Consultative selling Essay

For the last five years, I have held the fulltime sales position of Client Partner with a performance improvement origination. In this roll, I sell individual, team, and organizational solutions to mainly Fortune 500 and Fortune 100 organizations. My position as a Client Partner is a consultative sales job. I partner with clients helping them achieve better results. Consultative sales are quite different and very unique, from traditional or transactional sales. In the Consultative sales it is not about convincing the potential client that you have the product they need, or how you have the best price. Consultative sales are about results based conversations. Key concepts to Consultative selling are relationship building, effective listening, and closing the sale. Within the role of consultative selling, one must have the ability to build relationships, demonstrate effective listening, and then close the sale in order to be successful. I have been in this role for nearly five years. The last two years have been spent in the field, meeting face to face with clients and potential clients weekly. The face to face meeting is essential to the consultative sales role, as this is where the three key concepts are demonstrated. Prior to moving to the field, I had very limited experience in live consultative selling. My first year was really trial by error. I am confident in this first year; I lost many sells and even client relationships due to my lack of skills. However, I can recall one of the most satisfying consultative selling face to face client meetings where using all three key concepts, resulted in a large client engagement. The client was Orica they are the largest manufactures and full service explosive organization specializing in the mining and engineering fields. I received a call from someone in Orica, the individual was technical lead, and she was looking for time management training. She did not want to spend much time with me on the phone, nor did she want me to come out and meet with her face to face, she simply wanting the course outline and pricing to be sent over to her. This is the non-optimal consultative selling situation. However, two weeks later, I heard back from her, stating she wanted to go forward with the time management training program. Again during this conversation, she limited how much information she wanted to provide. All she communicated was this was for an engineering group of 25 employees who had challenges around working very long hours. In addition they were challenged with too many emails in the day. Although any sale is very much appreciated, this sales situation is not optimal. With consultative sales we are looking to solve business problems. If we do not fully understand the problem (diagnose) we cannot solve it (prescribe). Most often when we land sales as these, the clients do not reach the desired results, resulting in no future sales. During this work-session, I went out and sat in on the time management training. I joined in one of the tables. I began to participate to principals outlined in this session. This allowed me to hear the group responses to the questions, hearing what the actual challenges this particular group faces. Throughout the program, I checked in with my contact and would ask however thing was going. Unfortunately, she would not have much to say. Shortly after the work session ended I received a call from my consultant who delivered the program. He communicated to me that within the group today the Vice President of Learning and Development for Orica had been a participant. At the end of the session, the Vice President asks our delivery consultant many questions about the particular solution, and its capabilities. Due to the lack of communication from my original contact, I was never aware this executive would be attending! It was soon uncovered that there was building interest. The fact that there could be additional opportunity was great news! Two days later I called on the Vice President of Learning and Development for Orica, as soon as the conversation began, my intent was building a relationship. I called the Vice President asking for an appointment, with the intent of hearing his feedback on the work session along with giving a high level view of who FranklinCovey is and potentially have a deeper dive in conversation if he felt it was in alignment with Orica. I did not lead the conversation with what else I could offer Orica, but really wanting to hear his thoughts. He immediately agreed to appointment. The next day I drove out to his office. In the key concept of relationship building, one of the ways to do this is with a face to face appointment. In addition one must lead with questions that are personal, this always help to build rapport and allows me to really begin to understand the client. The second part to the questioning is to demonstrate effective listening. As soon as I arrived for the appointment, almost immediately as we shook hands I notice he had a unique metal bracelet on with multiple engravements. I asked him about the bracelet, and this began a fifteen minute conversation, he explained that he served two terms in Afghanistan with the United States Navy as an E. O. D. (Explosive Ordinance Device). The names inscribed on the bracelet are those friends who were killed. I spend the next hour really trying to understand him personally. I asked question, after question, the conversation flowed so naturally. The conversation evolved to where I uncovered his biggest challenge in moving to the civilian world which is finding purpose. There I had begun to build his trust. The questioning and effective listening have paid off. Through effective listening I navigated the conversations from personal question, to business framed questions. I really began to question the current organizational strategies, and structure, and goals. When I demonstrated effective listening, the questions naturally flow. The conversation did not sound interrogative, but genuine. Through this conversation, I uncovered so much more than just organizational time management needs. It allowed me to uncover the fact they are looking for a global time management solution, they needed a project management solution, an entry level managers training program, and even a solution to help them execute on their goals. Almost always when I schedule a face to face client meeting, it is always scheduled for an hour. This client appointment had gone nearly two hours and forty five minutes. The meeting thus far was spent building the relationship though effective listening. During the late portion of the conversation I looked down at my page full of notes, it is time for me to make my recommendation. I made a series of recommendations. My first recommendation is around the time management needs, then project management, then I tie in all the global and manager needs. I held off on the execution needs for the time. At the final closure of the meeting, I make the promise to send him what we talked about and the associated pricing. He shakes my hand and communicates he has already made his decision, and he would like to start with the first phase immediately. Because I was able to build the relationship, demonstrate effective listening, I did not have to sell him on the data. He didn’t need case studies, or industry comparisons, or how our solutions match to their competencies. He trusted me. He believed I did have the solution. He was ready to move. Had I not had the meeting with him, and was limited to the first contact within Orica; I would have never had this account produce what it has. When I initiated my face to face meeting with the potential client, I recognized almost immediately how well he responded to my personal questions. Walking into the meeting I knew what needed to be achieved, I needed to be closing a sale. I was aware of the key concepts behind a consultative sales role, but was unsure how I would achieve this. Opening the conversation with a personal question relating to his bracelet he was wearing, immediately set the tone for the remainder of the time together. It really was exciting to have the conversation flow so naturally. One question led to the next and the next after that. It was an enjoyable conversation that allowed me to learn so much about the client personally and his background with the war. I also enjoyed hearing more about his transitions and its struggles moving from military to civilian organizations. During this time of the conversation, I was not concerned about talking about