Hip Fracture Treatment in Older Patients

Hip Fracture Treatment in Older Patients 1.1 Background Hip (neck of femur) fractures are a common, serious and well-defined injury affecting mainly older people. As global populations age, projections for hip fracture numbers over the coming decades will rise. Delays to surgery are associated with increased post-operative complications, prolonged recovery and length of stay (LOS), and with increased morbidity and mortality (Trpeski, Kaftandziev, and Kjaev, 2013). In addition, the cost burden of hip fractures is substantial. The process of caring for people with hip fractures is complex, long, and involves several diagnostic, therapeutic and administrative activities. These activities occur in AE and orthopaedic departments, operating theatres, and in the community. They involve a range of health professionals and support staff. When this coordination fails, patients may suffer from avoidable delays and suffering. In the United Kingdom (UK), the bed occupancy rate for hip fractures was more than 1.5 million days, which represent 20% of th e total orthopaedic beds (Compston et al., 2009). The lifetime risk of sustaining a hip fracture in the UK from age 50 is around 11% for women and 3% for men (Van Staa et al., 2001). Many of those who recover suffer a loss in mobility and independence: approximately half of those previously independent become partly dependent, while one-third become totally dependent (Myers et al., 1996). 1.2 Current Process Watford General Hospital (WAT) treat 450 patients for hip fractures every year. Hip fractures are one of the most common complex trauma problems orthopaedic surgeons face. Patients are often seriously ill, elderly and frail, which can result in poor outcomes. Hip fractures generally result from a fall, patients present at AE where imaging tests are used to make a diagnosis and pain medication is administered (Appendix A). When possible, patients are moved from the emergency department to a ward. Ideally, patients will have surgery within 72 hours of arrival at hospital, provided they are in a stable condition. A pre-operative assessment is carried out to establish the patients overall health to make sure they are ready for surgery. They also have an anaesthetic assessment. Two main types of anaesthesia are used: general anaesthetic and spinal or epidural anaesthesia. A team of healthcare professionals will perform the surgery, including an orthopaedic surgeon. The National Hip Fracture Database (NHFD) produce an annual report that includes an analysis of 30-day mortality rates for hip fracture patients who are over 60 years old within the UK. WAT were alerted by the NHFD that they were an outlier, with 12% mortality over 3 years. In the UK the overall mortality rate within 30 days of hip fracture in 2014 was 7.5%   (Johansen, 2016). High mortality rates are a signal to hospitals that they should investigate to identify and resolve quality issues. Figure 1Funnel Plot of Crude and Adjusted Mortality Rates 2014 (Source: Johansen, 2016) Effective strategies are needed to reduce the burden on healthcare providers and to improve patient quality of life and outcomes after a hip fracture. Staff at WAT want to develop an action plan to analyse performance and instigate improvement programmes. This included questioning what elements of care could have been delivered better to ensure that high-quality care is delivered throughout the patients treatment, to improve 30-day mortality rates and functional outcomes for patients. 1.3 Perceived Issues with the Current Process In the present study, the incidence and mortality and functional outcomes in hip fracture patients was studied. The relationships between admission and treatment times, pain management drugs and anaesthesia, and their effect on the patients length of stay (LOS) in hospital were assessed and the following issues were found: Admission time from AE to treatment is high High level of opiate usage to manage pain Routine use of general anaesthesia 1.4 Value Adding Activities Admission to surgery times Pain management Days spent in hospital 1.5 Scope Older people with hip fractures aged 60 or over are in scope for this project.       1.6 Problem Statement 30-day mortality rates for older hip fracture patients at Watford General Hospital have been 12% for 3 consecutive years, 4.5% higher than the national average (NHFD). 1.7 Goal Statement Reduce 30-day mortality rates in older hip fracture patients to 8.5% by the end of June 2017. 2.1 Process Map Figure 2 Process Map 2.2 Process Narrative      Ã‚   The person arrives at the AE department by ambulance or car. The triage nurse assesses the patients condition. Patients are classified by severity of injury (red, yellow, or green). Patients presenting with suspected hip fractures are commonly assigned a yellow classification, which indicates an emergency but not of a life-threatening nature. An AE doctor or nurse checks the patients vital signs, records their pre-fall health condition, and administers pain medication (generally opiates). Subsequently, in consultation with an AE doctor (if available), several basic tests (blood tests) and X-rays (hip and often chest) are ordered and performed. The patient is transferred to the radiology department for x-ray. The AE doctor or nurse then reviews the test results. If a hip fracture is diagnosed, the patient is deemed admissible and an intravenous (IV) drip is started. The patient is transferred to the orthopaedic ward for admission when a bed becomes available. Admission times are curre ntly 13.4 hours. On admittance