Bees. Solve the problem. Essay Example for Free

Bees. Solve the problem. Essay Solve the problem. 1) Find the critical value that corresponds to a degree of confidence of 91%. A) 1.70B) 1.34 C) 1.645 D) 1.75 2) The following confidence interval is obtained for a population proportion, p:0.817 p 0.855 Use these confidence interval limits to find the point estimate, A) 0.839 B) 0.836 C) 0.817 D) 0.833 Find the margin of error for the 95% confidence interval used to estimate the population proportion. 3) n = 186, x = 103 A) 0.0643 B) 0.125 C) 0.00260 D) 0.0714 Find the minimum sample size you should use to assure that your estimate of will be within the required margin of error around the population p. 4) Margin of error: 0.002; confidence level: 93%; and unknown A) 204,757 B) 410 C) 204,750 D) 405 5) Margin of error: 0.07; confidence level: 95%; from a prior study, is estimated by the decimal equivalent of 92%. A) 58 B) 174 C) 51 D) 4 Use the given degree of confidence and sample data to construct a confidence interval for the population proportion p. 6) When 343 college students are randomly selected and surveyed, it is found that 110 own a car. Find a 99% confidence interval for the true proportion of all college students who own a car. A) 0.256 p 0.386 B) 0.279 p 0.362C) 0.271 p 0.370 D) 0.262 p 0.379 Determine whether the given conditions justify using the margin of error E = when finding a confidence interval estimate of the population mean . 7) The sample size is n = 9, is not known, and the original population is normally distributed. A) Yes B) No Use the confidence level and sample data to find the margin of error E. 8) Systolic blood pressures for women aged 18-24: 94% confidence; n = 92, x = 114.9 mm Hg, = 13.2 mm Hg A) 47.6 mm Hg B) 2.3 mm Hg C) 2.6 mm Hg D) 9.6 mm Hg Use the confidence level and sample data to find a confidence interval for estimating the population . 9) A group of 52 randomly selected students have a mean score of 20.2 with a standard deviation of 4.6 on a placement test. What is the 90 percent confidence interval for the mean score, , of all students taking the test? A) 19.1 21.3 B) 18.7 21.7C) 19.0 21.5 D) 18.6 21.8 Use the margin of error, confidence level, and standard deviation to find the minimum sample size required to estimate an unknown population mean . 10) Margin of error: $100, confidence level: 95%, = $403 A) 91 B) 63 C) 108 D) 44 Formula sheet for Final Exam Mean Standard deviation Variance = Mean from a frequency distribution Range rule of thumb Empirical Rule 68-95-99.7 z – score weighted mean Outliers if A and B are mutually exclusive if A and B are not mutually exclusive if A and B are independent if A and B are dependent Complementary events mean of a probability distribution standard deviation of a probability distribution Binomial probability Binomial probability calculator Exactly binompdf(n,p,x) At least 1 – binomcdf(n,p,x –1) At most binomcdf(n,p,x) Binomial mean Binomial standard deviation Expected value Margin of error p Sample size p or Margin of error mean Sample size mean Margin of error mean

Cognitive Behavior Therapy: Palliative Care

Cognitive Behavior Therapy: Palliative Care Individuals that have been deemed by their medical team to have serious diseases that are resistant, nonresponsive or have failed reasonable treatments are often referred to specialists for comfort measures only. According to the World Health Organization, Palliative care is the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems is paramount. The goal of palliative care is the achievement of the best possible quality of life for patients and their families (WHO, 1990). The National Center for Health Statistics (1996) estimated that 20% of all deaths and 30% of the deaths of elderly individuals occurred in extended care facilities. Extended care facilities are but one place where end-of-life issues are a common fact of daily life. However, regardless of the setting, each individual faces the end of life with his or her own view of life, death and the dying process. The estimated number of patients in palliative care varies due to the difficulty in capturing the actual numbers from hospitals, primary care practitioners, families and emergency rooms. The estimate of patients receiving the Medicare benefit for hospice and palliative care is approximately  ½ million, and it is estimated that, in 2000, approximately 20% of patients dying in the United States received hospice or palliative care services. It should be noted that although many, if not most, individuals in hospice/palliative care settings are age 85 or older, this level of care is not limited to older adults. Motor vehicle accidents, post-traumatic incidents, drug overdoses and other physiologically devastating disorders may result in permanent damage to the younger body as well as the older body. Mortality rates at a young age for those with mental illnesses is decreasing therefore it is estimated that by 2030 there will be 15 million individuals with mental illness residing in long term care facilities (SAMHSA, 2004). This chapter will focus on the reduction or modification of autonomic, psychiatric, or sensory symptom experience of these individuals through use of cognitive behavioral therapy. Cognitive behavior therapy (CBT) uses a structured and collaborative approach while helping individuals to recognize, evaluate and restructure the relationships between their thoughts, feelings and behaviors. Through a process of targeted interventions, the therapist assists individuals to identify, monitor and cognitively restructure the dysfunctional thoughts and/or to modify behaviors that are maladaptive, useless or even harmful (Beck, 1976; Turk, Meichenbaum, Genest, 1987; Freeman Freeman, 2005). CBT includes a range of both cognitive and behavioral techniques such as relaxation, guided imagery/visualization, biofeedback, behavioral experiments, guided discovery, stress management, training in pain or stress management strategies, and cognitive restructuring for dysfunctional thinking and many others . Although there is a paucity of research on the use of CBT in palliative care settings, CBT is effective for many of the psychological issues that are prevalent in palliative care including, depression, anxiety, pain management, and insomnia. The purpose of this chapter is to provide an overview on the use of CBT for assessment and treatment of psychological distress in palliative care settings. Assessment of Emotional Functioning in Palliative Care There are many challenges to the assessment of mood disorders in palliative care settings. An initial challenge is the myth that psychological distress is a normal reaction to end of life. Despite expectations, most individuals in palliative care settings do not have symptoms of anxiety, depression or dementia. Many individuals arrive at this stage of their lives or illnesses with a sense of calm resignation, if not expectations of relief and of going home to God, heaven or family members waiting for them in the hereafter. Therefore those individuals that are experiencing symptoms that require intervention may achieve significant benefit from the interventions. The most common presentations are those of depression, anxiety, pain management failures with exhaustion and anguish, and sleep disorders. The healthcare provider requires tools necessary to differentiate major depression from anger, sadness, and anxiety associated with the symptoms of an untreatable or chronic illness. Assessment of preparatory grief and depression. Another obstacle to the assessment process is simply overcoming the challenges of differentiating symptoms from normal grief of the illness itself. Differentiating between preparatory grief and depression is a key component to the proper assessment of depression in palliative care and has important treatment implications. Preparatory grief can be defined as what an individual must undergo in order to prepare himself for his final separation from this world (Kubler-Ross, 1997). Symptoms of preparatory grief include 1) Mood waxes and wanes with time, 2) Normal self-esteem, 3) Occasional fleeting thoughts of suicide, and 4) Worries about separations from loved ones (Periyakoil and Hallenbeck, 2002). Preparatory grief is a normal, not pathological, life cycle event (Axtell, 2008; Periyakoil and Hallenbeck, 2002). Major depression is defined as five or more of the following symptoms during the same two week period: depressed mood, marked diminish in pleasure, weight loss or gain, insomnia or hypersomnia, psychomotor agitation/retardation, fatigue/loss of energy, feelings of worthlessness or inappropriate guilt, lack of concentration/indecisiveness, and recurrent thoughts of death and suicidal thoughts or plans (APA, 1994). Table 1 provides a symptom list. The list is not intended to be all inclusive however it gives the clinician an overall view of symptoms that may be observed in the individual dealing with depression in a palliative care setting. Although