the solutions I could offer, or how I would close the sale, I was simply engaged in what the client had to say. With this appointment I was able to experience first hand why being face to face is vastly more valuable than a virtual meeting. Had I not been meeting with this client face to face, I would have not seen his bracelet, and chances are never had the opportunity to ask him about his background. I also realized that once I was in the midst of this personal conversation that was so very interesting, I was able to demonstrate effective listening. Because of the nature of the conversation, I was easily able to listen effectively. As I ask one question, how he responded would result in my next question. I was able to be very specific in my questions, really trying to understand the personal challenges he had face along with the new challenges as a result of becoming a civilian. As I reflect on the results of listening effectively, I realize how I was able to navigate the conversation to uncover many challenges within the organization. At the end of the client meeting, I looked down at the notes I had taken. I was genuinely impressed by how specific and deep my notes were. I could now make very specific recommendations. This really was an experience I had wanted for very long. The more specific and clearer understandings of what the client’s needs are the clearer and more specific of a recommendation I can make. As I talked through the solutions and then followed it up with the recommendation on next steps, the client was extremely engaged. He was even surprisingly enthusiastic, that I was able to provide solutions to the challenges to which he had been tasked. What came as an even bigger surprise, he agreed to my recommendations on the spot! He wanted to talk though the details of starting the implementation. This was the first client appointment I had experience where I had demonstrated building the relationship, through effective listening resulting in a client agreeing immediately to the recommendation. As a result I know have a deep pervasive relationship with the client who is so fulfilling and rewarding. In addition to this joyous relationship, I also have a large revenue producing account. This is the dream of every sales person. Since experiencing such success in executing the three key concepts, I have change and altered how I facilitate a face to face client appointment. I now see that the face to face appointment is more impactful and valuable to the sales process. Demonstrating the three key concepts at the meeting is vital to the success of my business. When meeting face to face with clients, I focus on building the client relationship by primarily focusing on the person to whom the meeting is focused. If I can build repoire by effective questioning and listening, the recommendation, and making the sale will come much earlier. This experience has also resulted in deeper personal relationships. In addition to applying these principles in a professional environment, I have now begun to practice these concepts in personal relationships. I spend time really focusing on gaining deeper relationships through effective listening. I have now gained the experience on how to grow deep pervasive relationships. An essential element of sales is building client relationships. â€Å"The fastest way to get what you want is first to help others get what they want† (Gaffney 2010). The best behavior change we can make as a sale professional is to simply get over ourselves and start focusing on our client and their needs. â€Å"Commonality of purpose unites you with people; it builds rapport that leads to trust and to the development of a long-term, profitable relationship’ (Graffney 2010). The key first step of the sales process is establishing trust though development of the relationship. The client or potential client is not interested in what we have to say or what we are selling, unless they see how it is in their best interest. When engaging with client the universal truth â€Å"Focus on the client is the key to getting what you want† (Graffney 2010). When meeting with a client, we need to maintain this as a paradigm; building the client relationship and not falsely ‘pretending’ to be interested. The interest generated prior to the sale must be intentional and genuine. A clients sustainable success is based on the principle; â€Å"success in business is about-helping your client, not helping yourself’ (Graffney 2010). The top 10 percent know that they can only be successful if they’re focused on helping people rather than helping themselves making the sale. Consultative selling is about starting a dialogue to uncover a prospect’s problem and then helping them solve the problem in the best way possible. In order to uncover the problem we must have the ability to not only ask questions, but to demonstrate the skill of effective listening. Listening is both a behavior and a skill† (Bonet 2001). Many believe they have the skill of listening. Effective listening is â€Å"receiving information, giving meaning to the information, deciding what you think or feel about that information, responding to what you hear† (Bonet 2001). Most of us are not good listeners. Research indicates â€Å"We listen to 25% of our potential which means, we forget, ignore, distort, or misunderstand 75% of what we hear† (Bonet 2001). When we are able to listen effectively we are able to â€Å"understand problems, and build relationships† (Bonet 2001). If we are not effectively listening to prospects or clients; how is trust established? Without trust there is no client relationship. â€Å"Consultative selling, in a nutshell is the art of effective questioning, listening, and probing the client to effectively ascertain their problems, challenges, goals, and objections; then presenting solution options, which is customized to meet their specific needs and are designed to form long-lasting working partnerships with the client to maximize their investment (Bennett 2006). Consultative selling us focused almost exclusively on the clients rather than the product they are selling. The object is to understand the client’s situation to the degree that the â€Å"sale and implementation of the product or service becomes a seamless integral part of the client’s ongoing business operation† (Bennett 2006). It is apparent when the sales individuals executes successfully on building the client relationship through effective listening, advancement of the sell through competent recommendations is inevitable. The success I experienced from the client face to face meeting has the potential to change almost all of my personal engagements with others. For example; by applying the same concepts to both personal and professional relationships I can deepen and broaden these relationships. The skillset of being intentional on building relationships through effective listening can transform almost any relationship. People enjoy talking about themselves. If we genuinely want to develop and grow any relationship, personal and professional, by taking the attention off of ourselves, and focus on the learning about others, people respond positively. The behavior of effective listening communicates to the individual that they are unique and special. I have learned that people are accustomed to only talking about themself. People are often pleasantly surprised when they learn you are not there to talk about yourself, but rather learn about them! Prior to this experience I would be very nervous and almost sick over high value appointments. I was under the belief that I need to have a strong business case, and with that alone, I would be able to make the sale. This experience demonstrated that focusing on the client through effective listen is the most effect way to gain sustainable results. I will now have the confidence and ability to meet and work with larger more complex clients. By applying the same principles of building the client relationship though effective listening, I can make competent recommendations, that the client will trust. This will allow me to grow my business and the depth I am able to penetrate. Finally since this experience, I am now aware the building relationships requires being intentional. A quote that really emphasis this, is by former GE CEO, Jack Welsh â€Å"Be interested, not interesting†. The experience with this particular client taught me how true this statement is. I have since experienced the same success in the personal setting as I did in the professional. I look forward to additional successes, based on this model.