to the orthopaedic ward an orthopaedic surgeon will review the test results. If the patient is deemed suitable for treatment the medical assessment team will assess if the patient has any existing medical issues that may affect treatment. If pre-existing medical conditions with the potential to affect treatment are found patients are referred to palliative care and discharged. If no pre-existing conditions are found patients are assessed by the anaesthesia team. Patients deemed suitable for surgery are placed on the trauma list, surgery generally takes place within 72 hours. Patients deemed unsuitable are referred to palliative care and discharged. Patients go to theatre, they are anesthetised using general anaesthetic and receive surgery. They are subsequently transferred back to the orthopaedic ward for ward-based management. Patients are discharged once they are mobile. 2.3 Identification of Problems, Weaknesses, and Change Areas High level of opiate use by AE staff for pain management Admission times of 13.4 hours Surgery wait times of up to 58.6 hours Routine use of general anaesthetic in surgery 3.1 Key Strategic Elements for Improvement Patients with hip fractures often require complex and challenging care, this is provided by a number of professionals in several departments, crossing a number of service boundaries. These patients are often frail, and their outcomes depend on how effectively their care pathway is managed. Pain management medications, avoidable delays, anaesthesia choices and post-operative care affect functional outcomes and mortality. The key strategic elements towards improving outcomes for older hip fracture patients are: Reducing morbidity and mortality rates Achieving better functional outcomes for patients Increasing discharge rates to original place of residence Increased value from the healthcare budget They can be achieved by: Altering pain management practices Altering anaesthetic management Reducing admission and treatment times 3.1.1 Pain Management Despite recent advances in the care of hip fracture patients, significant morbidity and mortality persists. Some of this is attributable to the pain medication administered in hospital. Opiates are the preferred pain management drug at WAT currently (Appendix A). Opiate use can cause nausea, constipation, and confusion (delirium) in the older patients (Coruhlu and Pehlivan, 2016). Effective pain management is a primary goal in hip fracture treatment. Research suggests fascia iliaca compartment blocks (FIB) is an alternative for pain management in hip fractures. Intravenous opioid therapy is used frequently (Appendix A). However, opioid side effects, such as nausea, vomiting and delirium, are common. Regional analgesic techniques have been shown to provide similar analgesia to opioids. FIB is reported to effectively block cutaneous lateral femoral and femoral nerves in adults (Nie et al., 2015). Studies have suggested superior analgesic effect with pre-operative FIB. They provided superior analgesia to intramuscular morphine in a randomised controlled trial of hip fracture patients (Callear et al., 2016). FIB is a safe and simple technique that can be administered by junior doctors and specialist nurses with training (Hanna et al., 2014). FIB administered in AE provided significant decreases in pain when compared to opiates. Post block analgesic requirements for patients in the FIB group were minimal. A study conducted by Callear and Shah (2016) concluded that a single dose of FIB given in the pre-operative period significantly reduced the post-operative and total analgesic requirements in the hip fracture patient. Patients also experience lower rates of delirium and were discharged faster. This reduces the cost of providing inpatient hospital beds and improves quality of life for older patients. 3.1.2 Anaesthetic Management Anaesthetists have an essential role in the preoperative, operative and postoperative management of hip fracture patients. Complications arising from anaesthesia in hip fracture surgery is influenced not only by the type of anaesthetic used, but also by patient comorbidities and the delays between admission and surgery. Approximately 25% of hip fracture patients display at least one episode of cognitive dysfunction during hospitalisation (Heyburn et al., 2012). A systematic review published by SIGN (2009), suggests that the use of spinal anaesthesia may reduce the incidence of postoperative confusion. 3.1.3 Time to Surgery At present admission times are 13.4 hours (NHFD statistics show the national average is 9.3 hours) and surgery wait times are 58.6 hours. Current guidelines recommend surgery to be carried out within 24 hours of injury (BOA, 2014). Observational studies suggest better functional outcomes, shorter hospital stays, duration of pain, and lower rates of complications and mortality are achieved by performing surgery earlier. Pre-operative delays increase mortality and, in those who survive, prolongs post-operative stay. For every additional 8 h delay to surgery after the initial 48 h, an extra day in hospital results (Colais et al., 2015). Currently WAT fall far short of the ideal to provide optimal care for hip fracture patients. 