Hr Field Of Human Resource Management - 1668 Words

HR in the 21st century Introduction: As the business world journeyed into the 21st century, the traditional ways of handling many business aspects slowly drifted away. This â€Å"turn-of-the-century† brought a whole new way of how businesses operate and the departments within. These new ways of the business include the prominence of technology, the ongoing fight for diversity in the workplace, and expansion on globalization. Because these changes also effect the employees within the workplace, this has forced the field of human resource management to change rapidly. Methodology: HR Management in the 21st Century: What’s Ahead? Objective: This paper examines the rapid change in Human Resource Management throughout the 21st century. Human†¦show more content†¦Before posting jobs online, HR teams relied on posting and seeking new employees through newspapers and other kinds of written publications. Since technology has evolved, employers are now using outlets such as social media, online job publications, i.e. Indeed.com, Monster.com, etc., and company websites to recruit. Dr. Richard D. Johnson (2011) writer of Transforming HR through Technology, states that: â€Å"Almost all firms now provide universal access to HR services through technology and web-based applications, dramatically changing the practice of human resource management.† (Johnson, 2011). These new technologies have also cut costs and are more efficient to use. A company is able to access possible candidate’s resumes, cover letters, contact information , and more through online publications and social media cites. This in turn saves money on using traditional form of recruiting such as search firms, temp agencies, and advertising methods. Human Resource departments are usually the holders of sensitive employee information at any company. This sensitive information includes social security numbers, health-related information, legal issues, etc. With technology being more prominent in the Human Resources department, this confidential information is readily accessed in computer systems. Because of the easily accessible documents, HR tries to be as safe and protected as possible when handling employee information with password protection databases

Semiotic Analysis of True Detective - 650 Words

Semiotic Analysis of True Detective In 1951, the first television crime drama series, Dragnet significantly influenced our American culture. According to the New Oxford American Dictionary, the term â€Å"dragnet† is a symbol, for, a system of coordinated measures used to apprehend criminals or suspects. Most crime drama series solve a different case each episode. Although, in current pop-culture crime dramas focus on one particular crime, throughout an entire season. Similar, to the show â€Å"Homeland,† the HBO crime drama True Detective adds a twist on the conventional series. The show depicts a subject matter that has affected modern society as a whole. Southern Louisiana police detectives Rust Cohle and Marty Hart, in 2012, are asked to revisit their solving of a ritualistic murder case from 1995. The murder of a former student of the Light of the Way Christian Academy lays the foundation, for detective Cohle’s doubts about the true design of religion. The True Detective storyline portrays the utilization of religion, education, and politics, by men in power who manipulate and control young innocent children. Questioning the validity of religion within a crime drama series is relative to modern society. The conspiracy within the Catholic Church to suppress hundreds of child molestations committed, by Catholic priests is a pertinent sign represented in True Detective . Southern Louisiana is located in the heart of the American Bible belt, where religion is not a choice, but aShow MoreRelatedGender Stereotypes And Gender Codes1754 Words   |  8 Pagesas the femme fatale character. These common roles that women actresses portray often re-emphasize stereotypes and gender codes in today’s American society by providing females with roles that often illustrate females as inferior to males. In this analysis, I will talk about how gender codes are expressed through popular American film by first examining the historical evolution of f emale roles in film, then further exploring femme fatale roles, and lastly by analyzing how actresses of color, specificallyRead MoreWitness by Peter Weir Notes12043 Words   |  49 PagesNOTES ON MODULE B, WITNESS BY PETER WEIR, 1985 Introduction: * Engage in a detailed analysis of a text * Understanding of how the ideas, forms and language of a text interact within the text and may affect those responding to it. * Students will need an understanding of film techniques and of the police drama genre. Important aspects to know: * Visual techniquesenhance understanding of characters * Editing techniquescreate suspense, establish characters, create atmosphere, positionRead MoreOrganisational Theory230255 Words   |  922 Pagestheory focuses attention on the human issues in organization ‘There is nothing so practical as a good theory’ How Roethlisberger developed a ‘practical’ organization theory Column 1: The core contributing social sciences Column 2: The techniques for analysis Column 3: The neo-modernist perspective Column 4: Contributions to business and management Four combinations of science, scientific technique and the neo-modernist approach reach different parts of the organization Level 1: Developing the organization

Similarities Between Anthem And Animal Farm - 877 Words

An open society like America is an imperfect society that holds itself open for improvements. In the books Anthem by Ayn Rand and Animal Farm by George Orwell are about societies that may seem perfect cannot exist. Although both books can’t live in perfect societies, they have dramatically different results on what the citizens do once they figure out their society is corrupted. The citizen, Equality 7-2521, in Anthem leaves the society to work for a better one, while the citizens in Animal Farm stay and do nothing about it. The books are both examples of situations that are not perfect, like having corrupt societies. By having these type of societies both citizens from each book have the same idea, rebellion. Here Equality 7-2521 is†¦show more content†¦Jones the society that comes after it may be more corrupt than it first was. Equality 7-2521 works to find a better society than just staying in one place getting nowhere in life. Once Equality 7-2521 runs away from his own society he ends up in a forest where he soon starts his own life. Here, he searches for ways to have people be equal instead of the government just telling them who and