Filipino Mode of Thinking Essay

We, Filipinos, are considered hospitable and merry. It has been an attitude the majority enriches or embraces. For instance, looking into our hospitality, when a guest is present in our home, a treatment of respect and comfort will be provided for the person as if the guest is a member of the family. Whereas for being merry, when a problem emerges, a joke or two about the problem will be the response to make the atmosphere be calmer. All these qualities root from are â€Å"communal relationships†. Again we are known from these qualities. All of which are embedded in our culture that originated since pre-colonial times that we still carry today. A lot of things can still be considered to show our identity and uniqueness. It could either be present only in some areas or in the general public but all of these points to our Filipino mode of thinking. Our Filipino mode of thinking is considered as â€Å"oriental, non-dualistic, holistic and has unity between the subject and the object†. It is true on so many ways. Just observing the way our people act and build their houses are fitting cases. A Filipino identity is present even if one goes abroad; a habit that every Filipino will carry whenever he goes – the Filipino mode of thinking. A mode of thinking is a desirable element to have a rich culture and country; every country might as well have it but differs in their own notions or form. It may not apply to everyone due to the globalization, but a hint or two would still pass if there are people with that mode of thinking around that person. To give out examples of this Filipino mode of thinking, a lot can be stated. Two eminent cases are the tattooing art in the country and our â€Å"kamay-kamayan† eating or the buddlefeast. PhilippineTattoo Philippine tattooing has been an art since pre-colonial times which spreads to the three main islands of the country. The word â€Å"Pintados† (Painted Ones) was even dubbed for the Bisayans by the Spaniards. Tattooing is a phenomenon in the whole world nowadays that evolves since the early times. The so-called Pintados of the island of Visayas, Manobo of Mindanao and Kalinga of Luzon are the front runners of tattoo tradition and culture in the country. However, this tradition and art in the country has been partially diminishing in some of the tribes or areas. The few organizations and institutions are at times the only hope in trying to save this continuing crisis. PHILTAG, Mark of Four Waves Tribe and many others are the organizations that are reviving the tribal designs of our traditional tattooing tribes. These people advocate the start of a new revolution in Philippine Tattooing. It has been doing greatly for the past few years. At present, a lot of Filipinos here and abroad, and even those who are not Filipino, are having our tribal designs tattooed on them. Diversities and similarities are present for each country in terms of tattooing but it could still be identified through the processes or the designs themselves. Designs that depicts animals and nature which is one with the people that shows our mode of thinking is non-dualistic. Kamay-kamayan Filipinos are really fond in eating; it is seen in our fiestas, birthdays, wedding or just any party on that matter. These practices can also be the way one could show it hospitality and cheerfulness; for there are times when hosts give out carry-outs or take-outs for the guests or cases when even people the host does not know are invited or welcome. Eating has been essential to show one that he/she is high cultured using proper etiquette like the use of table knives, spoons and forks in different manners or activities. However, some Filipinos don’t practice such customs from time to time for they use their own hands to eat. It may look unhygienic or improper to others but it has been a practice that has been ongoing since before in our history; â€Å"Kamay-kamayan† or â€Å"kamayan† as they called it. I myself tried such a practice and discovered it is quite gratifying; and fitting for eating certain foods. It might as well be our bond to our ancestors which did not have those spoons and forks. It is still abundant in the country even in the urban areas. There are even restaurants that suggest people to eat with their bare hands. Also, â€Å"buddle feasts† are being a trend nowadays. It’s all about eating together, with a small or big number of people, having all the food on a same long tables sharing all these to everyone; another special thing about it is eating with your hands as well. This just shows that we live as a community and shows unity like that of the buddle feasts happening in the Philippine Military Academy and the annual event in Taguig that promotes unity and bonding. The sakop mentality and holistic concept also comes into play in this kind of practices. Eating with your hands may have its pros and cons but a culture correctly done will always be right and rich. Conclusion The Filipino mode of thinking is â€Å"oriental, non-dualistic, holistic and has unity between the subject and the object† as stated in first paragraph. The examples given show all these qualities. The Filipinos should also preserve and enrich these practices for the sake of the country’s culture. The country since before the coming of the Spaniards has a culture to be proud of. It is unique and shows the Filipino in its own way for â€Å"without culture, and the relative freedom it implies, society, even when perfect, is but a jungle. This is why any authentic creation is a gift to the future.†