some symptoms of grief and depression overlap, there are ways to distinguish between grief and depression. Table 2 summarizes the ways to differentiate symptoms of grief versus depression according to temporal variation, self-image, hope, anheonia, response to support, and active desire for an early death (Periyakoil Hallenbeck, 2002). The first step to proper recognition of depression involves the identification of possible risk factors (Wilson, Chochinov, de Faye, and Breitbart, 2000). Certain demographic characteristics, such as younger age, poor social support, limited financial resources and family history of a mood disorder, as well as a personal history of previous mood disorders place individuals at a greater risk for developing depression or anxiety in end of life situations. Risk for developing a mood disorder also is elevated with certain types of diagnoses, including pancreatic cancer and brain tumors, and particular medical interventions such as radiation therapy (Hirschfeld, 2000). Symptoms of the illness, including poor symptom control, physical disability, and malnutrition also place individuals at higher risk. The second step to the proper assessment of depression includes utilization of appropriate assessment tools. Many times it is the degree and persistence of symptoms that provide the information necessary when considering major depression. Major depression, which is estimated to occur in fewer than 25% of patients in end of life care, may be best screened with targeted questions such as: How much of the time do you feel depressed? In addition, for those individuals that have a difficult time describing their symptoms or history, asking family members to provide information about a previous history of depression or a family history can be very useful. Although studies validating assessment tools vary greatly, many of the self-report measures have been shown to be effective in palliative care patients. The most common utilized tools in palliative care settings frequently omit physical symptoms of depression. Many symptoms of depression overlap with the terminal disease process (Noorani Montagnini, 2007). Examples of self-report measures that omit somatic symptoms include the Beck Depression Inventory II (Beck, Steer, and Brown, 1996), Hospital Anxiety and Depression Inventory (Zigmond Snaith, 1983), and the Geriatric Depression Scale (Yesavage et al., 1983). The Hayes and Lohse Non-Verbal Depression Scale (Hayes, Lohse, and Bernstein, 1991) is a third party observational measure that can be completed by staff, family, or friends to assist with the diagnostic process. Terminally Ill Grief or Depression Scale (TIGDS), comprising of grief and depression subscales, is the first self-report measure designed and validated to differenti ate between preparatory grief and depression in adult inpatients (Periyakoil et al., 2005). Assessment of anxiety. The symptoms of anxiety may differ in individuals in the palliative care environment. Many times symptoms of anxiety have a physiologic component. For example in those individuals with chronic obstructive pulmonary diseases difficulty breathing, low oxygen levels and overall compromised respiratory function causes air hunger which is experienced as anxiety and even panic. Table 3 lists some of the common anxiety symptoms seen in this population. Family members are often at a loss as to what they can do to assist their loved one that is experiencing anxiety, and especially fearfulness. It is often useful to provide significant others with a checklist of items that are important to report to the healthcare provider. Involving the family has the benefit of giving them a structured guide for response which reduces their own anxiety in response to the patient. In addition the patient may relax more knowing that a family member is involved with their care in an approved, helpful manner. An example of a list of items for family members to watch for and report to the healthcare team is listed in Appendix 1. Cognitive Behavioral Interventions in Palliative Care Psychological intervention in the palliative care setting includes those aspects of treatment that would provide relief from emotional distress while an individual is dying. Often this time period includes depression, anxiety, grief and organic brain dysfunctions such as dementia and/or cerebral vascular diseases. Individuals and their family members are both considered the patient during these times. Many of these individuals are suffering from chronic, unremitting pain conditions which negatively impact their emotional health. Treatments for pain and chronic conditions also play a part in the individuals mental status. The use of Cognitive Behavior Therapy (CBT) is extremely useful for these individuals. Cognitive Behavioral Therapy has the strongest empirical support of any psychological intervention for the management of symptoms typically seen in a palliative care setting. The most common presentations of psychological distress in the dying patient include anxiety, depression, hopelessness, guilt over perceived life failures and remorse. Persistence of these thoughts and feelings interfere with functioning, makes the person generally miserable as well as those around them and can severely affect his/her quality of life. Medical treatments, such as antidepressants, anxiolytics and cholinesterase inhibitors, exist for these problems however supportive psychotherapy such as relaxation training, imagery, distraction, skill training, and negative thought restructuring improves the possibility of remission. CBT can also improve the symptoms of spiritual distress that may include feelings of disappointment, guilt, loss of hope, remorse, and loss of identity. CBT for depression. Symptoms of depression are common in end of life care. It can be one of the most distressing groups of symptoms an individual can experience and may interfere significantly with daily tasks of life. Some experts have estimated that up to 75% of patients with terminal illnesses experience symptoms of depression. Amelioration of some of the symptoms of depression can increase the amount of pleasure and meaning in life, as well as add hope and peace. Treatment for depression can reduce the experience of physical pain as well as general misery and suffering. In addition, reduction of the symptoms of depression may improve the treatment of coexisting illnesses more effective. Most importantly, given that one of the most serious symptoms of depression is suicidal ideation, it makes sense to treat depression in order to prevent successful suicidal outcomes. There is a paucity of literature in the area of the use of CBT with depression in Palliative Care, due to the high attrition rate resulting from physical morbidity and mortality (Moorey et al., 2009). Therefore, these factors pose significant barriers to conducting randomized clinical trials in Palliative Care to address these components. The following is a review of the sparse literature on CBT in Palliative Care with depression. In an attempt to address this problem, Moorey et al., conducted a cluster randomized controlled trial in order to determine if it was possible to teach nurses CBT techniques in order to reduce anxiety and depression symptoms in patients with advanced cancer (2009). Eight nurses were trained in CBT by attending several 1- and 2-day workshops and then were rated on the Cognitive Therapy First Aid Rating Scale (CTFARS) for CBT competence. Seven nurses did not receive training and served in the control group. A total of 80 home care patients entered the trial; however most of these participants were excluded due to being too ill to participate. A total of 16 patients were in the CBT group and 18 patients were in the control group. The participants received home care nursing visits in which assessments were conducted at 6-, 10-, and 16-week intervals. The individuals who received CBT reported lower anxiety scores over time, but no effect of the training was found regarding depression. It was noted that both groups experienced lower rates of depression over the course of the study. The authors noted the heterogeneity of the sample and the high attrition rate due to physical morbidity and mortality presented several barriers to conducting the study and may have played in a role in the findings (Moorey et al., 2009). Cole and Vaughan (2005), in their review on the feasibility of using CBT for depression associated with Parkinsons disease (PD), found that it is a promising option. The authors noted that depressed inviduals with comorbid PD experienced a significant reduction in depressive symptoms and negative cognitions. In addition they experienced an increased perception of social support over the course of treatment (Cole Vaughan, 2005). The recommended course of action for individuals in this setting included: stress management training, relaxation training, behavioral modification techniques for sleep hygiene, and cognitive restructuring. Modification