what to be. One of the many ideas that he came upon was the most unformidable word that marks the sign of individualism, I. This one word, one letter gives him the opportunity to have a little bit more freedom and equality from people. Here Equality 7-2521 discovers this word and from now on uses it without regret, â€Å"I am. I think. I will. My hands . . . My spirit . . . My sky . . . My forest . . . This earth of mine . . . What must I say besides? These are the words. This is the answer† (Rand Chapter Eleven). This explains that the words I and my are the answer to a better life and a more ethical and honorable society. While Equality 7-2521 in Anthem works to find an equal society, the animals in Animal Farm do nothing to stop their leader Napoleon in making their society worse. After the first rebellion of Mr. Jones, they soon start their new lives as equal animals. Although, they start out as an equal the society soon changes with the help of their ruler Napoleon, who soon makesShow MoreRelated The Parallels Between Animal Farm and Soviet History Essay example2593 Words   |  11 PagesThe Parallels Between Animal Farm and Soviet History Prior to writing Animal Farm, George Orwell had stated: History consists of a series of swindles, in which the masses are first lured into revolt by the promise of Utopia, and then, when they have done their job, enslaved over again as new masters Together this statement and Soviet History provided a basis for a political allegory which is depicted through Animals and tells of the tribulations which surround certain political idealsRead MoreThe Point Of View Of Communism, Marxism And Totalitarianism1879 Words   |  8 PagesANIMAL FARM BY GEORGE ORWELL Review the novel with the point of view of communism, marxism and totalitarianism. Animal Farm is an allegorical novella by George Orwell and the book reflects events leading up to the Russian Revolution of 1917 and then on into the Stalinist era of the Soviet Union. This novel is about the oppressors and the oppressed and about the different ideologies used by oppressors to manipulate the farm animalsRead MoreHow Do Sociological And Psychological Needs Affect Form, National Identity? Essay2217 Words   |  9 Pagesshare a unique similarity, and this combination of similarities and dissimilarities make them different from other nations. The idea of national identity existed back in the eighteenth century as the term ‘national character’ given by the writers of that time period like Montesquieu and Rousseau. Artists, craftsmen, poets, writers or musicians play a huge role in sketching identity of a nation and similarly the obvious attributes to the national identity can also be flags, anthems, parades, folkRead MoreThe World Of The Vietnam War7446 Words   |  30 Pagesthe war, and the veteran soldier who has seen the reality of war. The film portrays that the American goal was to win the hearts and minds of the Vietnamese people, w hich many of the soldiers felt was difficult since they didn’t know the difference between villagers and their enemy. The soldiers use racial slurs in reference to the villagers, as well as sexual innuendos in regards to the young women. The film depicts the realist struggles of the soldiers who must follow through on orders that they knowRead MoreInfluence of Immigration on the American Culture and Language14362 Words   |  58 Pagesworship God as they pleased. More than a million of Irish emigrated to the America between 1846 and 1851 in order to escape disease in Ireland. During the same period, large number of other Europeans fled political persecution. And in the 1870s another wave of refugees left political turmoil of eastern and southern Europe to seek freedom and a future in America. The largest stream of European immigrants came between 1900 and 1920, that is, before, after, and during World War I. At other times, forRead MoreInternational Management67196 Words   |  269 PagesRole of Culture 89 94 105 4 The Meanings and Dimensions of Culture The World of International Management: The Cultural Roots of Toyota’s Quality Crisis The Nature of Culture Cultural Diversity Values in Culture Value Differences and Similarities across Cultures Values in Transition Hofstede’s Cultural Dimensions Trompenaars’s Cultural Dimensions 106 106 108 109 113 113 114 116 122 Integrating Culture and Management: The GLOBE Project Culture and Management GLOBE’s Cultural Dimensions

How Dopamine Works Human Body - 1956 Words

Tariku Sory Dr. Bowers Chem.130 M/W section How Dopamine works in Human Body Introduction Pleasure, happiness, love, excitation, motivation, pain, anxiety, sad, anger, and all emotional feelings related to human being are linked to the chemicals and hormones that reach to the brain. The human body needs to function properly using the chemicals, hormones and fluids to be found in balance. This state of being balanced is called homeostasis. If one or more of these chemicals fall out of balance from either an increase or a decrease in their levels, this may cause the systems of the body to work less efficiently. Moreover, chemical imbalances can occur for a number of reasons and may affect the body in a variety of ways. There are many internal and external factors that cause chemical imbalance in human body as well human brain. This paper focuses on one of the chemicals secreted by brain, dopamine, and the external organic elements that affect its secretion and function throughout the brain and body. Dopamine Dopamine is one of the organic chemical compounds secreted by the brain. It is mainly produced in areas of the central and peripheral nervous systems, substantial-nigra. It is a neurotransmitter that is mainly used to carry messages between different neurons. It also regulates a variety of functions within body and brain. It helps to regulate blood flow through the arteries, modulates eating habits, contributes to learning and high cognitive functioning, reinforcesShow MoreRelatedHow Dopamine Works Human Body2356 Words   |  10 PagesHow Dopamine works in Human Body 1. Dopamine 2. Drugs 3. Dopamine Deficiency 4. Dopamine Treatments Introduction Pleasure, happiness, love, excitation, motivation, pain, anxiety, sad, anger, and all emotional feelings related to human being are linked to the chemicalsRead MoreCompare and Contrast How Cocaine, Ecstasy, Heroin and Cannabis Work in the Brain1243 Words   |  5 PagesCompare and Contrast how Cocaine, Ecstasy, Heroin and Cannabis Work in the Brain Drugs of abuse, such as cocaine, ecstasy, heroin and cannabis, are of natural or synthetic origin, which can alter the emotional state, perception, body functioning and behaviour of an individual. Drugs are known to work in the brain by activating certain brain circuits via different mechanisms, and stimulate or inhibit different neurons in the pathway. However, due to the effects of each drug being different, aRead MoreEffects Of Drugs On The Central Nervous System1565 Words   |  7 Pages As humans we are all dependent on drugs, whether its drugs that we abuse or drugs that we need psychologically or physiologically. Drugs can either alter a person’s physiological state (coordination, activity level or consciousness), incoming sensations, or mood or emotion (depressants). (IB Chemistry Review, N.D) Drugs are categorized into three different groups: stimulants, depressants and hallucinogens. Stimulants are psychoactive drugsRead MoreThe Cause of Parkinsons Disease Essay1127 Words   |  5 Pagesnuclei due to insufficient secretion of the neurotransmitter dopamine† (Marieb Hoehn, 2013, p. G-17). The cause of Parkinson’s disease is unknown, but many factors play a role in the development of Parkinson’s disease. 