Planning Process Paper Essay

I will compare the planning process to my current workplace. Followed by what I believe would be more crucial and why I think that. Also, I will briefly go over why I do not believe organizations can over-plan during this process. The Basic: Planning Process Step #1: Situational Analysis—This step is where you would typically answer the question, â€Å"Where are we now? † (Amicaall). In my current workplace, the main focus in this step is to be sure that the customer is aware of the customer survey that lucky few may receive. Now, the goal is to be sure the ones who may receive this survey are honest when filling it out with the most accurate information. All survey’s are read and sent to the dealership the vehicle was serviced, or purchased. Therefore, any concern from the customer will highly be considered. We assure that ever individual that has an opportunity of receiving one of these important surveys is aware when delivering the vehicle after any services. So that if there is an issue with the service, that they please notify us before filling out the survey this way we are sure the customer is happy with all services. Also, so that the consumer will know how honesty we stand by our word of correcting and listening to their suggestions by making them happy right away. â€Å"Planners should gather, interpret, and summarize all information relevant to the planning issue in question. A through situational analysis studies past events, examines current conditions, and attempts to forecast future trends† (Bateman & Snell, 2007). By us being sure that are customers are aware of the survey ahead of time, we are more than likely to get a better knowledge of where we may need to focus more on improving or attempting the consumer’s ideas. By doing so, we are more like to achieve reaching our goals. Step #2: Alternative Goals and Plans—â€Å"based on the situational analysis, the planning process should generate alternative goals that may be pursued in the future and the alternative plans that may be used to achieve those goals† (Bateman & Snell, 2007). A lot of our goals set at work are not just to be sure that all customers are happy but also that they know if there’s something that has not instantly been put into effect that we are still in the process of doing so. It may be something that takes a little more financial effort as well as time. For example, a lot of customer have mentioned the would like if their vehicle was washed and vacuumed after every service. We state the following to the customer when this is brought to our attention, â€Å"As of now we are relocating to another facility, fortunately we will be in a bigger building that will also have a car wash available. But for now we have washed your windows and vacuumed the vehicle. We look forward to being able to serve you better. Step #3: Goal and Plan Evaluation—â€Å"next, managers will evaluate the advantages, disadvantages, and potential effects of each alternative goal and plan† (Bateman & Snell, 2007). This is pretty simple; the goal and plan evaluation is discussed every morning within our manager meetings. Some of the ideas in plans they’ve discussed in meetings are the following: complimentary snacks, drinks, opening a Starbucks coffee station and mai ling/emailing great coupons, specials off of services, even possibly a parking garage. The managers gather together to see what is best benefiting the customers and if there are any new ideas that may be brought to their attention. One, manager even stated he over heard a customer state to another customer, â€Å"that it wouldn’t be a bad idea if they had wireless internet so that I could continue to work while my vehicle is being serviced, you would think they would be caught up with the technology no days. † If so what they plan on doing to implant them, are they realistic and attainable? While in the meeting they’ll discuss several ideas and examples of how to keep all eyes and ears open for any future goals and plans. Step #4: Goal and Plan Selection—â€Å"once managers have assessed the various goals and plans, they will select the one that’s most appropriate and feasible† (Bateman & Snell, 2007). After everyone discussing and gathering information from consistent consumers the dealership has decided to select the following as plans for the future; parking garage, complimentary drinks, a Starbucks station that consists of snacks, breakfast and lunch sandwiches up for purchase. Until the Starbucks station has built their customers, we have coupon vouchers so that the customer may have their first Starbuck’s Drinks for free. As all these ideas come out the next step would be to be sure the news letter gets mailed and emailed out to all of our customers and consumers. The newsletters will state all goals and plans that have been selected for our future facility. Step #5: Implementation—â€Å"once managers have selected the goals and plans, they must implement the plans designed to achieve the goals† (Bateman & Snell, 2007). Well, as of now the dealership has implemented a lot of the planned goals. By this I mean, we now have a Starbucks station filled with snacks and many different beverages. We also have put a refrigerator full of all types of sodas and water all complimentary for all customers and purchaser of Toyota Sales and Service. As for the Parking Garage and Car Wash they are both in the works, we have blue prints showing where the next facility will be built. Step #6: Monitor and Control—â€Å"although it is sometimes ignore, this step in the formal planning process is essential. Planning works in a cycle; it is an ongoing, repetitive process. (Bateman & Snell, 2007). Now, the way the company monitors and tracks all the works in cycle is by asking all customers that look like they have purchased or used the vouchers if they enjoy having Starbucks. All mentioned it’s a great change and they all thanked the company for taking the time to listen to their ideas. The managers noticed that all surveys they were receiving had plenty comments about how the changes really benefit them. A lot commented on the wireless internet how covenant it was to have service performed on their vehicle and it didn’t even seem that they weren’t at work because they could still use their computer and complete work assignments. To management it seemed that they were on the right track, by listening to the customers they could make most of them happy and keep their business. By doing so it seems that they’re helping to provide a better workplace as well as a great setting for people to achieve personal as well as career goals. In conclusion, an organization can not be very successful if they do not stay within the basic planning process. As I’ve explained above every step is very important, though one I believe is most crucial and that is Step #! Situational Analysis. The reason why I feel this is most important is because if you analyze a situation incorrectly then you may be headed in the wrong direction as far as improving. The situation may not need any correction or improvement at the time, therefore the situation that needs most improvement may be overlooked. I don’t believe that any organization may over plan because the more effort put into planning the more correction or ideas m ay be created. This will prepare the organization for several different scenarios.

Edict the Expulsion of Jews (1492) Essay Example | Topics and Well Written Essays - 500 words

Edict the Expulsion of Jews (1492) - Essay Example Some conversos—Jews who converted to Catholicism—flourished in places of learning and commerce. However, many ruling Spanish—both secular and religious—viewed these Jews with deep suspicion heightened by the fact that some conversos were insincere. Some chose to save their social and commercial status by embracing the Catholic faith, but privately adhering to their Jewish practice and faith. The Alhambra Decree, or the Edict of Expulsion, was issued on March 31, 1492 by the joint Catholic Monarchs of Spain—King Ferdinand II of Aragon, and Queen Isabella I of Castile. Ferdinand and Isabella took seriously the reports that some crypto-Jews who were not only privately practicing their former faith, but were secretly trying to draw other conversos back into the Jewish fold. In 1480, the king and queen created the Spanish Inquisition to investigate these suspicions; under the authority of this new institution, thousands of converted Jews were killed within 12 years. It is not known how many, if any, had lapsed from their new Christianity, or were trying to convince others to do the same. The said decree was issued less than three months after the surrender of Granada—a vassal state to Spanish royals for more than two centuries. It was Juan de Coloma, secretary of the king and queen, who wrote it at the royalties’ command. Under the edict, Jews were only given four months and ordered to convert to Christianity or leave the country. However, Jews were promised royal "protection and security" for the effective three-month window before the deadline. They were permitted to take their belongings with them - except "gold or silver or minted money". In the edict, Jews were accused of trying "to subvert their holy Catholic faith and trying to draw faithful Christians away from their beliefs." The punishment for any Jew who did not convert or leave by the deadline was death. The punishment for a non-Jew who sheltered or hid Jews was the