of life stressors contributing to depressed mood should be identified and plans made to minimize stress and maximize quality of life. The use of thought restructuring is recommended in order to maintain a sense of purpose and fulfillment through meaningful activity and to adjust expectations of self and others. Individuals are also encouraged to return to previously enjoyed activities in order to maximize feelings of pleasure and happiness. Through systematic defocusing on physical conditions the person is able to experience more pleasant activities, which are also encouraged. Similarly, Dobkin et al, conducted a study which explored the effects of modified CBT for depressed patients with PD, in conjunction with a separate social support intervention for caregivers (2007). The patients received 10-14 sessions of modified CBT, while caregivers attended three to four separate psychoeducational classes. The modified CBT sessions were comprised of the same components of the previous Cole Vaughan, (2005) study, such as, stress management training, behavioral modification techniques for sleep hygiene, relaxation training, cognitive restructuring, modification of life stressors, and increasing engagement in pleasurable activities. The classes were targeted at providing caregivers with ways to respond to the patients negative thoughts and beliefs, as well as, strategies to offer appropriate support. As in the previous study, the modified CBT sessions were comprised of training in stress management, behavioral modification, sleep hygiene, relaxation techniques, an d cognitive restructuring. Participants reported a significant reduction in their depressive symptoms and cognitions and increased perception of social support at treatment termination and one-month post-treatment. CBT for anxiety. Along with depression, anxiety is a common mental health problem in palliative care settings and also appears to be alleviated with CBT interventions. In a small feasibility study examining the use of cognitive behavioral therapy techniques for mild to moderate anxiety and depression in hospice patients, four sessions of CBT techniques was found to significantly reduce anxiety and depression in a majority of patients (Anderson, Watson, Davidson, and Davidson, 2008). Overall, participants in the study found the CBT techniques acceptable, helpful, and qualitatively reported improved mood. A significant reduction in anxiety symptoms also was seen in a randomized controlled trial of CBT administered by home care nurses in patients with advanced cancer (Moorey et al., 2009). CBT techniques are particularly effective to assist with the management of anxiety related to breathing difficulties commonly seen with pulmonary diseases, such as chronic obstructive pulmonary disease (COPD). In a group of individuals with COPD, six sessions of guided imagery, a CBT relaxation technique, was found to significantly increase the partial percentage of oxygen saturation, which is a physiological indicator signaling more effective breathing (Louie, 2004). In another study, as little as 2 hours of CBT group therapy yielded a decrease in depression and anxiety among older patients with COPD, but there was no change in physical functioning (Kunik et al., 2001). CBT for pain management. Pain is not simply a biological response to unpleasant stimuli. It is a complex phenomenon that includes biological, psychological, behavioral and social factors that interact in complex ways to influence the pain experience. Some of the factors that can influence a persons experience of pain include: a) previous pain experiences, b) biologic and genetic predispositions, c) mood disorders such as anxiety and depression d) their beliefs about pain, e) fear about the pain experience, f) their individual pain threshold and pain tolerance level, and f) their skill with coping methods. Cognitive-Behavioral Therapy has the most empirical support for the management of chronic pain, especially when used as part of an interdisciplinary treatment approach to manage pain symptoms (Turk, Swanson, Tunks, 2008). Cognitive behavioral techniques can be used independently to assist with pain management or integrated into a comprehensive cognitive-behavioral case conceptualization framework to address pain (Turk, Swanson, Tunks, 2008). The three components to CBT for pain management are 1) Education and rationale for the use of CBT, 2) Coping skills training, and 3) Application and maintenance of CBT skills (Keefe, 1996). Useful behavioral interventions to assist with pain management include goal setting, relaxation strategies, such as deep breathing and guided imagery, and activities scheduling. Cognitive interventions would include increasing problem-solving skills and addressing an individuals maladaptive thoughts related to pain management. Examples of maladaptive thoughts include: 1) Ive tried every pain management intervention with no success, 2) I cannot do any of the things that I used to do, 3) nothing will help manage my pain, and 4) no one can help me feel better. CBT for pain manage ment has demonstrated efficacy in various diagnoses often addressed in palliative care. CBT has been found to be efficacious in the management of cancer-related pain in single studies (Syrjala, Donaldson, Davis, et al., 1995) as well as in systematic reviews (Abernethy, Keefe, McCrory, Scipio, Matchar, 2006). CBT for sleep hygeine. Insomnia, sleep duration and quality are major concerns for people with pain disorders such as osteoarthritis (Vitiello, 2009). Approximately 60 percent of individuals with chronic pain disorders report frequent nighttime awakening due to pain during the night. Disrupted sleep patterns exacerbate chronic pain intensity and experience which in turn causes more disturbance of the sleep/wake cycle. Successful treatment of interrupted sleep may reduce the pain experience as well as improve the overall quality of life for these individuals. Psychotherapeutic techniques that target sleep disturbances are easily incorporated within behavioral and cognitive management of other co-occurring disorders as well. Sleep disorders are common in patients who suffer from Parkinsons disease (PD) (Stocchi, Barbato, Nordera, Berardelli and Ruggieri, (1998). Specifically, insomnia, nightmares, REM sleep behavior disorder, sleep attacks, sleep apnea syndrome, excessive daytime sleepiness, and periodic limb movement in sleep result from changes in sleep structure, movement disturbances in sleep, disturbances in neurotransmission and medications. Individuals who are sleep deprived are at risk to develop infections, cardiovascular disease, hypertension, diabetes, depression, and require increased time to recover from stress (Schutte-Rodin, Broch, Buysse, Dorsey, and Sateia, 2008). CBT improves sleep by addressing unhelpful beliefs regarding sleep and misperceptions about the amount of sleep that one obtains. Many misperceive the amount of time they are actually asleep. People who suffer from insomnia actually sleep more than they are aware of because they are only attentive of when they are awake. Furthe rmore, many people believe they require 8 hours of sleep in order to be able to function during the day and any amount of sleep that is less is insufficient and will result in reduced ability to function during the day. Therefore, these beliefs and misperceptions can increase ones stress level about sleep and a stress response may result when one thinks about going to sleep. Clearly, a heightened stress response is not conducive to sleeping. CBT increases ones control over their unhelpful and inaccurate beliefs and enables them to replace them with more helpful and accurate beliefs (Whitworth, Crownover, and Nichols, 2007). CBT also addresses the behavioral components of ones sleep routine or patterns that interfere with ones ability to obtain restful sleep. Exercising, smoking, or drinking caffeinated drinks just prior to bedtime can interfere with ones sleep. All of these activities are stimulants that energize the body. Also, not having a bedtime routine, a regular sleep-wake pattern, or taking naps may interfere with ones ability to get restful sleep. Increasing ones sleep hygiene by developing positive habits that influence sleep such as, having a bedtime routine to prepare ones mind and body for sleep, regular exercise several hours before one intends to prepare for sleep, and avoiding coffee, alcohol, and smoking in the evening, as well as, increasing activities that produce relaxation (e.g., taking a hot bath one to two hours before going to bed, meditation, deep breathing, or muscle relaxation) can increase the likelihood of obtaining restful sleep. Another behavioral strategy utilized in CBT i s sleep restriction. This technique attempts to match ones actual sleep requirement with the amount of time one spends in his/her bed. The theory behind this approach is that reducing the amount of time spent in bed without sleep will increase ones desire to sleep (Harvey, Ree, Sharpley, Stinson, and Clark, 2007). Results of a study by Vitiello showed that treatment improves both immediate and long-term self-reported sleep and pain in older patients with osteoarthritis and comorbid insomnia without directly addressing pain control (2009). This study included 23 patients with a mean age of 69 years were randomly assigned to CBT, while 28 patients with a mean age of 66.5 years were assigned to a stress management and wellness control group. Participants in the control group reported no significant improvements in any measure while Individuals treated with CBT reported significantly decreased sleep latency (onset of sleep) by an average of 16.9 minutes and 11 minutes a year after treatment. Interruptions in sleep after sleep onset decreased from an average of 47 minutes initially to an average of 21 minutes after one year. Pain symptoms improved by 9.7 points initially to 4.7 points. Sleep efficacy (how rested does the person feel upon awakening) initially increased by 13 percent and 8 percent a year after treatment. The improvements remained robust in 19 of 23 individuals at a one-year follow-up visit. Furthermore, while many older adults experience insomnia, it is reported that up to two-thirds of those who experience these symptoms have limited knowledge regarding available treatment options. Sivertsen (2006), conducted a randomized controlled trial to compare the efficacy of non-benzodiazepine sleep medications with CBT. This study included 46 patients with a mean age of 60.8 years who were diagnosed with chronic primary insomnia. Participants were randomly assigned to either the CBT intervention (information on sleep hygiene, sleep restriction, stimulus control, cognitive therapy, and progressive relaxation), sleep medication (7.5 mg zopiclone each night), or placebo medication. Treatment lasted 6 weeks, and the CBT intervention and sleep medication treatments were followed up at 6 months. Data regarding total wake time, total sleep time, sleep efficiency, and slow-wave sleep was collected utilizing sleep diaries, and polysomnography (PSG; monitors physiological activity during sleep). Results revealed that total time spent awake improved significantly more for those in the CBT group compared to the placebo group at 6 weeks and the zopiclone group at both 6 weeks and 6 months. In comparison, the zopiclone group did not reveal significant results from the placebo group (Sivertsen, 2006). The CBT group experienced a 52 percent reduction in total wake time at 6 weeks compared with 4 percent and 16 percent in the zopiclone and placebo groups respectively. A statistically and clinically significant finding was that participants receiving CBT improved their PSG-registered sleep efficiency by 9 percent at posttreatment, opposed to a decline of 1 percent in the zopiclone group. Total sleep time increased significantly between 6 weeks and 6 months for the CBT group. The zopiclone group showed improvements at 6 weeks and maintained these improvements at 6 months, but did not show further improvements. The CBT group showed significant improvements compared to the zo piclone group in total wake time, sleep efficiency, and slow-wave sleep; total sleep was the only area that did not yield a significant difference (Sivertsen, 2006). ADAPTING CBT TO THE PALLIATIVE CARE SETTING Overview of CBT in Palliative Care Cognitive-behavioral therapy is effective for many of common mental health issues seen in palliative care and often augments the success of pharmacological interventions. In addition to the individual with the terminal illness, their family members, as well as multiple health providers are considered integral members to the success of the collaborative relationship. Use of a CBT case conceptualization framework and various components offer flexibility, which makes the CBT approach feasible to implement within a palliative care setting. The following section provides an overview of the components of cognitive-behavioral therapy and necessary adaptations to palliative care settings. Collaborative Relationship As mentioned in previous chapters in this book, a collaborative relationship is a core component of an effective cognitive-behavioral intervention. In a palliative care setting, the collaborative relationship often involves more than just the client and the therapist. The interdisciplinary treatment team works with the individual to develop an individualized treatment plan that is central to the case conceptualization and goal setting of CBT. A variety of disciplines, such as nursing and social work, use CBT techniques in palliative care settings. Individuals receiving palliative care often need assistance with CBT interventions as their illness progresses. Individuals receiving palliative care often need assistance from the treatment team with practicing skills, such as relaxation techniques, and adapting CBT interventions as goals of care change. Some individuals in the Palliative Care setting may not be facing death in the near future, and if they are facing impending death, they may not be aware of it. In these cases the primary patient may be the family member or significant other. It is also common practice for most individuals to seek help for mental health problems from their family practitioner even though the typical family practitioner has very little training in psychiatric/mental health assessment, diagnosis and treatment. In cases where the family is relying on an under-trained health care provider it may be incumbent upon the mental health provider to negotiate the gap between family and medical care. Case Conceptualization and Goal Setting Therapy with the dying person should begin with having the person identify, explore and determine outcome goals regarding the issues at hand. Similarly to the primary care setting, case conceptualization and goal setting need to occur almost immediately. The therapist uses the Socratic Dialogue to explore the persons concerns and worries. This gives the individual more of a sense of control over what will be happening in the therapy session. Once this sense of control is established it becomes easier to explore other, more emotion laden topics. Goals should be small, obtainable and proximal to the session to be most effective. For example, Mrs. Jones I will be back to see you tomorrow. One of the things you have decided to practice is your deep breathing at least twice tonight and again in the morning. When I return I will check with you to see how you are doing with the practice. In palliative care setting, it may be necessary to discuss how other people involved in care can assist with reaching goals. For example, nurses might remind individuals to practice relaxation strategies during wakeful periods, as well as talk an individual through the relaxation technique when experiencing a high level of pain. Behavioral Interventions Pleasant Events Scheduling. Activities scheduling is a useful intervention to assist with mood disorders, pain management, and sleep hygiene issues seen in a palliative care setting. Engaging in pleasant events distracts an individual from negative thoughts and provides experimental evidence to support more adaptive thinking styles. Often times in palliative care the first barrier to overcome is identifying pleasant events that can occur in a palliative care setting due to health limitations. Pleasant events need to be person-centered, meaningful, and feasible activities that can be built into a daily routine. Meaningful pleasant events can be identified through both clinical interview and self-report methods. Clinical interview queries should include taking a history of an individuals daily schedule and identify activities the individual enjoyed engaging in on a routine basis prior to their illness. From the generated list of previously enjoyed pleasant events it needs to be determined which activities the individual can continue to enga

Ecological Systems Theory, Urie Brofenbrenner