3.1.4 Multidisciplinary Approach The management of hip fractures requires complex, connected care from presentation at AE, through all departments. A study of 116 patients found that dedicated nurse specialists are effective at fast-tracking hip fracture patients to surgery by securing hospital beds, organising care, operating theatre lists and acting as a liaison with all other relevant departments (Larsson and Holgers, 2011). Many published guidelines recommend a multidisciplinary approach to the treatment of hip fractures, in addition to, a good care environment to promote best outcomes. The Scottish Intercollegiate Guidelines Network (SIGN, 2009), the National Institute for Clinical Excellence (NICE, 2013), and the British Orthopaedic Association in cooperation with the British Geriatric Society (BOA, 2014), have all produced guidelines supporting a multidisciplinary team approach to deal with hip fractures in older people. Figure 3 Multidisciplinary Team (Source: Orthopaedics and Trauma) Rieman and Hutichson, (2016) It is recognised that a team approach with excellent communication between all the members is essential. The multidisciplinary team looking after hip fracture patients is large (Figure 2), and each role is important in the jigsaw of care. 3.1.5 Clinical Pathway Clinical pathways should be used to aid the multidisciplinary team. They provide a description of the expected interventions and outcomes throughout the patient journey following a hip fracture. The use of clinical pathways ensures everyone knows the next step in the process and this minimises unnecessary variations in practice (Chudyk et al., 2009). A study of 1193 older hip fracture patients conducted at 6 hospitals in the Limburg trauma region of the Netherlands concluded that the use of a multidisciplinary clinical pathways (MCP) for patients with hip fractures tends to be more effective than usual care (UC). Time to surgery was significantly shorter in the MCP group when compared to the UC group. The mean length of stay was 10 versus 12 days. In addition, the MCP group had significantly lower rates of postoperative complications (Kalmet et al., 2016). 3.2 Proposed Strategy Establish a designated Hip Fracture Unit within the main orthopaedic unit. Appoint a multi-disciplinary team to be based on the ward comprised of: Physio /Occupational Therapist Orthopaedic /Orthogeriatric Doctor Specialist Hip Fracture Nurse Nursing staff Establish a Hip Fracture Pathway. Establish a protocol-driven, fast-track admission of patients with hip fractures through AE AE bleep specialist hip fracture nurse FIB administered by nurse for pain management and patient centred care Patients are admitted to the hip fracture ward within 6 hours Appropriate, medically fit patients receive surgery within 24 hours Use of spinal anaesthesia when appropriate Continuous tracking/live data systems that regularly update patient and logistical data may improve management by identifying patients location, delays in treatment and relevant clinical information. 3.3 Potential Process Improvement Tools 3.3.1 Continuous Quality Improvement Continuous Quality Improvement (CQI) is a quality management tool that encourages all members of the health care team to continuously ask, How are we doing? and Can we do it better? (Edwards et al., 2008). It focuses on improvement for the patient and the practice by asking questions like, can we do things more efficiently? Can we be more effective? Can we do it faster? CQI uses a structured planning approach to evaluate the current processes and improve those processes to achieve the desired outcomes. Tools commonly used in CQI help team members identify the desired clinical or administrative outcome and the evaluation strategies that enable the team to determine if they are achieving that outcome. The team can adjust the CQI plan based on continuous monitoring of progress through an adaptive, real-time feedback loop (NLC, 2013). A CQI approach can help improve patient care. There is a strong link between organisations with explicit CQI strategies and high performance (Levin, 2016). Figure 4 CQI Framework Model (Adapted from NLC) Structure examines the characteristics of resources, staff and consultants, physical space, and financial resources. Process -   the activities, workflows, or tasks carried out to achieve an output/outcome. Output the immediate predecessor to a change in the patients status. Not all outputs are clinical e.g. business or efficiency goals. Outcome the end result of care. Can be change in the patients current and future health status. Feedback Loop represents its cyclical, iterative nature. 3.3.2 Lean Management Lean is a process improvement method developed by Toyota in the 1950s. Lean management principles have been used in manufacturing for many years, however, these principles can be used in healthcare too. According to Womack and Jones, there are five key lean principles: value, value stream, flow, pull, and perfection. Lean drives out waste so that all work adds value from a customer perspective. Lean thinking focuses on how efficiently resources are being used, it looks at each step in the process and asks what value is being produced? Value from a patients perspective can be defined as timeliness of treatment, reduced stress, or better functional outcomes. The NHS defines value as anything that helps treat the patient. Everything else is waste (Jones and Mitchell,2006). Figure 5 Lean Principles Identify customer value in healthcare value is any activity that improves the patients health. Manage the value stream the value stream is the patients journey. Identify process that deliver value to patients. Create Flow align processes to facilitate the smooth flow of patients and information Establish Pull provide care on demand and utilising resources effectively. Seek Perfection optimise the process through continued development and adjustment to meet patients needs. Optimal delivery of high-quality care to reduce mortality in hip fracture patients is an achievable goal. There are numerous opportunities to enhance the quality of care: reduced length of stay, reduced institutionalisation, reduced mortality and better functional outcomes for patients. Better quality care minimises treatment delay, promotes recovery and facilitates a speedier discharge. Cost and quality are not in conflict providing high quality hip fracture treatment is a lot cheaper than poor quality treatment. Lean inspired and clinical pathway related process improvement efforts make inconsistent and inefficient practices in health care more visible. The implementation and adherence to evidence based standards will considerably improve the care and management of older patients with hip fractures, this will result in significantly improved outcomes for patients and the healthcare system. 