The current trends in hardware Essay Example | Topics and Well Written Essays - 1500 words

The current trends in hardware - Essay Example An OS also takes care of sharing of a system by multiple users and also handle the various authentication issues in multiple user systems. The sharing of resources also forms a vital functionality of the OS in a multi user system. Conventionally all these functionalities of the OS are implemented in the kernel. And the kernel is accessible to all the programs that run in the system. Almost all systems use a system language or command to program the kernel. This is not modifiable by the user and remains outside his purview. Even if it needs to be modified, the complexity and the vastness is overwhelming and it requires heavy debugging and testing to ensure that the modification is bug free and it does not affect the rest of the functionalities. Also the pageability of kernels is extremely limited and even if it can be pages it takes a lot of work to decide what can be paged. All these restrictions and drawbacks of adding and modifying functionalities are slowly being eliminated and on ly those functionalities that are absolutely necessary are being added to the kernel. Innovative ideas to efficiently retrieving and handling information are thus being ignored because of the complexities involved in implementing them. Though Lisp Machine and Smalltalk managed to bring this user modifiable functionality in an easy to use language they failed to separate the user from the program. This principle of separation between the user and the program is one of the core principles of an operating system by definition. Another design method is the multi server system which attempts to break down the kernel into logical parts with interfaces between them. This makes it easier for the user to add more functionality separately to the specified block. Also the debugging phase becomes much easier since the code is less. This OS design addresses the users need to customize but the barrier between the user and the system still remains. I.e. the user still needs certain privileges to m odify the system code. [9][2][16][17][3] [5][6][10] GNU Hurd This new development seeks to address all the drawbacks mentioned till now and also to provide the dynamic user modifiable functionality to the OS. This new design seeks to achieve this goal by restricting the area of the system code. It makes the system code pertain to only specified basic areas and leaves the rest of the process to be defined by the user. The user can also add the remaining parts and can share these parts with other users without being bothered about the viability and the authenticity of the code and system. Let us take a look at each of the mechanism that is part of the new design system called Hurd. In the Translator Mechanism, the Hurd is found to use the Mach ports as a method to communicate between the user and the server. Every mach port is different and it implements a certain set of protocols which identify the operations that it can do and also represents the object of the port. The protocols or rules of conduct specified by the Hurd are the input/output protocol, the file, the socket protocol, and the process protocol. Each file can have a translator associated with it. Here the server executes the translator program associated with each file instead of each file returning its own port. The translator is allotted a port to the actual contents of the file,

Law Enforcement U1IP Research Paper Example | Topics and Well Written Essays - 750 words

Law Enforcement U1IP - Research Paper Example Why is the Command of Temper Important to the Demeanor of the Typical Police Officer? With regards to the principle i.e. â€Å"No quality is more indispensable to a policeman than a perfect command of temper; a quiet, determined manner has more effect than violent action†, it has often been viewed that police department, in the early 19th century, accepted violence as a norm for punishing wrong–doers, resulting in categorizing the department as large bureaucratic structure along the military lines. The increasing trend of treating the offenders violently resulted in criticizing the department concerning their theories and policies on ethical grounds. Scenario, since then, has apparently changed in the 21st century, where ethical conscience and responsibilities in every sphere of the society is considered as incomparable. Thus, it can be stated that the command of temper is very important in respect to the demeanor of a typical police officer, which restricts the policem an to conduct any aggressive behavior that might result in breach of his ethical commitments (Olsen, 2011). Again, the principle of â€Å"the securing and training of proper persons is at the root of efficiency†, it can be affirmed that rights availed to a policeman, holds significant influence on the law enforcement efficiencies of a society. Apparently, if the rights are availed to wrong person, who is observed as incompetent to understand and likewise, responds to their responsibilities, it might impose grave consequences on the societal health. Therefore, it was considered as quite vital that the selection and training of policemen made in accordance to a set standard to proper personnel who will be suitable for the department (Olsen, 2011). Do you feel that enough has been done in Law Enforcement to Develop the Proper Demeanor of Law Enforcement Officers? As per my understanding, in order to implement the principle of maintaining a perfect command of temper amidst the po licemen, enough law enforcements have been done. For instance, the ‘Law Enforcement Code of Ethics’ has been finalized and is implemented to generate adequate awareness and oblige policemen to maintain ethical conduct remaining calm and focused by controlling their temper. However, the change in the ethical and the cultural ways of living amidst the current periled may highlight the need of changes in some policies (Lawriter LLC, 2008). Again, the law provisions enacted under the ‘4973.17 Commissions for special police officers - term of office – training’, states the different criteria which are necessary requirements for becoming a police officer. However, there are certain factors that can improve the Demeanor of a police officer if implemented during their training session (Lawriter LLC, 2008). If you were the Chief of Police of a Local Law Enforcement Organization with the Opportunity to Establish Guidelines on Developing the Demeanour of Law En forcement Officers, What Methods Would you utilize? In relation to the stated principle of â€Å"no quality is more indispensable to a policeman than a perfect command of temper; a quiet, determined manner has more effect than violent action†, it can be viewed that the main reason behind implementing the Code of Ethics in the police department is to generate moral awareness within the policemen