Ecological Systems Theory, Urie Brofenbrenner The ecological systems theory of human development is proposed by Urie Brofenbrenner, a Russian American psychologist. In this theory, he stated that everything in a child and also the surrounding environment can affect the child development (Oswalt, 2008). He also developed this theory to comprehend the relationship between the child, the family, teachers, and the society (Growth and Development Theory, 2013). This ecological systems theory is divided into few different levels which are micro system, mesosystem, exosystem, macrosystem and chronosystem. The first level is micro system which is the small immediate environment that is directly connected to the child (Sincero, 2012). As an example, a child has the closest relationship with his parents and family which also can influence the childs development mentally or physically. The relationship between the child and the teachers, friends or also neighbours is also considered to be in the micro system. Next, mesosystem includes the interaction between two microsystems such as the relation between the childs home and the school (Growth and Development Theory, 2013). Exosystem is the level which includes other people and also places that may have no direct interaction with the child but still affects the childs development like his parents workplace, the neighbourhood or even the extended family members (Oswalt, 2008). Macrosystem is a larger level consists of the cultural contexts like ethnicity or other influences such as economic influences and cultural influences (Sincero, 2012). Every environmental event and transitions occur in an individuals life is included in the chronosystem (Sincero, 2012). The events such as marriage, divorce or others that can affect someones life are the examples of this system. 1.2 How does Urie Brofenbrenners ecological systems theory affect the child development? As I have already explained before about this ecological systems theory by Brofenbrenner in the previous page, this theory can actually affect the child development. According to Doll-Yogerst (2011), this model of the ecological systems recognizes that a childs development is affected by the settings and also affects the surrounding in which he spends his time every day. The relationship of the child and the microsystem can also give impact in both directions which is being called as bi-directional influences (Doll-Yogerst, 2011). For example, a childs parents may affect his behaviour or belief but he can also affect his parents behaviour or belief. Particularly, his family is the most essential setting because he spends his time mainly with the family and it has the most influence on him especially the emotion (Doll-Yogerst, 2011). This situation shows that a childs development is influenced the most by his family, if one of his parents is working as a doctor and he understands it a s doctors are good people since they help others, it may gives him the idea to be just like his parent in the future. There are also other important settings that may influence the childs development such as his extended family, teachers, peers, child care centre, school, and preschool or kindergarten (Doll-Yogerst, 2011). These settings are directly interacting with the child because he will encounter his teachers when he is at the school, or playing with his peers in the neighbourhood. The childs development is based on how he experiences while spending time in all these settings (Doll-Yogerst, 2011). It is can be seen in the situation where the child may have stumbled upon a bad experience while playing at the playground that will probably make him to avoid playing at the playground anymore or even good experiences he has that will affect his development. Other than that, a child involves in many microsystems (Bronfenbrenners Microsystems, n.d.). Each of the microsystem interacts with each other which also can be called as mesosystem. The number of quality interactions between settings also has important implications for a childs development (Doll-Yogerst, 2011). For instance, the parents and the teachers at school are both considered as microsystem from the childs point of view. These two microsystems will interact with each other in such situation like parents-teachers conference that usually being held in school. The child probably acts differently in school than at home since he is surrounded by his peers. If the child is having any difficulties or problems at school, the teacher will tell the problems to his parents so that they will acknowledge how their child is doing at school. This interaction between both parties is important that will reflect on the childs development. The other external environments that may have indirect connection with the child but still give huge impacts on him are included in the exosystem level (Doll-Yogerst, 2011). This exosystem level is when the settings that may be unknown to the child for example the parents workplace or colleagues will affect his growth. It can be exemplified in the situation when the parents coming back home with the stress that they get at their workplaces that will influence the childs thoughts (Doll-Yogerst, 2011). Besides that, the government, the economical factors, the mass media can also affect the childs development. For instance, the child is influenced by the animation series on television that leads him to follow what the characters are doing. The largest system in this theory is the macrosystem which consists of the most remote of people and things to a child nevertheless still has a great influence for the child (Oswalt, 2008). This includes cultural values, customs and laws (Ecological S ystems Theory, n.d.). As an example, the child has been raised by following the national laws that drugs are illegal or murder is a crime that will make him obey and acknowledge which is wrong and which is right. The events that happen during the transitions over a lifetime are called chronosytem, which means everything happens in a childs life while he is growing up that may changes his perception. 1.3 How does Urie Brofenbrenners ecological systems theory apply children in preschool and early primary levels. The ecological systems theory is somehow applied to the children in preschool and early primary levels. Horowitz-Degan claims that the childs behaviour can be analyzed by using the environmental influences, as well as the cognitive factors (as cited in Bronfenbrenners Ecological, n.d.). This situation can be seen in preschool or primary school, where the class acts as the microsystem that will give influences to the child. As an example, if a teacher walks into a classroom brightly, it will automatically sets up the mood of the classroom to be warm and friendly which will positively affect the childs cognitive sphere of influence then next encourage the process of learning (Van-Petegem, Creemers, Rossel, and Aelterman, 2005). For instance, a teacher teaches the students excitedly and happily in the classroom, the students will have more interest to listen to the teacher because they have been influenced by the positive vibes from their teacher. In addition, Van-Petegem defines that t he teachers behaviour can also affect the students and can be a model for the consideration of the feelings of others and the value of interactions (as cited in Bronfenbrenners Ecological, n.d.). This shows that this ecological systems theory gives effect on the childs social development in mircosystem which also can be increased through the encouragement given by the teacher. Furthermore, in the preschool centres or primary schools, there will be a playtime provided that will develop the motor skills development in the children (Brofenbrenners Ecological, n.d.). Activities such as creating craft, indoor arts like drawing, colouring or painting can also help in the growth of the students motor skills. While in the classroom, the students will be given the opportunity to speak up their opinions that may give influence to the other students who are listening to the opinions and it will help them in the intellectual development. This is because the students will start thinking about the opinions and try to relate to the knowledge that they already have. If there is an argument happen in the class, the students will try to convey their thoughts to the teacher that will also give a huge impact to them intellectually since they use their minds to counter the argument. Besides, the issues associated with the adults who are involved in the effect of the childs mic rosystem despite of the child have no direct connection to the exosystem (Brofenbrenners Ecological, n.d.). If the parents are having problems at the workplace, it will influence the child at home. Parents may be spend more time on solving their work issues that probably make the child feels that he is being ignored which affects his emotional development. The development of children will also be affected in the macrosystem even though it is the largest layer of ecological systems theory (Brofenbrenners Ecological, n.d.). In this level, the child is influenced by the cultural values that give impact on the social development. 1.4 Summary of Urie Brofenbrenners ecological systems theory. To sum up, the ecological systems theory by Urie Brofenbrenner does apply to child development including the children in preschool and early primary levels. This theory helps the children in intellectual development, emotional development and especially, the social development. Each of the levels in the ecological systems model, microsystem, mesosystem, exosystem, macrosystem and chronosystem, interact with each other to help the childs development. As adults, we need to observe how the child is growing and we need to bear in mind that everything in a childs surrounding has the probability to influence their growth. Parents should be more concern about their childs microsystem in school and spare more time communication with them and not only focusing on work or career.