5.1 Appendix A References       BOA (2014) BOA standards for trauma (bOASTs). Available at: http://www.boa.ac.uk/publications/boa-standards-trauma-boasts/ (Accessed: 5 December 2016). Callear, J., Shah, K., Hospital, J.R. and Oxford (2016) Analgesia in hip fractures. Do fascia-iliac blocks make any difference?, BMJ Quality Improvement Reports, 5(1), pp. 210130-4147. doi: 10.1136/bmjquality.u210130.w4147. Chudyk, A., Jutai, J., Petrella, R. and Speechley, M. (2009) Systematic review of hip fracture rehabilitation practices in the elderly, Archives of physical medicine and rehabilitation., 90(2), pp. 246-62. Colais, P., Di Martino, M., Fusco, D., Perucci, C.A. and Davoli, M. (2015) The effect of early surgery after hip fracture on 1-year mortality, BMC Geriatrics, 15(1). doi: 10.1186/s12877-015-0140-y. Compston, J. (2009) Guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK, Maturitas., 62(2), pp. 105-8. Coruhlu, O. and Pehlivan, S. (2016) Worst pills. Available at: http://www.worstpills.org/includes/page.cfm?op_id=459 (Accessed: 5 December 2016). Edwards, P., Huang, D., Metcalfe, L. and Sainfort, F. (2008) Maximizing your investment in EHR. Utilizing EHRs to inform continuous quality improvement., JHIM, 22(1), pp. 7-12. Hanna, L., Gulati, A., Graham, A. and Corporation, H.P. (2014) The role of Fascia Iliaca blocks in hip fractures: A prospective case-control study and feasibility assessment of a junior-doctor-delivered service, International Scholarly Research Notices, 2014. doi: 10.1155/2014/191306. Heyburn, J., Holloway, G., Leaper, E., Parker, M., Ridegway, S., White, S., Wiese, M. and Wilson, i (2012) Management of proximal femoral fractures 2011, Association of Anaesthetists of Great Britain and Ireland, 67(1), pp. 85-98. Jones, D. and Mitchell, A. (2006) Lean thinking for the NHS. Available at: http://www.nhsconfed.org/~/media/Confederation/Files/Publications/Documents/Lean%20thinking%20for%20the%20NHS.pdf (Accessed: 11 December 2016). Kalmet, P.S.H., Koc, B.B., Hemmes, B. and ten Broeke, R.H.M. (2016) Effectiveness of a Multidisciplinary Clinical Pathway for Elderly Patients With Hip Fracture: A Multicenter Comparative Cohort Study, Geriatric Orthopaedic Surgery Rehabilitation, 7(2), pp. 81-85. Levin, D. (2016) Using continuous quality improvement to improve patient experience. Available at: http://bivarus.com/using-continuous-quality-improvement-improve-patient-experience/ (Accessed: 7 December 2016). Myers, A.H., Palmer, M.H., Engel, B.T., Warrenfeltz, D.J. and Parker, J.A. (1996) Mobility in older patients with hip fractures: Examining Pre: Journal of Orthopaedic trauma, Journal of Orthopaedic Trauma, 10(2), pp. 99-107. NICE (2013) Falls in older people: Assessing risk and prevention. Available at: https://www.nice.org.uk/guidance/cg161 (Accessed: 5 December 2016). Nie, H., Yang, Y.-X., Wang, Y., Liu, Y., Zhao, B. and Luan, B. (2015) Effects of continuous fascia iliaca compartment blocks for postoperative analgesia in patients with hip fracture, 20(4). NLC (2013) Continuous quality improvement (CQI) strategies to optimize your practice Primer provided by. Available at: https://www.healthit.gov/sites/default/files/nlc_continuousqualityimprovementprimer.pdf (Accessed: 7 December 2016). Rieman, A.H.K. and Hutichson, J.D. (2016) The multidisciplinary management of hip fractures in older patients. Available at: http://www.orthopaedicsandtraumajournal.co.uk/article/S1877-1327(16)30025-2/fulltext (Accessed: 5 December 2016). Scottish intercollegiate guidelines network part of NHS quality improvement Scotland SIGN management of hip fracture in older people (2009) Available at: http://www.sign.ac.uk/pdf/sign111.pdf (Accessed: 5 December 2016). Simunovic, N., Devereaux, P. and Bhandari, M. (2011) Surgery for hip fractures: Does surgical delay affect outcomes?, 45(1). Trpeski, S., Kaftandziev, I. and Kjaev, A. (2013a) Fast-track care for patients with suspected hip fracture. Available at: http://www.injuryjournal.com/article/S0020-1383(11)00002-7/fulltext (Accessed: 10 December 2016). Trpeski, S., Kaftandziev, I. and Kjaev, A. (2013b) The effects of time-to-surgery on mortality in elderly patients following hip fractures, Prilozi (Makedonska akademija na naukite i umetnostite. Oddelenie za medicinski nauki)., 34(2), pp. 115-21. Van Staa, T.P., Dennison, E.M., Leufkens, H. and Cooper, C. (2001) Epidemiology of fractures in England and Wales. Available at: http://www.thebonejournal.com/article/S8756-3282(01)00614-7/fulltext (Accessed: 5 December 2016). Verhelst, J., Dawson, I., Paul T. P. W. Burgers, Esther M. M. Van Lieshout and Piet A. R. de Rijcke (2013) Implementing a clinical pathway for hip fractures; effects on hospital length of stay and complication rates in five hundred and twenty six patients, 38(5).