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An Introduction to Metallurgy

Question: Describe about An introduction to metallurgy? Answer: The healthier device or machine is measure according to low cost maintains as well as depending on the low cost manufacturing. The barbecue is made by the help of the Stainless steel, because it is low operational cost as well as the economic rate of the material is also low and better respect of the other engineering materials (Cottrell, 1995). The construction of the barbecue is also depends some valuable factors, which are shown in below. Accessibility of the material(should be readily available or easily creatable Cost or Prize of the material used and (Cheaper as possible and also durable at the same time) Stability of the material in the operational situation or environment.(Should be able to bear large amounts of thermal stress) Often ferrite materials are used for the making of barbeque grills. The main The Stainless Steel is used for the making of the Barbecue plate. Also the materials used must be weather resistant and can be used in both extreme heat and extreme cold temperatures. The surface finishes made to the body should also be fine and smooth so that the grills mounted on top should fit perfectly. Also the presence of any unevenness can result in uneven heat distribution and lead to damage of the entire product. The material is water proof and also works on the high temperature. In most cases the temperatures used is about 230-250 degree Fahrenheit about (121 degree Celsius). The highest temperature used is about 1700 degree Fahrenheit which is about 927 degree Celsius. The melting point of the engineering material or Stainless Steel is 1500 degree Celsius, which helps to improve the basic construction of the barbecue model, hence it is a perfect choice for the body. B. The computer chassis or computer case is the main part that holds the parts inside the central processing unit together. Hence it must be lightweight and durable at the same time. Most of the Computer and Laptop manufacturer are used for making the laptop and computer always by the help of the metals or plastic engineering materials.Often SECC (or steel electro galvanized, cold rolled coil)is used for the manufacture of the chassis (Smallman and Bishop, 1999). Plastic engineering materials are in very light weighted and it is also very easy to make a form or shape cy the help of moulding procedure. The thickness of the plastic determines the durability and also the price of the case. The metals are used for some basic purposes because the cost of the metals are very high as well as weight respect of the other engineering materials for making the computer and laptop. Due to the issues of cost and effectiveness only four materials can be considered: Aluminium- Aluminium is durable. Another important property of aluminium is that it is greatly ductile; hence it is quite easily beaten into sheets. It is highly corrosion resistant. Thermoplastic polymer- The dictionary defines thermoplastic polymer as soft solid that changes its form irreversibly when exposed to 200 Celsius and through a suitable (Kerrod, 2002). Due to this property they can be easily set into moulds to form their required shape. Mild steel- It also has durability and malleability and is also cheaper than that of aluminium. But still aluminium wins the race because aluminium is more malleable than steel. Another disadvantage is that is often quite heavy due to its high density. Titanium-This is the most expensive one of the lot as it is the one that provides the maximum amount of strength and durability and it is also difficult to beat it into sheets because of its huge strength.It also has the highest corrosion resistance and not easily prone to cracks. Often the cases made with titanium are used in military equipment. The best engineering material for making the computer and laptop is the alloy of the Acrylonitrile Butadiene Styrene or ABS plastic and Polycarbonate or PC (Fiell and Fiell, 2009). The mixture of the ABS and PC is the best materials for the computer and laptopbecause the cost of construction is quite low. The combination of the two gives a more lightweight solution on the construction because the addition of the polycarbonate to ABS reduces its density. Another important point to mention is that the strength required to break ABS is around 30-65 Mpa while that of ABS+PC is 60Mpa. This tells us that ABS has more of a fluctuating value of the yielding stress (the greater the thickness the greater is the yielding strength). For this section, we selecting the above case study or Task 1 (a). In this section the barbecue is consist by the help of the Stainless Steel respect of the other engineering materials. For a material to be used as an engineering material, it must have a few qualities like cheap construction, strength and durability in terms of heat produced (i.e. it should be able to withstand large changes in temperature and also not get deformed under the process) and also on the maintenance costs incurred on the grill itself (Dasgupta, 2012). In other words, the installation cost of the used material is low respect of the others engineering materials. The construction of the barbecue by the help of engineering material is also depending on some common factors, which are already discussed in above section of the paper. The selecting engineering material or Stainless Steel is mouldedand also form a barbecue, which is used in outside of the home for that reason the selecting material is so useful because Stainless Steel is water proof (and also weather proof). The Stainless Steel is also helpful for the above mention case study because the constructed barbecue is