The Human Eye in Space :: essays research papers

Human visual hardware is a result of a billion years of evolution within the earths atmosphere where light is scattered by molecules of air, moisture, particular matter etc. However as we ascend into our atmosphere with decrease density, light distribution is changed resulting in our visual hardware receiving visual data in different format. Some Aspects to Consider: 1. Visual acuity is the degree to which the details and contours of objects are perceived. Visual acuity is usually defined in terms of minimum separable.Large variety of factors influence this complex phenomenon which includes : # Optical factors- state of the image forming mechanisms of the eye. # Retinal factors such as the state of the cones. # Stimulus factors such as illumination, brightness of the stimulus, contrast between the stimulus and background, length of time exposed to the stimulus. * Minimum separable: shortest distance by which two lines can be separated and still be perceived as two lines. "During the day, the earth has a predominantly bluish cast..... I could detect individual houses and streets in the low humidity and cloudless areas such as the Himalaya mountain area.... I saw a steam locomotive by seeing the smoke first..... I also saw the wake of a boat on a large river in the Burma-India area... and a bright orange light from the British oil refinery to the south of the city (Perth,Australia.)" The above observation was made by Gordon Cooper in Faith 7 [1963] and which generated much skepticism in the light of the thesis by Muckler and Narvan "Visual Surveillance and Reconnaissance from space vehicles" in which they determined that a visual angle of ten minutes was the operational minimum, and that the minimum resolvable object length [M.R.O.L] at an altitude of 113 miles would be 1730 ft. This limitation of acuity was revised the next year to 0.5 seconds of arc for an extended contrasting line and 15 seconds of arc for minimum separation of two points sharply contrasting with the background. Orbiting at 237 miles in the skylab it was possible to see the entire east coast [Canada to Florida Keys] and resolve details of a 500 feet long bridge based on inference. Of Interest is the fact that even though the mechanical eye [camera systems] can resolve objects greater than fifty times better than the human eye, without the human ability to infer, interpretation of the data is meaningless. Conclusion: Visual acuity in space exceeds that of earth norm when objects with linear extension such as roads, airfields, wake of ships etc. 2. Stereoscopic vision: the perception of two images as one by means of fusing the impressions on both retinas. In space one has to deal with a poverty of reference points.

The Dreamers of The Glass Menagerie :: Glass Menagerie essays

The Dreamers of The Glass Menagerie "The Glass Menagerie" by Tennessee Williams shows the struggle of two people to fit into society, Tom and Laura, and how society wouldn't accept them. They were the dreamers that were unjustly kept out and you may even go as far as to say persecuted into staying out and aloof like the other dreamers which are forced to become outcasts and not contribute to the actions of all. Tom and Laura, the two dreamers, were pushed by their mom, Amanda, to her frame of mind and the thoughts of a hard working society. They both stumbled on the fire escape which served as a gateway, physically and mentally. Tom had the problem of fitting in at the warehouse were he worked, because is the warehouse really a place for someone like him and his mind rebelled. Lastly you can see how society forced them to change and Laura to lose her status in order to fit in with Jim and that's shown by the horn breaking. Tom then realizes that and leaves which causes him to change too. Tennessee Williams artfully depicted this. The fire escape. A downtrodden red thing off the sides of buildings showing societies ineffectual escape from itself. In this case it served as a passageway between the real world and the dream one that Laura and Tom were living in at home. Both somehow stumbled both physically and mentally. When Laura said â€Å"I'm all right. I slipped but I'm all right†(47). She was trying to pass to the real world to do a real job and couldn't because of societies â€Å"inability† to accept her and her ways. She wasn't strong enough to make the trip by herself, but needed the moral support of the other dreamer in the area, which was Tom who came running out. Tom is the one who stumbles mentally in his inability to look at the escape, which would be his way out of the place. He was always losing his strength while out there smoking and looking out into the world. Recognizing the sounds and trying to connect but unable to. He was forced away and unable to bring up the strength inside himself to go out and leave and to stay strong as a dreamer. Forced by society to use it as a gateway instead of just keeping it the same and just a mode of transportation to go down. Every night you hear Tom say, "I'm going to the movies" (42). He uses that as an escape of the imagination which is what made him a dreamer.

Phonemic awareness Essay

Phonemic awareness has been defined as the ability to deal unequivocally and segmentally with sound units which are smaller than the syllable. Phonemes are the tiniest elements that make up the spoken language. Phonemic awareness thus is the ability that enables an individual to focus on and manipulate these phonemes in spoken language (National Reading Panel (NRP), 2010). It has been established that the term phonemic awareness became popular in 1990s when researchers were attempting to study the development of early literacy and reading disability. Having been defined as the ability of the language learner to manipulate the sounds of spoken words, phonemic awareness plays a crucial role in language development in children. This paper will explore the impacts of phonemic awareness on the child’s early development of reading and spelling skills. Phonemic skills: More often than not, the term phonemic awareness has been used interchangeably with phonological awareness. However, the two terms are very distinct considering that phonemic awareness concentrates on the phonemes which are the smallest units that make up the speech whereas phonological awareness focuses on both the small and the larger units as well including the syllables, onsets, and rhymes. A child who possesses the phonemic awareness skills will be able to segment sounds in words for instance, they are able to recognize and identify a word from the separate sounds in the word (International Reading Organization, 1998). Phonemic awareness can therefore be said to be the only aspect of reading that is highly crucial in children before they can start to learn reading. Phonemic awareness is therefore a pre-requisite for development of reading in children (Brummitt, 2007). Impacts of Phonemic Awareness: Phonemic awareness has great impacts on a child’s early development of reading and spelling skills. Phonemic skill like segmentation of words is very crucial in determining how the child will be able to master spoken language. The amount of sound information that children can handle at a time will determine the ability of the children to learn the phonological skills in language. Studies have shown that phonemically aware children are more capable of reading words in prose with minimum mistakes than those who are phonemically unaware. Children are known to learn the spelling skills in two ways which includes internalization of the orthographic patterns of written words through imitation, and by synthesizing their understanding of letters and letter clusters with how the word is said in an analogy process. Learning to spell unfamiliar words either by imitation or analogy with familiar words is usually â€Å"influenced by Knowledge of letter-sound mappings, the amount of complexity of orthographic information the kids can process, and their knowledge of word structures† (Munro, 2010, para 27). Definitely, there is a relationship between the awareness of sound segmentation in words and learning how to spell using the two techniques described above (Munro, 2010). Conclusion: Phonemic awareness is a very essential aspect of language development in children during their development stages.  Phonemic awareness can be responsible for positive development in IQ, vocabulary, listening, comprehension, and how well kids can learn to read, write, and spell. The children should also be able to express what is in their mind by the aid of phonemic awareness even when they had never seen the printed version of the word before. It is evident that by teaching the children how to manipulate the sounds in language improves their reading capabilities. In general, training in phonetic awareness positively impacts on the children’s language development in reading and spelling.