Breakfast of Champions by Kurt Vonnegut

Kurt VonnÐ µgut’s BrÐ µakfast of Champions criticizÐ µs AmÐ µrican sociÐ µty as a wholÐ µ, by addrÐ µssing aspÐ µcts such as racism and mans vulnÐ µrability towards mÐ µdia, which both spring from thÐ µ ignorancÐ µ of thÐ µ AmÐ µrican culturÐ µ. ThÐ µ continuous critical viÐ µwpoint of AmÐ µricanism and thÐ µ incÐ µssant quÐ µstioning of thÐ µ AmÐ µrican drÐ µam throughout this novÐ µl makÐ µ it a modÐ µrn artifact, a contÐ µmporary rÐ µprÐ µsÐ µntation of AmÐ µrican sociÐ µty, and a guidÐ µ to lÐ µarning out of past mistakÐ µs. As media and propaganda play a big role in the story, Vonnegut criticizes what an immense impact it has on the American and how its influence can lead to hysteria and madness.After Trout’s kidnapping, when the police questions him about the criminals, he cannot recall anything due to his blackout. His provocative reply,  «For all I know, they may not even have been Earthlings . . . that car may have been occ upied by an intelligent gas from Pluto » serves as the  «first germ in an epidemic of mind-poisoning » (76) amongst the credulous masses. As a reporter rewrites Trout’s recollection into a story with the headline  «Pluto Bandits Kidnap Pair,  » various papers soon copy the story and it all escalates to the point where all of New York is taught to fear a so-called ‘Pluto Gang’.People purchase locks for doors and gratings for windows, and the sensationalist media continually feeds the mass hysteria with this rubbish terror. No one questions the existence of the Pluto Gang and everyone believes what the media spreads across the country. Vonnegut goes on about the foolishness of these people, yet his style is  «both too funny and intelligent for many », who fail to recognize his  «earnestness » and critical voice due to his recurrent  «satirical sketches ». Racism and discrimination in American society is another aspect Vonnegut at-tacks and pla ys an important role in Breakfast of Champions as well.As the American College Dictionary defines racism as any  «belief that human races have distinctive makeups that determine their respective cultures, usually involving the idea that one’s own race is superior and has the right to rule others », it becomes clearer and clearer how filled with criticism about this certain practice this Vonnegut’s novel is. Again and again, does the word  «Nigger » come up in the novel to underscore the harsh treatment blacks were forced to undergo, and it is used in a particular manner by Vonnegut to express again, how pathetic, blunt and almost funnily absurd this entire notion of discrimination towards blacks was.Vonnegut purposely generalizes opinions on blacks when saying how  «White people were the only people with money enough to buy new automobiles, except for a few black criminals, who always wanted Cadillacs »(41). His striking generalities poke fun at those masse s that discriminate blacks and try to force them all under a certain, negative cliche. His blunt and exaggerated language also makes this particular discrimination seem absurd. Obviously, not every single Blackman feels the desire to own a Cadillac, but hearing this point presented in such a comical way brings across the stupidity of such bigotry.Vonnegut’s, seemingly depressed view of life, uses America to criticize mankind and to make people aware of their capabilities. He shows how people can act ridiculous, cruel, and naive. He criticizes to show humankind what mistakes have been made, so that future prevention is possible. His thoughts go under the skin and point out things everybody can learn from. America is such a good example to show this by, because this nation was founded on a dream of self-realization and happiness. This dream, however, can only be obtained through seeing past mistakes with a critical eye, learning from them, and fighting to achieve dreams.

