necessary to trace all of his close contacts, so that they could be screened for TB, and could be treated if necessary.

Patients who are diagnosed with active TB which is not drug-resistant, and who are not clinically unwell do not necessarily need to be admitted to hospital for initiation of treatment.  However, if there are concerns about the patient’s condition or extenuating socio-economic circumstances, the patient should be admitted to a single room in hospital – this should be a negative-pressure room if the ward concerned also cares for immunosuppressed patients (e.g. those with HIV).  The patient should remain in this room until discharge, or until at least two weeks’ treatment has been completed.  The patient should wear a mask if there is a need to leave the room during this period. ^{(3, 4)}

In this case, the patient’s eligibility to remain in the UK was being examined by the authorities.  There was concern that if he did not receive appropriate treatment immediately, the patient might default from attending for treatment, and would present a public health risk if he remained untreated.  For this reason, he was admitted to a ward with a negative pressure room, where he remained for almost three weeks.  During this time, his legal status was clarified, and he was discharged into a much more stable environment.

Empirical treatment

The standard treatment for TB for adults and children consists of four drugs.

Rifampicin

Rifampicin is a bactericidal agent which acts by inhibiting RNA polymerase.  It is effective at killing organisms with slow metabolic activity.  It can cause transient elevation of aspartate aminotransferase (AST), alanine aminotransferase (ALT) and bilirubin, which does not generally require disruption to treatment; however, more serious hepatic toxicity can occur, and patients should be told how to recognise signs of liver disorder, such as persistent nausea, vomiting, malaise or jaundice.  (Vomiting is usually the initial sign).  Treatment should be stopped and immediate medical advice should be sought.  Rifampicin also causes body secretions such as urine and tears to become orange-red; this may have consequences for patients who wear soft contact lenses.  Rifampicin also induces hepatic enzymes, which can accelerate the metabolism of several drugs, including oestrogens, corticosteroids, phenytoin, sulfonylureas and anticoagulants.  Adjustments to a patient’s usual medication regimen may be necessary when TB treatment is both started and stopped.  Mild cutaneous reactions may also occur.

Rifampicin is taken for six months, and dose is decided by body weight (Adult dose: <50kg, 450mg daily; 50kg and above, 600mg daily). ⁽⁵⁾

Isoniazid

Isoniazid is a bactericidal agent, which acts by inhibiting mycolic acid synthesis, thus disrupting cell wall synthesis.  It is also associated with liver toxicity.  Its main side effect is peripheral neuropathy, and may also rarely cause psychosis.   TB patients who receive isoniazid and who have pre-existing risk factors for peripheral neuropathy (e.g. malnutrition, HIV, diabetes mellitus, alcohol dependence, pregnancy, chronic renal failure) should therefore be prescribed prophylactic pyridoxine as part of their treatment.  The pyridoxine dose used is normally 10mg daily; however this strength is difficult to obtain, so 25mg daily or 50mg on alternate days may also be used.   Isoniazid is taken for six months, and the adult dose is 300mg daily. ⁽⁵⁾

Pyrazinamide

Pyrazinamide is a bactericidal agent, particularly in acidic environments.  It is thought to inhibit cell membrane transport function and/or to disrupt energy metabolism, and is only active against intracellular dividing forms of M. tuberculosis.  It is also associated with liver toxicity and with gout.  Pyrazinamide is taken for the two month “initial” phase only, and dose is decided by body weight (Adult dose: <50kg, 1.5g daily; 50kg and over, 2g daily). ⁽⁵⁾

Ethambutol

Ethambutol is a bacteriostatic agent.  It prevents cell wall synthesis by inhibiting arabinosyl transferase, which is responsible for producing arabinogalactan in the cell wall.  It is associated with visual disturbances (loss of acuity, colour blindness and restriction of visual fields): all patients should undergo visual acuity testing by Snellen chart prior to treatment, and should be counselled to report any visual changes during treatment.  Ethambutol is taken for the two month “initial” phase only, and dose is decided by body weight (Adult dose: 15mg/kg daily). ⁽⁵⁾  If the patient does not have isoniazid resistance, ethambutol treatment can be stopped as treatment with three drugs is sufficient.