Successful Property Development

Throughout this paper the masculine gender is used when referring to developers. This is purely for convenience and does not imply that successful developers have to be male. Demand for new buildings from tenants and owner occupiers is the basis of all commercial property development in the United Kingdom. A typical development scheme will be initiated by a developer identifying a demand for a new building or buildings in a certain location. A major office user for example may wish to combine a number of regional offices into one new building able to accommodate new echnology and enable all of the Company's departments to be housed under one roof. The image to be presented by the new building will also be important and the Company may prefer a prominent town centre location with easy rail access or a fringe of town location on the motorway network. The experienced developer will know that if a development is to be successful the location must be the one which will appeal to tenants or purchasers who will either pay rent or a capital sum to occupy the property. There are many examples of unsuccessful schemes which failed because of poor location. With shopping centre evelopment the choice can be very subtle and a slightly ‘off-pitch' location may be enough to discourage tenants from leasing shop units in the new centre. If a site for a new development is identified and the site (or redundant buildings) is available for purchase, planning consent for the scheme must be sought from the Local Authority. It is usually the case that the developer will have concentrated on those locations where the planners will support development proposals and planning consent is likely to be received. If the location is correct and planning consent is likely the developer must also rrange finance to buy the site, build the scheme and let (or sell) it. He may also wish to sell the completed income producing investment. If he does so and the money he receives from the sale of the investment is more than the capital and interest he borrowed to build the scheme, he will receive a monetary profit. There are many sources of finance for developers but conventionally money will be borrowed from banks to buy the site and build a scheme with long term finance being provided by life assurance funds and pension funds. Long term finance in this ontext means the purchase of the completed investment by the fund which will enable the developer to repay all his short term debt and (hopefully) give him a profit. The investment market and development market are therefore closely linked and the developer will be mindful of the fund's requirements from the start of the development process. The most common form of development funding which involves the institutions if known as ‘profit erosion, priority yield'. This method allows the developer to borrow most of his short term finance from the institution and not pay it back until the cheme is completed and let. At this time the fund takes over the scheme in return for providing the developer's short term monies. The developer departs with a lump sum fee for carrying out the project which will be calculated by capitalising that amount of rent from the scheme which will be calculated by capitalising that amount of rent from the scheme which exceeds the fund's required return on the money lent; in other words its ‘priority yield'. Even if the rent from the scheme does not exceed the fund's priority yield, the developer will still receive a fee but obviously not as uch as he would get if he lets the building(s) at a high rent. There are many other types of development funding some of which are described in ‘Property and Money' by Michael Brett (see the bibliography at the back of this booklet). The developer will employ a professional team to design and cost the proposed building. The architect as leader of the design team has a crucial role to interpret his client's intentions and produce a design which will meet the requirements of tenants, planners and long term funders. Other commentators such as journalists, he general public, and the Prince of Wales may also criticise the design of a scheme where it is perceived to be ugly or inappropriate for its location. Successful commercial development requires therefore a combination of good location, planning consent, good design and funding. Even if these factors are present the scheme may still fail, at least in the short term, if the economy is weak and firms cannot expand. This introduction provides a resume of a typical development and the process can now be considered in more detail. The Developer The developer is the instigator of the scheme. He provides the entrepreneurial flair to identify the development opportunity and bring it to a successful conclusion. In doing so he will make use of established relationships with commercial estate agents and his knowledge of the occupier market. Most large development companies specialise in particular areas of the market. Slough Estates for example, built its reputation in the development of industrial and warehouse property whereas Hammersons developed the first shopping mall in the United Kingdom at Brent Cross. Some life assurance funds act as their own developer and one example is Norwich Union in the development of the Bentalls centre in Kingston on Thames. Various government agencies also act as developers such as District and Regional Health Authorities with hospital building. Increasingly, the newly privatised utilities will carry out their own developments. There are many types of developers. Some are ‘developer traders' who build with a view to selling the scheme when it is complete. Others will develop and hold the completed investment in their investment portfolio. Some developers are quoted on the stock exchange and others are little more than one man bands. Throughout the development process, but crucially at the start before funds are committed, the commercial developer will carry out an appraisal which will predict the eventual profits to be earned from the scheme. A considerable amount of work has to be done to produce a full appraisal as all the costs of the scheme have to be considered. The site itself will have to be fully investigated and this will involve bore hole surveys to enable the structural engineer to estimate the cost of the foundations. An environmental impact study may be required before planning consent is forthcoming. With the assistance of his agent, the developer will also predict the rent which the scheme will produce and (if the investment is to be sold), the investment value. If a scheme is to be successful the investment value less all capital and interest costs will have to leave an acceptable profit. If a developer has used rents in the appraisal which are too high, perhaps in expectation of rent rises in the development period, he may eventually make no profit at all and the scheme (from the developer's viewpoint) will have failed. To avoid risk and to attract other tenants to a development, a developer will often eek a pre-let tenant for a scheme. Before construction starts, a tenant will sign an agreement to lease all or part of the scheme at an agreed rent. This is particularly valuable in shopping centre development where an anchor tenant such as a department store will make a commitment before development commenced, thereby giving confidence to other lessees to take shop units. A developer who borrows money to buy a site, construct a building, and seek lessees will have no appreciable earnings until the scheme is let. It would be difficult therefore, for any interest on capital borrowed to be repaid during the development period. It is usually the case that interest is repaid as a lump sum when the fully let investment is eventually sold. Interest in these circumstances is said to be ‘rolled up' until the end of the development period. In arranging finance, the developer will often have a short term interest in the scheme, whereas the fund purchasing the investment when fully let, has a long term interest. Funds are, therefore, particularly interested in tenant quality in the longer term and building flexibility which may not be of primary importance to the developer. Local Authorities may initiate development, particularly retail, by making town centre ites available on ground leases to developers. The Authority will have a long term interest in the scheme's success, as they will receive a grounds rent, probably geared to the full rental value of the development. Not all developers have a short term interest in a development. Major developers may hold completed investments in a portfolio rather than ar range long term finance by selling the investment to a fund. Planning In the words of Clara Green ‘planning applications (like prayers) receive one of three answers – yes, no or yes but. ‘ The process can be one of great frustration and ifficulty for developers and for a major scheme it is usual for a specialist planning consultant to be employed to negotiate a consent with the Local Authority. Planning law is complicated but in general terms, planning consent is required for most major building in the United Kingdom. The department of the Environment is responsible for planning and the Secretary of State for the Environment is advised by teams of professional planners, surveyors and architects. All applications are made to local councils and it is only the most important or controversial applications which will be of interest to the higher tier of overnment. Most applications are, therefore, decided locally although the Secretary of State may decide to call in any application at his or her discretion. To obtain planning permission, an application will be made to the District Council although applications in the future also may be considered by the new unitary authorit ies. The developer can choose the type of application he wishes to make. If he wishes to seek approval to the principle of development, he can make an outline application. This is sometimes referred to as a red line application, as a red ine is drawn around the site plan supporting the application. If consent is granted, this will be subject to reserved matters and the developer will have to seek a subsequent consent for these detailed matters later. Alternatively a full application may be made which will include all detailed matters as well as the basic principles. The Local Authority will decide the application in the context of plans which will have been previously published and approved by the Secretary of State. Under the present two tier system of Local Government, the County Councils produce structure lans for their area which show in strategic terms the type and location of development which will be permitted during the period of the plan. The District Councils produce local plans which deal with detailed matters related to specific areas of land. If the planning application does not accord with the local plan, the