How do you account for the success of Korea’s chaebol What Essay

How do you account for the success of Korea’s chaebol What problems did the chaebol face in the Asian financial crisis of the late 1990s - Essay Example formance of chaebols and it is regarded that Korean economy became able to recover from the financial crisis of late 1990s due to the efficient performance and adequate restructuring of chaebols (Buzo, 2002, p187). At present, chaebols are successfully operating in South Korea significantly contributing towards the economic development (Choe and Chinmay, 2007, p232). The essay aims to discuss the performance of Korean Chaebols after the financial crisis that hit Korea along with many other Asian countries in late 1990s. The essay examines the recovery path adopted by the Korean Chaebols to identify the factors that have contributed towards re-stability of these conglomerates after the financial crisis. It is revealed that financial crisis draw devastating impact upon the performance and growth of Chaebols however, they recovered from the crisis within few years with the help of government support and adequate business strategies and planning. Chaebols are the South Korean business conglomerates that have attained strong position at international level and own several multinational enterprises. There are several dozen Chaebols working in Korea that are mainly operated by Korean family controlled corporate groups (Fields, 1995, p35). These Chaebols enjoy government support as well as finance that allow them evolving as well known international brands. Some of the well known Chaebols operating in South Korea include Samsung, LG and Hyundai etc. Traditionally Chaebols have played a very important role in economic as well as political progression of Korea. Chaebols have significantly contributed towards the development of new industries, markets and expansion of trade relation at international level (Kim, 1991, p272). It has been widely accepted that Chaebols have well supported Korean economy in attaining the position of East Asian Tiger (Rowley et al, 2001, p21). Chaebols use to play dominating role in the economy of Korea because these entities remain the focus of

Occupational health and safety Case Study Example | Topics and Well Written Essays - 1500 words

Occupational health and safety - Case Study Example This research will begin with the statement that Occupational Healthy Safety (OHS) has the responsibility of ensuring that people engaged in employment are safe and healthy while at work.   It is an organ that fights for the welfare of employees and advocates for a healthy and safe working environment. As a working environment, it is an interaction of different people like customers, staff, and family members. Therefore, for the effectiveness of health and safety of those involved, OHS system should be active in an organization so as to avoid injuries and deaths that result from a dangerous working environment. Human life should be treated sacredly by taking preventive measures that will create confidence with the workers to offer their service without fear. Companies, which do not take such measures, expose their workers to dangerous consequences inform of injuries.   These injuries make workers stay home while nursing their wounds and pain. When people are not able to attend to their normal duties at work, they affect service delivery, which was seen through the limited returns that the company realizes. Titanic Cove Resort (TCR) is a business firm found in Byron Bay, which provides conference facilities, accommodation services, and food and beverage choices among many to their customers. This indicates that being a service industry; it has 420 members of staff, who attend to approximately 800 guests that visit the business. This paper shall discuss the efficiency of OHS system in TCR in detail, and suggest recommendations that will improve the safety and health of TCR employees and customers. Breaches in WHS Legislation According to New South Wales legislation The world Health Organization and the New South Wales legislation in Australia have a common ground in regard to occupational health and safety (Levy & Wegman 2005). According to these two organs, it is the duty of occupational health to maintain a high level of psychological and bodily safety to workers so as to avoid risks that come with working conditions. The working environment should be improved to create a reliable condition that will protect workers from work related risks. Companies should create a positive climate which would enable workers to improve their productivity in the business. TCR has shown a breach of New South Wales legislation since it has not promoted health safety. The case study indicated that a bar attendant was assaulted by an intoxicated person. This attendant was hospitalized and was to be laid off for tree weeks. This was not according to the labor legislation, which advocates for a suitable working environment. As an employer, TCR should provide securi ty for her employees while at work, but this incident where one of her works suffered these injuries, indicates a breach of legislation. Secondly, the working environment does not promote a healthy and safety climate. This was shown when a fight broke in the firm, and the security offered to go and settle the dispute, but instead he was knocked and became unconscious. This shows that TCR does not uphold occupational health and safety hence a breach of legislation in the company. Cost and Benefits of Occupational Health The above illustration indicates that the current level of occupational health and safety is not legal compliance. When workers are exposed to risks that harm their lives, they lead the company to an extra cost of providing for their medical treatment (Alston 1994). Such expenses can be avoided if the occupational health and safety system is upheld. Lack of proper occupational health may lead to deaths that make families lose their loved ones, who in this case are the bread winners. The loss of a family bread winner indicates that other family members will face challenges in meeting their basic needs. This propagates the rate of poverty in the society. Families that lose their loved ones undergo pain and grief and take time to accept the departure of their friend or relative. Therefore, to avoid such

Critically evaluate the contribution that music can make to health and Literature review

Critically evaluate the contribution that music can make to health and wellbeing - Literature review Example People with mental health issues can benefit from music because it takes them away from thinking of themselves as patients by promoting their self-esteem, social recognition, confidence and status especially when they participate in singing (Bradt & Dileo, 2009:2, Music for stress and anxiety reduction in coronary heart disease patients). The relationship between arts and health has been a topical issue for a long time. The linkage between arts participation and health has been developed for instance the influence of sports on physical health and the influence of music on mental health. It is indeed true that arts participation has an effect on key health indicators. Music, health, and well-being: A review by Raymond and Macdonald (2013) asserts that musical participation as part of arts participation has a direct influence on the mental health and well being in people. Research has indicated that music contributes to mental health and wellbeing of people in different stages of life for instance children and the elderly. Rose Perkins and Aaron Williamon (2013) in their article Learning to make music in older adulthood: A mixed-methods exploration of impacts on wellbeing explore the links between older adulthood, wellbeing lifelong learning and music and posit that music has an important aspect for healthy ageing (Unkefer & Thaut, Eds. 2009:23). By healthy ageing, Unkefer & Thaut, Eds. (2009) refer to the absence of illnesses in old age in terms of social, physical and mental health. In this respect Unkefer & Thaut, Eds. (2009) acknowledge the fact that, â€Å"There is a growing body of literature exploring the relationships between music and wellbeing in the ageing population, and we know that music is a powerful part of many older adults’ lives† (Perkins & Williamon, 2013:551). While citing other sources, Downey, et.al, (2013)