In order to aid patient adherence to treatment, fixed-dose combinations of the standard treatments are available.   As well as reducing the tablet burden for the patient, these also have the advantage of containing most or all of the drugs in one tablet – the patient cannot, therefore, be selective in which drug he takes. ⁽⁶⁾

Available products include:

Rifater – Each tablet contains rifampicin 120mg, isoniazid 50mg and pyrazinamide 300mg.  Dose is by body weight: adult <40kg, 3 tablets daily; 40-49kg, 4 tablets daily; 50-64kg, 5 tablets daily; 65kg and over, 6 tablets daily.  Used for the “initial” two month phase. ⁽⁷⁾

Rifinah – Available as two strengths: 300/150 – rifampicin 300mg + isoniazid 150mg – for adult patients 50kg and over, 2 tablets daily; 150/100 – rifampicin 150mg + isoniazid 100mg – for adult patients under 50kg, 3 tablets daily.  Used for the “continuation” phase following “initial” two month phase. ⁽⁸⁾

Voractiv – Each tablet contains rifampicin 150mg, isoniazid 75mg, pyrazinamide 400mg and ethambutol 275mg.  Dose is by body weight:  Adult 30-39kg, 2 tablets daily; 40-54kg, 3 tablets daily; 55-70kg, 4 tablets daily.  Not recommended for use in patients weighing over 70kg.  Used for the “initial” phase of treatment. ⁽⁹⁾  (Note this product was not available at the time that this patient was treated; it is also (at the time of writing) not accepted for use within Scotland by the Scottish Medicines Consortium). ⁽¹⁰⁾

COUNSELLING

It is vitally important that TB medication is taken correctly for maximum benefit.  Patients should be counselled to take all of their tablets at the same time, (preferably before breakfast), either at least 30 minutes before food or at least 2 hours after food.  Patients who are prescribed regimens containing isoniazid should be advised to avoid foods which contain histamine (such as skipjack tuna) and tyramine (such as red wine and cheese).   Patients should be advised to check with a pharmacist that any other medication prescribed does not interact with their TB treatment, and should be reminded of the possible signs of hepatotoxicity.  They should also be advised to report any loss of visual acuity, or tingling of the hands or feet, and should be reminded that their bodily secretions may be stained red.

At the beginning of treatment, the patient weighed 63.6kg.  He was commenced on Rifater (five tablets daily) and ethambutol 1000mg daily.  His weight was monitored during his admission; after 15 days of treatment, his weight was recorded as 66.3kg.  His Rifater dose was increased to six tablets daily, whilst his ethambutol dose remained unchanged.  This regimen remained unaltered on discharge, and the patient was to be reviewed at clinic four weeks later.  He was counselled (via an interpreter) both on commencement of treatment and on discharge, on how to take his medication, on the main potential side effects of treatment, and on the need to report potential signs of hepatotoxicity and visual disturbances promptly.  He showed good understanding of the information given.

The patient was prescribed pyridoxine 25mg daily.  On discharge, he received his medication in a dosette box, so there was no need to counsel him on the need to halve tablets.  He was aware of having received the halved tablet as part of his daily treatment, and the reason for which it was prescribed. 

MULTI-DRUG RESISTANT TB (MDR-TB)

TB is said to be multi-drug resistant where resistance to at least rifampicin and isoniazid is demonstrated.  Treatment is necessarily more complex, involving the use of a greater number of drugs over a much longer period of time.  Fortunately, in this case, the patient demonstrated no drug resistance, and was able to be treated with the standard TB regimen.

DIRECTLY-OBSERVED THERAPY

The importance of good adherence to treatment cannot be over-stated, and all patients should therefore be assessed at the commencement of treatment as to whether they will be able to comply unaided.  Where there is concern, various measures may be instigated, one of which is Directly-Observed Therapy (DOT).  Here, the patient is observed to swallow his TB medication by a healthcare worker, either in his home or at a clinic or hospital.  For reasons of practicality, the regimen is usually tailored to three times a week dosing.  This type of regimen is useful for patients who are street-dwellers or who have demonstrated poor adherence in the past; medication can be kept at the clinic or by the nurse so that it is not mislaid.  DOT should be used for patients who are stable and clinically well.  ^{(3, 4)}

The patient was initially considered for DOT as his housing situation was unclear.  When this was clarified, it was decided that it would be more appropriate for him to remain on a daily regimen and to manage his own medication with the aid of a dosette box, with regular support from the TB liaison nurse.   As he did not have a GP at the time of discharge, his TB medication continued to be supplied from the hospital pharmacy.  This situation was to be reviewed at his next clinic appointment.