operated or burns by the help of the LPG or Liquefied Petroleum Gas and Charcoal. The burning temperature of the charcoal is in range of 7000 degree Celsius or 900 degree Celsius and flaming temperature of LPG or Liquefied Petroleum Gas is depends on the compressed gas (Kerrod, 2002). The flaming temperature of the LPG or Liquefied Petroleum Gas is different in range according to the nature of the compressed gas such as, normal house hold LPG or Liquefied Petroleum Gas (mixture of Propane Butane) is 1970 degree Celsius when its burning with air or normal condition. And respect of the combustion of the charcoal and LPG or Liquefied Petroleum Gas, the melting point of selecting engineering material or Stainless Steel is 1500 degree Celsius, which is quite good respect of Mild Steel and Aluminium. TheSelecting engineering material or Stainless Steel is containing low carbon and large amount of chromium contents. For that reason the burning of fuel (LPG or Liquefied Petroleum Gas) or charcoal are having low capitulate strength and also having great amount of elongation authorizes, which is successfully outward appearance of composite size or shape. In the barbecue cooking gates or grids are for grill the food or meat, which is in the surface of the barbecue (Moniz, 1994). It is also this part that is directly in contact with the flames at all times and hence the most common partto get damaged quite easily.Also the thickness of the grills is also under debate. The thicker they are the lesser amount of heat iscoming in contact with the meat that is cooked. Hence in other words, thinner grills mean better cooked food and thicker ones means that the food is lesser cooked. The materials used for the cooking surface or more specifically the grills have to be- (a)Strong and resilient to thermal stresses, (b) It should be able to transfer heat quickly and efficiently, (c) It should be durable, (d) It should keep the food from sticking to each other. Hence the materials considered for this process are the cast iron, porcelain coated cast iron, stainless steel, and porcelain coated steel. Now we often prefer cast iron grills because they are resistant to high temperatures. Hence they can cook the food quite quickly and easily. But it not free from all troubles. The cast iron ones tend to emit a lot of heat. They should be taken care of by proper oiling and greasing. But due to the high amount of heat emittedby them, they can burn off all the grease applied (Smallman and Bishop, 1999). Hence they need to be checked regularly for rusting by keeping them clean. A good quality cast iron grills can last for years if taken care of properly. Next we come to porcelain cast iron grills. They are quite cheap and come with various qualities. These ones are good but they come with their share of troubles. The cheap ones often tend to chip away due to wear and tear and expose the metal beneath. Now due to the constant presence of moisture and tend to rust the metals beneath the coating. Also once you use the porcelain ones we have to keep in mind of not scrubbing and hence removing the upper cover of porcelain and exposing the metal beneath.Now we come to stainless steel grates. Their advantage is in the fact they are quite easy to maintain and clean. They can never be rusted and are completely immune to any sort of corrosion.They are also cheaper than cast iron grills. The grill marks on the food come out to be very good. They are very durable and can last decades with proper care. But all is not roses with Stainless steel grills.They have a disadvantage of not being able to have the same amount of heat retentive capacities of cast iron (cast iron can hold more amount of heat). They can develop black colour due to the oxidation of the alloy at the contact with the food being cooked.Lastly we come to the porcelain coated stainless steel ones (Dor and Others, 2010). They also like their steel counterparts do not to rust. But due to the porcelain coating care has to be taken while cleaning them. No excess force should with hard substances as it can scrape of the porcelain coating.By the help of the cooking gates or grids the foods are easily grill but if we use iron gates or iron grids respect of Stainless Steel grids or gates then food are making with healthy because when iron grids or iron gates are used in barbecue then foods are containing more acidity respect of the Stainless Steel gates or grids. Hence taking into consideration all the pros and cons about the materials available we can safely take Stainless steel to be the best of the lot. References Cottrell, A. (1995).An introduction to metallurgy. London: Institute of Materials. Dasgupta, R. (2012). Aluminium Alloy-Based Metal Matrix Composites: A Potential Material for Wear Resistant Applications.ISRN Metallurgy, 2012, pp.1-14. Fiell, C. and Fiell, P. (2009).Plastic dreams. [London]: Fiell Pub. Kamdem, Y., Bouvard, D., Doremus, P., Imbault, D. and Dor, F. (2010).Production of bi-material tubular structures by powder metallurgy.Powder Metallurgy, 53(4), pp.274-277. Kerrod, R. (2002).Materials. Oxford: Oxford University Press. Moniz, B. (1994).Metallurgy. Homewood, Ill.: American Technical Publishers. Smallman, R. and Bishop, R. (1999).Modern physical metallurgy and materials engineering. Oxford: Butterworth Heinemann. Smallman, R., Ngan, A. and Smallman, R. (2007).Physical metallurgy and advanced materials. Amsterdam: Butterworth Heinemann.

Thomas Paine The History of an American Visionary free essay sample

The paper discusses the life and times of revolutionary writer, Thomas Paine. This paper describes the life of Thomas Paine, renowned early American figure. The author looks at his most famous writing, Common Sense- the pamphlet that inspired many to seek independence from the British monarchy, and join the American Revolution. Thomas Paine was admired by many, and seen as one of the causes of the colonies formal declaration for independence. He had support from other national leaders, including Ben Franklin, George Washington, and others. His Common Sense pamphlet was read and argued throughout the colonies. Its contents would always be brought up in taverns, reading clubs, parlors, and street corners. He was uncaring about other peoples views of him, and wrote what he thought. At the time He was one of the few men to do so. He wrote in a voice that was understandable to the common people, and placed before them the facts. We will write a custom essay sample on Thomas Paine: The History of an American Visionary or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page His works are still being read and studied today, because of the importance of his outspoken views about government and life.