Comparative Methodological Critique

The aim of this paper is to compare two academic research papers, one informed by qualitative and another one by quantitative research designs with focus on the methodological factors. Both papers describe working lives and attitudes of gay and lesbian workers in the UK and USA, possible consequences of disclosure of sexual orientation on their working relations and organisational arrangements towards equality and diversity of working practice. These research projects add to the growing number of studies which shed light on the sensitive nature of homosexuality in the workplace and anti-discrimination policies and practices that organisations deploy to create a more inclusive working environment. Governed by the difficulty of access to gay and lesbian population both in UK and USA, and its â€Å"hidden† nature both teams chose their own strategy in unveiling the nature of work attitudes of gay and lesbian employees and demonstrating the progress organisations have made or are making towards the establishment of good practice. st paper (qualitative) The paper deals with identifying good organisational practice concerning equality, diversity and sexual orientation in the workplace, and considers any changes following the introduction of Employment equality (Sexual Orientation) regulations 2003. It also aims at addressing the gap between equality policy and practice which provides the foundation for further analysis of the significant shortfall in knowledge relating to the experience of LGB (lesbian, gay and bisexual) employees in UK organisations. Even today, the issue of sexuality still remains a sensitive one, despite the coming into force of legislation offering protection to LGB people. It is also the cause of unease for some employers in the modern world in discussing (not to mention dealing with! ) this issue, and consequential bullying, suffering and fear which make life and work unbearable for so many LGB people. So far progress has been made based on social justice and business case studies which means that this still â€Å"remains †¦an under researched area in which there have been very few case studies of particular organisations† (Colgan et al. 2007:591). Having adopted a phenomenological position in their design, the research team chose to carry out a longitudinal (2 year) qualitative study in 16 â€Å"good practice† case study organisations in the area of employment of LGB workers, to discover â€Å"the details of the situation†¦[in order to] to understand the reality† (Remenyi et a l. , 1998:35) of working relations in organisations with LGB workers. Also focusing on the ways that people make sense of the world especially through the sharing of experiences with others has dictated the use of a social constructionist framework (Bryman and Bell, 2007). The case studies involved the analysis of companies’ documentation and reports, trade union publications and websites to get an inside view of companies’ attitudes and practices. The main challenge of the project in data collection was â€Å"limited resources †¦ inability to specify a sampling frame† (Saunders et al. , 2003:170) which dictated the use of non-probability sampling. Therefore, snowballing sampling was applied as the most appropriate for this kind of research. The research team interviewed in depth 154 LGB employees who, prior to that, completed a short survey questionnaire. All completed the survey giving a complete census. However, due to â€Å"a lack of robust statistical evidence concerning the proportion of the UK population who identify as LGB† (Colgan et al. , 2007:591) and the difficulty of access to such people, it’s hard to say how representative this sample of LGB people is. Determined by these practical constraints, the research team adopted a mixed methods research strategy (case study/interviews) with various data collection methods that allowed them to have a cross-check against each other's results. Difficulty of accessing LGB employees also dictated the choice of analysis focusing only on â€Å"good practice† organisations. Hence, using survey, in-depth interview and secondary data enabled the team to combine the specificity of quantitative data with the ability to interpret perceptions provided by qualitative analysis. Though, there is evidence and justification by the research team of how respondents were selected, the project itself demonstrated a disproportioned balance of respondents not only in terms of gender (61,7% -men, 38,3% – women) but also in terms of ethnic division. This means that the balance tipped so far in terms of the depth of their research. The research team adapted an inductive research approach to accommodate the existing theories and findings as well as their own empirical studies, for example â€Å"that those in lower level and perhaps more difficult working environments are less likely to be â€Å"out†Ã¢â‚¬ ¦at work† (Colgan et al. , 2006a cited in Colgan, 2007:593). The paper also gives a good historical overview of how public and private sector organisations have made progress towards the â€Å"inclusion of sexual orientation within its organisational policy and practice† (Colgan et al. , 2006a cited in Colgan, 2007:593). This provides readers with a comparative overview of how the situation has changed following the introduction of the legislation. The research team identified the number of steps organisations took to follow â€Å"good practice† in relation to equality and diversity, at the same time outlining the differences in progress between public and private sector companies. In doing so, the authors also assert that the implementation gap between policy and practice still exists and requires further measures such as â€Å"the need to see policy championed, resourced and implemented by senior line managers† (Colgan et al. 2007). Whereas the Regulations empowered LGB people to step in and â€Å"challenge discrimination and harassment† (Colgan et al. , 2007:604), the key factor, as identified by the authors, â€Å"that prevented some respondents coming out at work †¦ the fear† (Colgan et al. , 2007) remained the main obstacle to LGB workers to blowing the whistle and reporting an incident. These findings are supported and justified throughout the paper by respondents’ statements and results of previous studies. The research team also defined the relation between the impact of the employment equality (SO) regulations, considered as independent variable, and such dependent variables like job satisfaction, being out at work, experience of harassment and