Contact tracing

Once a patient has been diagnosed with active TB, it is important to perform contact tracing, and to screen all household members and close contacts.  Whilst it is important to identify further active cases, it is also important to identify latent cases and to determine the extent of transmission which has occurred.  Testing is by Mantoux test, with interferon-gamma testing used in those who have positive skin tests or who have received the BCG vaccine. ⁽¹¹⁾ If detected, latent TB can be treated with regimens including rifampicin and/or isoniazid – the exact regimen used depends on the age of the patient and whether they have HIV.

Further information

This patient was not a native of the UK and had only a few words of English.  It was extremely important that the patient understood the serious nature of his illness and the need for strict adherence to his treatment.  For this reason, an interpreter was booked for the period of the ward round twice a week, so that the multidisciplinary team could communicate with him clearly and could ensure good understanding.  As clinical pharmacist, I was able to counsel the patient on his medication during this period, and was satisfied with his understanding.

MARKETING PLAN

Branding Strategy

The branding strategy involves coming up with a long term plan aimed at ensuring the success of the organization. In this case, the company name, as seen previously, will be Heritage Automobile. This will be a hypothetical company that will be involved in the manufacture of hybrid and electric vehicles. The Logo for the company will be as follows.

A logo, is one that symbolizes the company as well as the products it is offering. First, a keen examination of the image will show that it comprises of two elements. The first is letter H, and the second is the electricity sign. First, the idea behind the use of the H letter is the selection of the first letter of its name, Heritage Automobiles. On the other hand, the use of the electricity sign will help to show that the company is making electric and hybrid cars. The use of this model will greatly help to clearly understand the company.

Looking at the company Slogan, it will be as follows:

Driven by Sustainability 

            This slogan will be very appropriate for the company based on the fact that it will be company that will be producing hybrid and electric cars as noted earlier. Through this slogan, it will make the customers realize that it is producing sustainable vehicles that are centred on the protection of the environment.

Having entered into the market, a notable brand extension for the company will be coming up with stationary batteries that can be used by consumers and businesses. Today, when individuals required back-up power, they usually resort to generators. However, with the new batteries that will be introduced by the company, this will be bound to change. They will have the capacity to store large amounts of power. They will especially be useful in enhancing sustainability especially based on the understanding that the current generators available in the market are major polluters of the environment.

Marketing Strategy for the product

As noted earlier, the company will use of Omni-Channel marketing strategy. This is a strategy in which consumers will be provided with a fully-integrated purchasing experience through the use of different marketing activities that will be aimed at attracting as many customers as possible. Under this strategy, there are different marketing methods that will be employed including traditional marketing, social media marketing, and affiliate marketing.

Under traditional marketing, the company will lay emphasis on television marketing. This will help it attract a relatively large group of people. Social media marketing will be done through the most famous social media sites including Facebook, Twitter and Instagram. Under affiliate marketing, the use of social media influencers will make it possible to inform potential customers about the existence of the company.

The implementation of the marketing plan will be done as per the following Gantt chart.

The above diagram Gantt chart shows a proper timeline in which the marketing strategy will be implemented. The first form of marketing, and which will be given the first priority will run from the 1^st to the 30^th of June. This will be important in order to immediately capture the viewers of prime television programs immediately after the company has begun its operations. Immediately informing these of the existence of the company will make it possible for them to immediately develop an interest for the company and hence end up making the purchase. Social media marketing will run from the 1^st of July to 31^st December. This will take a relatively longer period of time due to the need to capture the high number of people that make use of social media. Affiliate marketing will commence a month after the commencement of social media marketing. The one month period will help to establish the most effective affiliate marketers, and later engage their services.