Literature Review of Pain Management in Dementia. Essay Example

Literature Review of Pain Management in Dementia. Paper LITERATURE REVIEW. Abstract Within the dementia care environment, it is my experience that it is often unclear to nursing staff as to appropriate assessment and management of pain for clients in the palliative stage of their illness. Although nurses have their experience to guide their practice, as the health professional most involved with the client at the end of life, there is a need for review of current assessment tools and management strategies to ensure the care given is evidence based and best practice. Aim The aim of this review is to examine what is the most appropriate method of pain assessment and management when working with clients with cognitive impairment. Methods Searches were made of several databases Cinahl Embase Medline BNI Psych For articles published between 1990 and 2006 using the keywords, pain assessment, pain management, elderly, dementia and palliative care. Findings Most evidence in relation to this area of practice is anecdotal demonstrating a need for further research. Evidence presented in this review shows encouraging results in regard to the development of assessment tools and that there are clear standards of process for management of pain at the end of life. The results also show that nurses are concerned and are making attempts to be proactive in this area of care despite many barriers. Conclusion Good pain control requires both sensitivity to the clients needs on every level and the competence to meet them. Assessment and management of pain for individuals with a dementia is still very hit and miss, with evidence of both very good and very poor practice being demonstrated. We will write a custom essay sample on Literature Review of Pain Management in Dementia. specifically for you for only $16.38 $13.9/page Order now We will write a custom essay sample on Literature Review of Pain Management in Dementia. specifically for you FOR ONLY $16.38 $13.9/page Hire Writer We will write a custom essay sample on Literature Review of Pain Management in Dementia. specifically for you FOR ONLY $16.38 $13.9/page Hire Writer Nurse education is still an unmet need within this area of practice. And that overall clients are experiencing unnecessary pain on a regular basis which could have been prevented. Introduction Pain Pain can be a common experience for many older adults and has negative effects on their health, functioning and general well being Pain presents an enormous challenge for most nurses within their daily working lives. This is due to the individual nature of pain; a client’s experience of pain is affected by their life experience compounded with the procedure or illness. Macaffrey identified the individual nature of pain when he said, â€Å"Pain is what the experiencing person says it is and exists whenever he says it does†(1979, Cited in Epps 2001). Pain can be present in the older adult for many reasons. Chronic pain conditions may include arthritis, gout and peripheral vascular disease, acute conditions such as cancer; cardio vascular disease and surgery are also prevalent causes of pain. An elderly client may present with more than one type of pain in different locations with varying causes making the nurses job all the more challenging. Dementia. The word dementia comes from Latin and translates as â€Å"out of ones mind†(Epps 2001). Although this gives a broad definition of the symptoms, dementia is actually a disease caused by permanent brain changes and loss of neurons. These changes affect the client in several ways. The impairment of cortical functions affects â€Å"memory, orientation, comprehension, calculation, learning capacity, language and judgement†(WHO 1993). Various dementias exist the most common being Alzheimer’s, which accounts for 65% of UK diagnosis’s (Stevens et al 2001). There are other dementias such as vascular, lewy body and picks. All of the dementias impair basic functioning and the ability to communicate also the client’s ability to interpret the feelings of pain and recall them to communicate to the nurse. This impairment potentially results with individuals unable to express pain and report it appropriately. This in turn may result in inadequate assessment and management as has been shown in studies (Bernabei Et al; 1998. Horgas Tsai; 1998). One study reported that 60% of nursing home residents with a physical diagnosis known to cause pain had not received any pain relief in the previous month (Feldt et al 1998). The American geriatric society (1998) believe that clients with dementia are at high risk for unidentified and under treated pain. As with all older adults, clients with dementia present with chronic conditions such as arthritis and acute pain experienced in the aging and the end of life process. Moss (2002) gives evidence that most elderly clients who move into long-term care will die in an institution either a nursing home or a hospital many of whom will have dementia. She states that 91% have a strong co morbid condition likely to cause pain. â€Å"The control of pain is the key to all other care†(Raiman 1998). This is especially true within old age psychiatry as if a client is in pain it may be impossible to recognise a pure diagnosis of agitation or depression and intervene accordingly when there is the possibility that these symptoms may be reactive due to inadequate pain relief. The key to therapeutic success is how well are the symptoms being relieved. Untreated pain in the client with dementia can delay healing, disturb sleep and daily activity, reduce quality of life and prolong hospitalisation (Horgas 2003). Appropriate assessment and management of pain should be paramount to nurses working in the elderly care sector. Search methods A search of the Cinahl, Medline, Embase, BNI, psycINFO databases were made using the following key words, pain assessment, pain management, elderly, dementia and palliative care. The reference lists of identified papers were also searched for relevant articles. The use of many databases was deemed necessary due to the specialism the enquiry relates to as research in dementia is still relatively new. Inclusion criteria are as follows: Articles must relate to palliative care and/or pain relief in the elderly that have reference to impaired cognition within the main body of the text and not just articles solely referencing dementia in order to gain a wider breath of material. Articles must not be specific to a particular medical condition such as breast cancer as the recommendations will be specific to condition and not transferable to an elderly psychiatric unit. Articles must have been published between 1990 and 2006. The review was not limited to a study design type as most papers identified are qualitative and give anecdotal evidence. Anecdotal evidence may not be seen as the most reliable (Parahoo 1997) but there are reasons why within this area of research most results fit into this category. Atkinson et al (1999) suggest that palliative care and adequate pain relief does not attract much funding from the pharmaceutical companies therefore unattractive to researchers, also as suggested by Ray et al (1998) ethical committee accreditation may be difficult to obtain particularly with issues as consent and suitability to participate in controlled trials as they may last longer than the client remains alive giving inaccurate results. Another reason maybe that the cognitively impaired are often excluded from research studies, as they are unable to give adequate feedback to fulfil the researchers needs for the inclusion of data. The