discrimination, this in fact gives an idea of the existing problem in organisational practices. In terms of structure, language and appropriateness of referencing to other material this paper proves highly informative. It suggests that further research needs to be done in order â€Å"to gain a more â€Å"representative† picture of working lives of LGB employees† (Colgan et al. , 2007) as it only explored the â€Å"tip of the iceberg†, because the research project was able to examine only a fraction of the whole, and, unless an organisation adopts more effective and proactive leadership on equality and diversity, the legislation on its own will take only a small step towards the inclusivity of LGB people and the creation of harmonious equal working practices in UK organisations. The research project involved cross-sectional design that allowed the team to compare and contrast their findings derived from each of the cases. This is considered to be a great advantage of the project as it allowed the team to consider â€Å"what is unique and what is common across cases† (Bryman and Bell, 2007:64), thus facilitating an attempt to generalise their findings. The research team does not explicitly express their own opinions, allowing personal values to sway the conduct of the research and the findings deriving from it, this ensures that they acted in good faith and followed good practice. However, having conducted a survey following the implementation of (SO) Regulations 2003, this study failed to provide a sufficiently broad spectrum of opinion of how organisational culture has changed as a consequence of the legislation. Moreover, the research team did not specify whether any of the key informants or interviewees had worked in â€Å"good practice† organisations before the regulations came into force which would allow a comparative analysis of organisational practice to take place and, thereby, for data to be more representative. Much attention was focused upon good practice organisations in their study; however, there was a failure to demonstrate what was meant by â€Å"good practice†. This would have enabled readers to have a more explicit understanding of what expectations are from any organisation with LGB employees. In terms of access to respondents, although the team acknowledged the difficulty, they were not as resourceful as they might have been. Lack of robust information undermines the conclusions, arguably, brings into question the credibility of the findings as the research net was not cast widely or deeply enough. For the readership of this paper there is no ultimate enlightenment as the paper does not show any argument or advocacy that invite readers to the world of unexpected discovery; instead, it is rather a presentation or portrait. It also remains difficult to conduct a true replication of this study, even though majority of the organisations â€Å"were willing to be identified by name† (Colgan et al. 2007). 2nd paper (quantitative) This paper describes the relationship between reported disclosure of sexual orientation, anti-discrimination policies and top management support. It is also aimed at identifying work-related attitudes of gay and lesbian workers if such disclosure takes place and its effects on individual performance of gay and lesbian workers. At the time of the research very few empirical studie s had been conducted to investigate work attitude and disclosure of sexual orientation. Since the recognition of the gay and lesbian population within the workforce, inclusiveness of gay and lesbian employees in organisational diversity management policies was desperately needed. It has been argued that â€Å"an approach of workplace tolerance is needed† (Day and Shoenrade, 2000:347) which can contribute to the knowledge of human resource function when taking appropriate actions if conflict arises and to help create a more conducive environment for the disclosure of sexual orientation. Emphasising the importance of collecting facts and studying â€Å"the relationship of one set of facts to another† (Anderson, 2009:45) underpins their positivist paradigm. Focused on key unresolved questions such as â€Å"closeted homosexual workers will have a less positive work-related attitude† (Day and Shoenrade, 2000:346) the research team takes a deductive research approach to test three formulated hypotheses which together with research paper aims do not appear until well into the text. This can lead to uncertainty on the part of the readership. In terms of selection of respondents and its rationale, the research team fails to demonstrate the proportion of respondents relating to ethnics; also gender division appeared to be highly disproportioned with 485 gays and only 259 lesbians. Their chosen data collection methods (sampling, focus groups and a questionnaire) highlighted some problematic issues such as â€Å"identifying a representative sample of working lesbians and gays† (Day and Shoenrade, 2000:350) due to the sensitive nature of research and lack of current data on the lesbian and gay population. Great attention was paid to demonstrating their strategy in obtaining possibility sample. Having looked at various options, the sampling choice was justified on the basis of geographical location (USA Midwest) which it was thought would benefit in the existing research as it involves lesbian and gay population not surveyed before. A large sample would allow them to easily obtain a significant test statistic (Esterby-Smith et al. 2008), the research team sampled several resources, principally Human Rights Project (HRP), and then broadened them getting a reasonable response of 29% which â€Å"showed no statistically significant difference from the larger sample on the major variables† (Day and Shoenrade, 2000:351). However, such considerations cannot be viewed as justification for not following the principles of probability sampling and therefore team’s findings do not represent the whole gay and lesbian population of USA and cannot be generalised. In testing three formulated hypotheses the research team established three independent variables (disclosure of sexual orientation, presence of anti-discrimination policy and top management support) and 5 dependent ones (affective commitment, continuance commitment, job satisfaction, job stress and conflict between home and work) and selected a multivariate analysis to find a way of summarising the relationship between these variables and at the same time capturing the essence of the said relationship (Esterby-Smith et al. , 2008). Adopting objectivist ontology the