Policy analysis about Economics Research Paper Example | Topics and Well Written Essays - 750 words

Policy analysis about Economics - Research Paper Example Due to the disparities of income between the high skilled and low skilled labors, the union advocates for rise in the minimum wages among the low skilled workers. These help to decrease the gap between the high income earners to the low income earners. Through this, they ensure equitable distribution of income in the society that ensures demand is relatively high hence economic growth (Duerrenberger, 2009). The unions usually lobby for strict immigration rules which limits labor supply within the United States economy especially the low skilled workers from abroad. Hence any labor supply from over-sees are highly qualified which is necessary for the general economy as it would ensure quality products that increase revenue to the country. Through these, they ensure higher incomes to the available labor (Duerrenberger, 2009). High wages results in increased consumption that raises demand hence higher productivity leading to economic growth. Unions have also supported the restriction of imported goods and services through the imposition of tariffs and quotas that discourages imports while promoting exports leading to increasing in demand of the domestic products. High demand results in increased productivity which raises the labor demand of the country (Duerrenberger, 2009).As a result, more units of output are produced, raising the sales revenue that increases income to the GDP of the nation hence high economic growth. However labor unions have various impacts on the economic operations of the country. They constantly bargains for increase in the minimum wage rate without an equivalent rise in the production capacity. Increasing wages by firms’ results into high operational cost in terms of salaries.This would otherwise reduce the productivity reducing output leading to decreased sales. As a result, the firms and business will incur loss and may be forced to lay off workers leading to high unemployment rate. High rates of unemployment affect

Societal Impact & Cost vs. Benefit Research Paper

Societal Impact & Cost vs. Benefit - Research Paper Example Combustion of diesel also pollutes the environment by producing smoke, which is hazardous to survival, and removing diesel engines would reduce the levels of poisonous gases and smoke hence improve the health of people. However, cost of transportation would greatly increase since diesel offers lower costs of transportation than other fuels used for transportation. Alternative fuels would replace diesel in all forms of road transport, and this will make the energy sector sustainable over the years. The alternative fuels can be a mixture of bio fuels, synthetic fuels, methane and liquefied petroleum gas, which significantly reduce the amounts of poisonous gases in the atmosphere (Business Green). These alternative fuels produce minimal or no amount at all of greenhouse gases, and this means that global warming will be significantly reduced. Pollution will also be reduced through elimination of the smoke and poisonous gases emitted by combustion of diesel in the diesel engines. This implies that the environment will be protected from pollution hence healthy surroundings. Alternative fuels will enhance locomotion using electric and fuel cell vehicles, which will meet the demands for all transportation needs. Taking diesel engines off the roads will protect the environment from pollution, prevent air pollution from smoke and reduce health disorders related to the gases emitted from combustion of diesel. Bio fuels have the potential to meet all transport costs as well as reduce emissions of carbon dioxide and other green house gases, which cause health complications and environmental degradation

Psychological Critical Perspective Essay Example for Free

Psychological Critical Perspective Essay The utilization of a psychological critical perspective in literature entails the utilization of a specific psychological perspective to be used in the assessment of the various elements within the text as they are related to both the author and the intended audience of the work. Bernard Paris (1997) states that the use of psychology in the analysis of a literary text enables us â€Å"to understand the behavior of characters in literature from the past, to enter into their feelings, and to enrich our knowledge of ourselves and others through an understanding of their inner conflicts and relationships† (p. xii). In line with this, what follows is a psychological analysis of the representations of life and death in Sophocles’ Oedipus Rex and Susan Glaspell’s Trifles. Within Sophocles’ Oedipus Rex, the psychological representation of death is evident in the representation of the sphinx. The sphinx, as a mythical creature, represents perplexity and death. In its many versions, the sphinx may be said to be a representation of perplexity in its employment of riddles in its interaction with human beings. Furthermore, it may be said to be a representation f death since it is depicted as a creature that brings death [or at least bad luck or misfortune] to those who cannot solve its riddles. In Greek mythology and drama, this creature is depicted as a beast with a feminine gender. Though generally regarded as an unhappy monster, the sphinx also serves as a symbol of femininity, power and confusion. In Sophocles’ Oedipus Rex, one may infer that in Greek tragedy, sufferings and tribulations are intertwined with the hero’s existence. To a certain extent, one may say that in the case of Oedipus Rex, the sphinx defines the existence of Oedipus; his ‘being a hero’, so to speak. The same holds true for the sphinx. In other words, the hero and the villain define each others’ being. Note for example that within the text itself, Oedipus’ existence is intertwined with the Sphinx in the sense that the Sphinx and hero are twin-born. In terms of its monstrosity, the sphinx is depicted in many ways. These depictions are as follows. In Oedipus Rex, she is depicted as a singing sphinx that has permitted the oversight of dark secrets as well as a winged maiden with crooked talons who sang darkly. Oedipus’ incapacity to discern both the oracle at Delphi and the true nature of the sphinx and its closeness to himself present us with a rather different view about human nature and the ancient Greeks’ belief in fate. The sphinx reminds us of two things. First, it reminds us of our inability to fully know ourselves because of human nature’s enigmatic character. Second, it poses significant questions with regards to human freedom and our capacity for choice. In other words, it toys on the idea whether freedom and choice are mere illusions that human beings would like to think that they possess when in fact, they do not. Within this context, life and death are represented within Oedipus Rex in such a way that it places emphasis on the difficulty of discerning the conditions of life. Such a difficulty is mirrored in the portrayal of the Sphinx as well as the Sphinx’s relation with the hero of the text. As opposed to this, Susan Glaspell portrays life and death differently in Trifles. Trifles recounts the tragedy that occurs within marriage during instances wherein there is an absence of homosocial dimensions in a woman’s life. Within the text, life and death are represented in such a way that they are made to be seen within the context of a masculine gaze. The reason for this lies in the subjectivity of the portrayal of both freedom and objectivity within the text. Consider for example the case of Mrs. Hale and Mrs. Peter who both tried to conceal the evidence of Minnie’s crime. One might note that such a decision mirrors a certain amount of freedom on both characters’ part. Both characters may be said to possess freedom in the negative sense that they may choose to omit specific information that they have however the subjectivity of this freedom is evident if one considers that the psychological reason for omitting such an information may be traced to their embeddedness within a masculine point of view that requires them to maintain the existence of order within their immediate surroundings. Life and death, within Trifles, may be said to be determined by a patriarchal point of view. Such a point of view, however continuously contradicts the feminists perspective as can be seen in the controversies that arose as a result of Minnie’s death. References Bernard, P. (1997). Imagined Human Beings: A Psychological Approach to Character and Conflict in Literature. New York: NYU P. Glaspell, S. (2003). Trifles. Np: Thomson Wadsworth. Sophocles (1991). Oedipus the King: Oedipus Rex. Trans. George Young. London: Dover.