search returned nine articles that fully met the inclusion criteria these have been included in the review. Findings The findings will be divided into two sections pain assessment and pain management. All papers bar one fell in to the naturalistic paradigm of research in that the researchers explored the nurse’s feelings and thoughts during semi- structured interviews about assessment and management of pain and recorded their findings in a descriptive manner. The paper set in the positivist paradigm was a correlation design that examined the relationship between two variables in this instance pain and agitation and generated results of a quantative nature. In all papers the sample was purposive in that clients were selected because they experience the phenomena under investigation in this instance, elderly institutionalised clients. All studies identified within the papers had been ethically approved. Pain assessment. A barrier to effective pain management is a failure to assess pain. Pain assessment is invaluable; it sets a base line against which the intervention can be compared. There are several methods of pain assessment identified within the literature. This review explores the findings drawn from the research. This article will draw reference to self-report scales as they still hold their place within pain assessment as well as those methods that concentrate on adults that are unable to communicate their pain. Pain can be assessed by means of self reporting and research by Davie et al (2004), Kovach et al (2000), Panke (2003) and Zwackhalen et al (2006) identify this as the â€Å"gold standard† in pain assessment. There are several self-report scales available to assess pain in the elderly. Most self report tools focus on pain intensity these include The visual analogue scale (VAS) which asks a client to select a number between 1 and 10 and the verbal rating scale (VRS) where you ask the client to verbalise their pain on a scale between no pain and worst pain possible. Molony (2005) found the VRS the most popular scale to use when questioning nursing staff; the main drawback of the tool that she identified was that clients learnt to anticipate the nurse’s questions. nd therefore the test may lose objectivity. There is some conflict within the literature in that Zwackhalen believes that these scales hold little benefit within dementia following her research as she identifies that these scales requires the capacity to understand the task and also the ability to communicate pain therefore generating inaccurate generated scores this view is supported by Hayes (1995) and Ferrell (1995) where as Davies generates evidence that 80% of clients in midstage dementia were able to use these scales effectively. It is because of these contrasts that it would be beneficial to explore behavioural tools and other methods as a means of supporting self-report tools in order to gain comprehensive assessment. Panke (2003) believes that non-verbal cues are their own means of self-report and should be regarded as such by patients that can’t communicate. The most commonly referenced tool within the literature is The Checklist of Nonverbal Pain Indicators (CNPI) by Feldt (2000), research on this tool by Horgas (2003) and Davie (2004) have deemed this to be an effective tool to use within dementia care. There are other tools identified within the literature but due to the frequency that it was referenced and studies that included it within their framework the critique of literature in regard to this tool seemed most relevant. The tool is designed as an observational tool for use by nursing staff. It was designed to assess postoperative clients. It asks nurses to observe for certain behaviours and score a point of one if they are present. There is no clear definition attached to this tool as to how the score correlates to pain intensity, the papers that reviewed this tool recommended that it be used in conjunction with a self reporting tool but also if there were any behavioural indicators of pain scored present further investigation and treatment should be actioned. Both of these researchers conducted their studies in community settings which could have biased the results as the tool is designed for acute pain not chronic pain and you can make the assumption that clients were not postoperative also the samples used were small there by not possibly encompassing the full range of cognition and varying physical illness. Also this tool is subjective to the nurse’s viewpoint hence the researchers results are biased towards the nurse’s viewpoint and not the client’s experience. Epps (2001) believe that nurses often under report pain of clients with dementia. It is assumed as the researchers indicated the use of another tool that this a limitation of this tool that it cannot be used as a stand-alone assessment. It may be worthwhile to repeat these studies in an impatient dementia environment to test the validity of the results. Behavioural indicators of pain as outlined by Evans (2002) in addition to those in Feldts tool are aggression, loss of appetite and withdrawal Kovach (2003) further expands on this by advising staff to look for changes in mobility and respiration. Evans and Kovachs work highlights that Feldt tool is not comprehensive, as it does not highlight what people are trying to communicate with their ongoing behaviours and that it can only be used at that snapshot in time, this factor is something that was not identified by the authors. Also how often this tool should be utilised is not explored would it be beneficial to use it daily or just when the nursing staff notice change. Panke (2003) believes you should consider all cue verbal and non-verbal and that continual reassessment of these cues is vital. Molony (2005) asked nursing staff to document the frequency of assessment. The highest frequency was found to be on admission, as determined by medical condition and those patients receiving â€Å"narcotics†. This concurred with 95% of participants. This study was comprehensive as it had 160 participants covering a cross section of job roles within the nursing sphere. Panke (2003) points out that behavioural cures are not always reliable, as moaning and grimacing are symptoms that occur with delirium as a common factor in the client in the end stage of life and that this may require assessment for both causes. This is supported by Ferrell (1995). Cohen Mansfield et al also concluded through their study that assessment is made further difficult as the client group expressed discomfit Constipation, emotional distress, cold and hunger in the same ways such as calling out and increased agitation. Cohen Mansfield study was extremely limited as it was restricted to one nursing home with a very small sample all of which had a moderate dementia and had been placed there for over two years. Most literature reviewed did not account for other possible causes of pain like symptoms. This is both positive and negative as the papers remain focused on the topic of pain assessment but the detraction is that it does not encourage the reader to view the client’s situation holistically. Only Kovach (1999) within my included literature highlighted the importance of the nurse client relationship in interpreting none verbal cues and that familiarity with the client develops the nurse’s intuition of changes in behaviour. Kovach cited another study by Parke (1998) within her research that advocated that assessment methods require nurses to know their patient intimately in order to recognise behaviours which signal presence of pain. The ability to communicate and relate to your clients is important as often the nurse is the main caregiver and clients need to feel that we will respond to them and make them feel safe at a time when the situation is alien and fearful. It would be beneficial to further explore the importance of the skills needed by the nurse in this area of care. All papers identified a lack of nurse knowledge and competence as a barrier in the assessment of pain and many suggested the need for action to improve this also nurse attitude was cited. This was mainly centred on nurse’s unfamiliarity with the assessment tools. This is identified by Davie (2004). ) Who when gaining feedback on the research conducted, the nursing staff felt that tools could be too time consuming and difficult to interpret. 