research team aimed at analysing the relationships between these variables thus creating static view of social life (Bryman and Bell, 2007). However, there was a failure to specify which statistical test was used to demonstrate and examine interdependence between them. This, in fact, point to a lack of transparency of their project. Based on several example questions the team demonstrated it can be deduced that they were dealing with categorical data (ordinal and cardinal) and therefore the Spearman correlation test and regression analysis (linear regression model) were used to represent non-parametric data. This allowed them to measure the strength and the direction of association between the variables, and confirm whether there is any difference in the population from which the sample was drawn. The research team also used a qualitative research method. They conducted a focus-group discussion to ensure that â€Å"the construct of disclosure of sexual orientation be precisely defined and relevant to†¦ [this] population (Day and Shoenrade, 2000:351). This helped to ensure that the concept was precisely defined and relevant to the population. The lack of secondary data sources also explained the rationale of their chosen method of data analysis. However, had this data been obtained, it would have allowed to create a more comparative analysis. For each independent variable the research team demonstrated several example questions and interpretation of the results which provided readers with an overview of a critical analysis of the conclusions the research team came to. However, those who are not familiar with statistical data would find it hard to follow the argument as there was a failure to provide basic explanation of roman letters and include notes when referencing to the tables. Therefore, it is impossible to cross-check their results and to confirm their findings. Focusing on facts, and looking for causalities throughout their analysis, underpinned their positivist paradigm and reflected their research approach and strategy. Like any other quantitative researchers the team was trying to describe why things are, rather than how they are. They admit that the issue of causality should be discussed to achieve a better understanding of the relations of the variables. Nevertheless, the research team found the evidence to support portions of the three formulated hypotheses. They critically evaluated each one by giving their own suggestions and recommendations to organisations and HR practitioners on how to improve their working practice and establish the inclusiveness of gay and lesbian workers. The presence of modal verbs in the quantitative research once again emphasised the invariably implicit nature of this research often criticised by the qualitative researchers for its high level of assumptions (Bryman and Bell, 2007). Their data analysis and interpretation of their findings are well structured and presented. The ability of the research team to point out the pitfalls of their own project and critically approach their findings is considered to be a great advantage of this research paper. Conclusion The papers provide a solid foundation for further analysis in the field of equality and diversity in organisations with gay and lesbian workers. Governed by own choice for research strategy and approach to answer research questions, they were both affected by the same practical constraint during the research, extremely sensitive nature of sexual orientation and the â€Å"hidden† nature of the gay and lesbian population which led to that fact that probability sampling was impossible as there was no accessible sampling framework for the population from which the sample could be taken. Hence, one cannot confirm that both research projects were successful in generalising their findings beyond their chosen sample. Both research projects lack of robust evidence of the proportion of the UK gay and lesbian population and base their research projects on out of date information. This, in fact, stress the importance of secondary analysis to take place which would allow them to obtain good-quality and up-to-date data, and, as outlined by the quantitative research team, offer the opportunity for research to â€Å"compare an individual’ responses longitudinally† (Day and Shoenrade, 2000:361). It would also provide the opportunity to gain a more descriptive picture of gay and lesbian working lives and facilitate the emergence of a new data interpretation and theoretical ideas as new methods of quantitative data analysis are constantly appearing in the business research field. Unlike the qualitative research team which totally avoids any advice, the quantitative research team succeeded in providing various recommendations for organisations that can help them create a more inclusive environment, â€Å"this process could begin through education top management in the importance of the issue and the consequences of ignoring it† (Day and Shoenrade, 2000:360). In terms of contribution to the field unlike quantitative research the qualitative research project rather confirmed the existing findings and results of previous studies then introduced new information that would benefit and add to the existing knowledge. However, both research projects draw the parallel between UK and USA in terms of work attitude and practice in organisations with gay and lesbian workers pointing at lack of effective leadership and commitment of top management needed to create inclusive working relations in a contemporary business world. Both research teams admitted that further analysis will be required, perhaps, a combination of two research methods, as stated by the quantitative research team, â€Å"to gain a more â€Å"representative† picture of working lives† (Colgan et al. , 2007:606) of gay and lesbian workers.

Latin Prepositions That Take the Ablative Case

The following Latin prepositions may be used with the ablative case. Note: Some of these prepositions may also be used with the accusative case, but the meaning may be slightly different. Some of these prepositions can also be used as adverbs. Where there are 2 forms of the preposition, the form with a consonant is used before words beginning with vowels. ab, a -from coram -in the presence of, before cum -with de -down from, from ex, e -out of, from in -in intus -within palam -openly in the presence of prae -in front of, before pro -before procul -far from simul together with, simultaneously with sine -without sub -under If you have any additions or corrections, please send them to me.