Positioning Statement

The positioning statement of the company will be: A company that sells environmentally friendly cars at a relatively low price. This can be illustrated in the perpetual map below.

The above perpetual map clearly shows that position of the company as compared to its competitors. The elements that can clearly help to tell its position are price and sustainability. Companies which it is highly likely to outdo in the sustainability front are those that are low on sustainability. It will especially be a position to achieve higher competitive advantage for those charging a higher price. Consumers that will go for the cars that have a lower price and low sustainability are those that will not be keen on protection of the environment. On the high on sustainability front, its direct competitors will be both charging a high price and a low price. However, will easily be in a position to win over the market through charging a lower price. For the companies charging low prices such as Kia and Wheego Electric Cars, the strategy will be first determining the exact prices that are charged by these companies. It can then seek to charge a relatively lower price. However, in doing this, the company will need to be careful in order to avoid lowering its price to an extent that it is not even able to gain any margins.

Consumer behaviour for the target market

Consumer behaviour examines how customers behave in a market towards a particular product. Looking at the consumer behaviour of the target market, these will be individuals who tend to portray a sustainability lifestyle. This means that in making their purchases, they usually make consideration of whether or not the product is sustainability. If it is, then they will go ahead and make the purchase. In addition, for these individuals, they will also make considerations on the price of a product. The item does not only need to be sustainable, but also should be sold at a relatively lower price. This is because they will fall under the low income segment, and hence their financial ability will only lead them to make such purchases.

The brand name, the logo, the slogan, the brand extension, positioning statement and the marketing strategy are right of the identified target. Looking at the logo, the inclusion of the electric sign means that the company has targeted those consumers that prefer to live a sustainable lifestyle. Further, the slogan of the company, driving sustainability, is one that is also geared towards attracting these individuals towards the purchase of these types of cars. The brand extension on the other the other hand shows another product of the company that will drive sustainability. Instead of using cars that generators that pollute the environment, the company has introduced the sustainable batteries. In the positioning statement, the company has positioned itself as a highly sustainable company that sells its products at a lower price. This will help to attract the sustainable lifestyle consumers as well as the low income earners. In the use of the omni-channel marketing strategy, it is possible to reach these people irrespective of the channel that they may be using.

Company’s mission statement and introduction

The company mission statement will be as follows.

To satisfy the sustainability needs of its clients through offering the highest quality cars at a consumer friendly price.

This mission statement will help to show what the company seeks to achieve in the market. Through it, one can clearly see that the company has set an agenda of making sure that sustainable cars have been introduced in the market that are friendly to the pockets of the consumers. Through this mission, it seeks to attract a lot of people, not only those that want sustainable cars, but also those who will be willing to pay a relatively lower price for its product.

In its operations, a simple introduction of the company will be as follows.

Heritage Automobiles is a manufacturer of hybrid and electric cars. The company is headquartered in Mason, Ohio. The formation of the company was formed after the realization that there is a huge gap that needs to be filled in the sustainable cars market. Although there are notable companies that have entered into this front, most of the cars they produce are not pocket friendly. The company, in line with the needs of the customer has sought to produce hybrid and electric cars that will be attractive to our clients not only due to their quality and environmental friendliness, but also due to their low prices.

References

Agarwal, G. (2016). Consumer Behaviour. New Delhi: SBPD Publications. .

Anderson, C. D., & Anderson, ‎. (2017). Electric and Hybrid Cars. Jefferson, N.C: McFarland.

Gautam, A., & Dhar, ‎. (2017). Sustainable Energy and Transportation: Technologies and Policy. Singapore: Springer.

Lee, A., Yao, J., Mizerski, R., & Lambert, C. (2015). The Strategy of Global Branding and Brand Equity. London: Routledge.

Pophal, L. (2016). Best Practices In Influencer Marketing: Insights from Digital Marketing Experts. Sudbury: eBookIt.com Store.

Ramadan, S. (2017). OMNICHANNEL MARKETING : the roadmap to create and implement omnichannel strategy. New York: CREATESPACE.

Starling, L. (2011). The Logo Decoded: What Logos Can Do to You. New York: Balbao Press.