99% of respondents who participated in Molony’s study (2003) felt that education was something that should be ongoing and be presented in the form of workshops, seminars and peer teaching by the bedside in order to update practice. The main barrier identified of staff not receiving appropriate training was the need for more nurses to staff units so others could attend training. This is in conflict with the NMC code of conduct that states it is the nurses own responsibility to update her practice and therefore ward staffing should not be an issue although many trusts have policies to support learning and development. Evans (2002) reviewed the literature and other research within her study, she found that educational initiatives that address clinical skills in pain and symptom management were required. Moss (2002) in a study of four hundred nursing homes in the united states that 29% of staff did not feel confident to adequately assess pain although 55% agreed pain was a problem for clients with dementia. This would leave 45% to believe that there is no problems with this issue hence highlighting further the need for nurse education, as almost half the staff in four hundred nursing homes did not recognise the problem. This figure is astounding. Kovach (1999) as part of her study evaluated the education programme currently being piloted to address the discomfit needs of clients with moderate to severe dementia. She found that staff using the protocol for assessment for which they had been trained resulted in increased awareness of resident’s discomfit and improved assessments. The findings of this study could have been strengthened by the use of a control group of nurses already competent in the assessments to provide a conclusive baseline that nurses should attain and a larger sample size. Also the recognition of variables such as physical diagnosis would have been beneficial to assess if they impacted on the findings. Glaring omissions in all research critiqued was that of involving family in the decision making process and also the gaining of information from families in order to ascertain normal behaviours and responses to pain, this could be for many reasons. Is this due to the nurse being perceived as the expert or are families at this distressing time not considered to be able to give eliable information. This requires further exploration as to the benefit of relatives input in a clients care. Also omitted was the use of do not escalate or do not resuscitate order and what they men to the client receiving palliative care and in the age of the expert patient many making advance directives and how this dictates the care we can give as nurses, do we have the right to override these statements if we deem it to be in the clients clinical best interests and where does this feature in the assessment process. This requires further research. The use of documentation and the value of the nurse-to-nurse handover is not explored within the literature as a means to aid assessment both of which are commonplace in a nurses daily routine, which leads me to believe that both these activities happened but were not documented by the researchers. Pain management Horgas and Tsai (1998) investigated prescription administration of analgesic medication of clients with cognitive impairment. The research question they posed was that cognitively impaired nursing home residents might not be prescribed adequate analgesia. The researchers concluded that clients with dementia were being prescribed and administered significantly less analgesic medication both in number and in dosage than clients without cognitive impairment it was also reported that clients who were more disorientated or withdrawn were prescribed significantly less analgesia. This correlation study drew from a large sample of 339 residents from four homes showing the study to be both reliable and valid. Moss’s study provides anecdotal evidence to support that nursing staff felt that pain in client with dementia is as aggressively treated as pain in other clients whilst Panke (2003) identified that physician were loathe to prescribe for any thing that wasn’t cancer. These conflicts may be explained as the United States and the United Kingdom have different protocols for appropriate treatment disseminated from government and allied agencies and moss’s study was in the UK and the others in the U. S. Kovach (2000) reports that the treatment strategies used by nurses are poorly understood. The outcome of her interviews with nursing staff was that nurses often felt that psychotropic drugs were being inappropriately used to treat the behavioural symptoms of pain and that analgesics commonly underused. Both the observers and the workers have identified this as a problem yet it still continues to happen as Swakhalen’s 2006 study shows. It is because of this that the need to review best management is vital. Recent research by the Joseph Rowntree foundation indicates that these problems could be overcome by the use of the NICE guidelines for analgesia (2004) these recommend regular administration and treatment adjusted from one step to the next according to increasing or decreasing pain severity, history of analgesic response and any side effects. This approach also calls into question the use of as required medication and its prevalence. The literature concurs that regular scheduled pain relief is most effective in managing symptoms. The foundation also advocates the use of non-pharmacological intervention for Pain management. The literature mainly identifies methods of drug administration and drug type most appropriate to the client group. Management of pain is one of the most important goals when caring for clients at the end of life. Horgas (2003) identified the goal of pain management is to maximise function and improve quality of life. Kovach (2000) found that nursing staff prioritised comfort over issues such as side effects or toxicity. Although some staff expressed concerns about sedation and falling in mobile clients but this becomes less of an issue with clients in the end stage of life, as they are normally bed bound. The issue of constipation was also raised by Panke (2003) as a common side effect of analgesics that was likely to cause pain and recommended that clients should be prescribed laxatives as a matter of course. Horgas (2003) identified the considerations for administering analgesics in the elderly. It is noted that aging has an affect on the effect of the drug on the client and also the concentration of the active drug is affected. Elderly clients are at higher risk of side effects due to decline in metabolism and elimination. Gradual titration is recommended to over come this. A Diamorphine as opposed to morphine is commonly the drug of choice for subcutaneous administration due to greater solubility. Kovach (2000) found that nurses felt that narcotics were underused but appreciated