Local Authority will be justified in refusing the application but obviously a developer would be unwise to make an application of this type. Structure plans have a life of between 5 and 15 years and comprise a lengthy written statement supported by explanatory diagrams. The important matters dealt with in the structure plan are strategic matters such as tourism and leisure, waste disposal, new housing, employment and transport. The Authority has a two month period in which to decide an application but it can ask the applicant for more time. If the application is refused the applicant can appeal to the Secretary of state and the matter in the majority of cases, will be decided by a Government Inspector. In major cases, the Inspector will make recommendations to the Secretary of State who will, after advice, take a decision. There may also be a Public Local Enquiry here evidence is heard by the Inspector over a number of days from all interested parties. In producing their structure and local plans as well as deciding applications, Councils have to take into account policy statement produced by the government. These are called Planning Policy Guidance Notes (PPGs) and they are published or amended from time to time. Two of the most important are PPG 6 which relates to out of town retail development and PPG 13 which deals with transport. There are a total of 25 PPGs and many are frequently revised. For example a new PPG 12 was produced in April 1999. This revision emphasised the importance of regional planning which now has it own PPG (PPG 11) and also stressed the government's commitment to a plan led system. Any developer seeking to build against government guidance as stated in the PPGs faces a long, expensive and uncertain battle and therefore is well advised to tailor development proposals to accord with published guidance. The government is at pains to demonstrate that the plan led system is sensitive to demographic changes and this is seen in the revisions to PPG 3 (Housing) which take account of the prediction that ‘7 out of ten new ouseholds forming over the next 20 years are likely to be single person households' (Nick Raynsford, Housing and Planning Minister). A topical revision PPG 25 (Flood Risk) which aims to avoid development in flood risk areas and emphasises a precautionary approach in marginal areas with flood defences to be shown to be in place (and paid for by the developer) before development is approved. The Development Team The team will be employed by the developer at the start of a project and it role will encompass design, costing, funding and marketing. In summary its functions are as follows: Architect The Architect is the leader and coordinator of the design team who has a major role in interpreting his client's requirements and producing a design brief. The brief establishes the client's basic requirements and from this the Architect and other members of the design team will produce detailed design drawings. These will eventually be given to selected building contractors who will tender for the job of constructing the building. During construction, the Architect will inspect the work as it proceeds on behalf of his client. Because the Architect's work is so important he ill be paid a fee based on a percentage of the total cost of the building work. For a new building this will normally be between 4% and 5% of the cost of the work. Quantity Surveyor The Quantity Surveyor estimates the eventual cost of the new building and will produce regular cost checks as the design is developed. Before tenders are invited from building contractors, he will inform the client of the estimated cost of the works (the pre-tender estimate) and the client can then proceed to tender with confidence. Services and Structural Engineers In some instances the engineers will be responsible for producing design drawings nd specifications of the building services (air-conditioning, electrical installation etc) and the structure (foundations, structural frame). Increasingly however, the services engineer will only produce a statement of how the services will perform (a performance specification) rather than a full design. In these circumstances, design becomes the responsibility of the contractor. Estate Agents Developers usually have established relationships with firms of estate agents who will be aware of development opportunities. The agent will also provide marketing advice and will be responsible for letting the building. Other Consultants Other consultants include solicitors, landscape architects and planning consultants. With some complicated and large schemes, a project manager may oversee the project on behalf of the client. Specialist noise or environmental consultants may be required where development will take place in environmentally sensitive areas where special planning conditions have been imposed. Successful Schemes A scheme will be successful if its location and design has attracted a number of first class tenants and will continue to do so in the future should any tenants vacate. A uccessful scheme will provide a secure and growing investment for the eventual long term investor as well as an adequate monetary profit for the developer. There are many reasons why development schemes are unsuccessful, some of which are discussed below: Poor Location This is the most obvious but nevertheless very common reason for failure. A shopping scheme may be located where there is a lack of pedestrian flow. An office building may be located where vehicular access is difficult or the chosen site does not provide the required image and identity for the tenant/s. On a wider scale, he development may be located in a city which is in decline, to the detriment of long term investment quality. Some commentators are casting doubt on the future quality of fringe of town retail warehousing schemes which do not have the support of an established town centre. Poor Design A shopping centre must be designed to maximise pedestrian flow and enable shoppers to both park and gain easy access. If the design fails to do this, the public may avoid the centre and tenants will be hard to find. Also shopping centres must allow frequent changes of image and must provide the correct ambience for the ublic. Attention to detail with the internal design will allow this to benefit the investment. Thee are many examples of office buildings constructed in the 1960's and 1970's which do not provide the necessary ducting and image for modern tenants using today's technology. These developments may have been regarded as successful when they were first constructed, but in terms of a long term investment are of dubious quality. Lack of flexibility with many buildings means that where occupier requirements change the buildings cannot and voids are the result. Increased Costs during Design or Construction If a developer allows costs to increase, he will eventually make no profit whatsoever from the scheme. If costs increase beyond those used in the appraisal the developers profit will be eroded. The expertise of the design team to contain costs whilst, at the same time, producing a quality building is of vital importance but sometimes mistakes are made. A lack of coordination between building work and services is a typical example leading to redesign, delay and increased costs. Planning Errors When a contract is awarded to a contractor, it is important that the site of the evelopment is firstly in the legal control of the developer and secondly the same site for which planning consent has been granted. There have been many examples of mistakes in this area to the detriment of the project. Empty Property A newly built shopping centre with few tenants is clear evidence of a scheme which falls short of success. There are many examples amongst those centres completed during the recession. As with office and warehousing property pre-let tenants are particularly valuable in recessionary periods. Public Sector Development The Private Finance Initiative. In the past public sector development such as roads, hospitals and bridges were built by government contracting with the private sector for the design and construction works. Civil servants and their consultants would work to precise specifications of what was required to be built. When the development was complete the government would then be responsible for running the completed hospital, road or whatever to the benefit of the public. The Private ~Finance Initiative (or PFI) is intended to revolutionise the traditional method of producing public facilities described above. It was conceived in 1992 during Norman Lamont's troubled chancellorship and was vigorously supported by his successor Kenneth Clarke. In essence PFI only required the government to state how the building is to be used and the performance it must achieve. The private sector is then invited to tender for the design, construction and running of the new facility. The reward for doing this is negotiated with the government agency responsible for the facility and will usually take the form of a regular monetary payment so long as the facilities provided continue to meet the agreed criteria. Kenneth Clarke stated that PFI is ‘a radical and far reaching change in capital investment in public services which will break down further barriers between the public and private sectors'. The central argument in favour of PFI is that the private sector is more capable of promoting efficiency than government and will provide business solutions to public sector requirements. It is also argued that the risks of increased construction and running costs, which appears to be a feature of public sector schemes, will disappear with PFI where all the risks are borne by the private sector. Critics of PFI point out that it is extremely difficult to produce a performance specification for, say, a highly complex building such as a hospital and this will lead to private sector contractors being allowed to cut corners to the detriment of the public. It is also pointed out that the government can always borrow money more cheaply than the private sector and that this will inevitably lead to increased costs which will be passed on to the public. The change of government in May 1997 led to a thorough review of the experience gained from using PFI in the previous five years. Malcolm Bates was appointed to arry out a review which resulted in 29 recommendations aimed at rationalising and reinvigorating the PFI process. The ‘Treasury Taskforce' was the government's response to the review and this body consisted mainly of city financiers who were charged with building up PFI expertise in government. The taskforce had a life of three years and is replaced by ‘Partnerships UK' which will operate as a joint private/public consultancy to assist with the PFI process. There are currently hundreds of PFI schemes in the process of completion and the present government is wedded to this form of procurement for public sector projects.