the value of them to maintain comfort and dignity. She supports this with several anecdotal accounts from staff. Nurses only commonly used morphine for severe pain and to promote comfort during dying. The literature concurs that longer acting opioid medication such as Fentanyl should not be rescribed for the dying client because of the slow onset of pain control and it being difficult to titrate quickly. Kovach (2000) identified that fentanyl was more commonly used than morphine in the relief of clients pain. It is recommended that fentanyl is administered via a transdermal patch as this can overcome many reasons for non-compliance in the demented client such as resistiveness; lack of understanding or forgetting to take medica tion also it is considered helpful for those clients that are unable to swallow oral preparations. If fentanyl has previously been administered and deemed not effective this will need to be supplemented with diamorphine via a syringe driver as recommended by many researchers within the review. Only half of the participants in Kovach’s study were able to identify appropriate dose escalation, most identified that there was a need to increase dosage but unable to identify a systematic process within which to work. Does this mean that clients are only getting the appropriate treatment 50% of the time due to a lack of staff education? Not all pain is opiate sensitive such as pain on movement that’s breakthrough. This is more likely to be effectively managed by the use of a non-steroidal anti-inflammatory drug (NSAID). This group can cause gastric irritation and the use of a gastric protective drug is advised. Panke (2003) identified that nurse were proactive in advocating supplementary pain relief of this nature. The literature cited the transcutaneous electric nerve stimulation (TENS) as an appropriate method of pain relief, but no evidence is available to state how effective this method actually is. All literature that cites the TENS also states it should not be used for first line pain relief. Conventional medication may not always be affective and nurses should have an awareness of complementary therapies and relaxation. Nurses in Kovachs study were not questioned about non-pharmacological measure but common themes drawn from the interviews were that massage, one to one intervention, repositioning and music therapy were thought to be effective. None of the literature mentions the involvement of other agencies in promoting comfort such as the tissue viability team or the music therapists, the onus is put on the nurse to provide these things which may be outside her sphere of competence also lacking within the research is the use of equipment such as airflow mattresses and relaxing fragrance atomisers or fans to assist with those that can’t maintain body temperature. Although the literature is comprehensive on chemical pain relief, it is often not holistic as to assess the client’s environment. There are articles on alternatives to medication that were generated during the literature search such as one by Pearce (2004) advocating that the approach be high touch and include things such as hand activity and soothing touch, but sadly articles such as this that make complete sense to the reader are not evidence based and therefore inadmissible to be critiqued in this review. Actual research in this area is desperately needed to guide nurse’s practice to create a holistic approach. It should be noted that techniques such as relaxation require higher levels of functioning and may only be successful if the client can participate. Restlessness and delirium are common close to death. This may be due to opioid toxicity, a recommendation of haloperidol is recommended for drug toxicity. Panke (2003) is the only author to identify this. I have commonly seen it myself in practice that a low dose antipsycotic is very effective. Haloperidol also can assist with nausea and vomiting. The ethical issue as to whether analgesia will hasten death is identified within the literature as a concern for nurses and relatives. With nurses interviewed by moss (2002) asking what is permissible? The American nursing association in 1991 stated â€Å"nurses should not hesitate to use full and effective doses of pain medication for the proper management of pain in the dying patient. The increasing titration of pain medication to achieve adequate symptom control, even at the expense of life is ethically justified†. None of the literature asks what is the patient’s quality of life and if we are, why are we attempting to extend this, also could unrelieved pain hasten death due to the stress level it places on the client. These are all area that needs further research. No mention is made in the research as to the impact of hospital policy on the treatment of these clients and whether there are set standards dictated from trust level. Conclusion There is a clear need to address this issue as the proportion of people with dementia is likely to increase along with the increasing proportion of elderly persons in the population as due to more effective health care people are living longer. Although pain assessment and treatment is complicated with the client with dementia. Many clients pain can be relieved by the nurse’s efforts to understand each individual and their unique way of communicating pain. Effective assessment and management requires â€Å" listening to and believing in reports of pain as well as the knowledge and skill in detecting pain among those unable to convey its presence verbally† (Horgas Tsai 1998). All management should be individualised and tailored to the client. The most important step in improving pain control in clients with dementia as identified by this review is for nurses to be proactive in the assessment of pain. Pain assessment is the important first step in effective pain management. This review has identified that individuals with dementia can answer simple questions about the presence of pain and pain assessment in older adults should always start with self-reported pain. Nurses need to be aware of all possible sources of information when assessing clients with dementia and other conditions that impair communication and take into account non verbal behavioural cues such aggressiveness and increased vocalisation. This review also identified the need for increased frequency of assessment and that it is performed at a relevant time as clients may not be able to recall past experience of pain due to their impairment. Pain is a significant problem for older adults and has the potential to negatively impact on all areas of their lives. Pain management that includes both pharmacological and non-pharmacological measures was considered to be effective. The need for appropriate nurse education has been highlighted throughout the review and that most nurses felt that they did not have sufficient knowledge to care for these clients, this is something that needs urgent address in order to provide a good quality of service. With the advancement of technology and medication, pain is not an experience that should be commonplace for any individual receiving medical care whether it is in hospital or in the community and with the effective use of strategies we as nurses can really improve the quality of our client’s lives. Areas highlighted for further research from this review are nurse education and ethical issues regarding pain relief and non-pharmacological treatments. This review found many omissions in the research but this could be due to the fact that certain activities are commonplace and the expectation is on the reader to assume these activities happen.