Factors Affecting Antipsychotic Medication Compliance

Factors Affecting Antipsychotic Medication Compliance INTRODUCTION The aim of this dissertation is to explore the factors affecting concordance with prescribed antipsychotic medications. The rationale for selecting this topic is derived from personal working experience with mental health service users. Having worked as a nursing assistant for the past eight years on acute admissions wards and as a student nurse for the past three years it was observed that a large proportion of compulsory re-hospitalisation under the Mental Health Act 1983 occurs due to relapse of mental illness as a result of non- concordance with medications, particularly service users with a diagnosis of schizophrenia. This led to believe that concordance with antipsychotic medications plays a crucial role in managing psychosis as it positively contributes towards the effective management of the illness in the community. In support to this view, Gray et al (2002a) assert that prophylactic use of antipsychotic medication reduces the risk of relapse among individuals with schizophr enia and non-concordance with medication has the potential for frequent re-hospitalisations. This has been recognised as the revolving door syndrome. During most mental health placements it was noted that non-concordance with medication has become significant, as this has been identified as a risk factor within the risk assessment checklist. Furthermore, despite the well-documented therapeutic effect of antipsychotic medications, some patients are reluctant to accept treatments and some may even wish to cease taking medications altogether. Therefore, this empirical knowledge has reinforced the desire to examine the factors associated with non-concordance with antipsychotic medications. According to Brimblecombe et al (2005) medication is one of the major therapeutic tools available to help people with schizophrenia. There is also growing evidence that schizophrenia can be treated effectively with a range of psychological and social interventions together with antipsychotic medications. Norman Ryrie (2004) emphasised that antipsychotic medication has been the mainstay of treatment for schizophrenia since the 1950s when it was discovered that the dopamine antagonist haloperidol and chlorpromazine exerted antipsychotic effects. The National Institute for Clinical Excellence (NICE) (2002) recommends that atypical antipsychotic drugs such as amisulpride, aripiprazole , olanzapine, quetiapine or risperidone must be considered in the choice of first-line treatments for individuals with newly diagnosed schizophrenia or to promote recovery for those who have experienced unacceptable side-effects on conventional antipsychotics, as atypical antipsychotics appear to have less extrapyramidal symptoms (side effects) than the conventional antipsychotics such as haloperidol and chlorpromazine. The care and treatment of individuals with schizophrenia have advanced considerably over the past ten years, since the introduction of atypical antipsychotics and medication continues to be the first line treatment for schizophrenia (Walker MacAulay, 2005). However, Gray et al (2002b) claim that despite the effectiveness of these atypical antipsychotic drugs, non- concordance with prescribed antipsychotic medications is observed in around 50% of people with schizophrenia and is a major preventable cause of psychiatric morbidity. In addition, Mitchell Selmes (2007) claim that over the course of a year, about 75% of patients will discontinue prescribed antipsychotic medications, often coming to the decision themselves and without informing a health professional. According to Gray et al (2006) relapse rates is five times higher among individuals with schizophrenia, who are non-concordance with medication compared with concordance. Non-concordance during acute treatment of psychosis le ads to chronic symptomswhereas non-concordance after remission increases the risk ofrelapse and both may have serious consequences; re-hospitalisation (Hamer Haddad, 2007). Furthermore, the impacts of non-concordance with medication not only affect the individuals with schizophrenia, as each relapse causes a stepping down of cognitive functioning which is rarely retrieved but also their carers and the costs of treatments (Institute, 2007). To facilitate this project as a literature review, an analysis of secondary sources only will be use. Secondary sources were mainly obtained from nursing journals such as Nursing-Standard, Nursing-Times, Advances in Psychiatric Treatment, Mental health practice, Schizophrenia Bulletin and The British Journal of Psychiatry, containing the key words: schizophrenia, oral antipsychotic, medication management and non-concordance. An Internet search of Google was also done with the same keywords to access any relevant documents. To address the factors affecting concordance with prescribed antipsychotic medications, these will be divided into patient-related factors, medication-related factors and clinician-related factors. LITERATURE REVIEW According to White (2007) schizophrenia is a debilitating psychiatric disorder characterised by a range of positive and negative symptoms and these symptoms were first described in detail by the British neurologist Hughlings-Jackson in the late 1800s. There is no physical test for schizophrenia rather it is diagnosed by the presence of certain positive and negative symptoms over a period of time (Brennan, 2001). According to Issacs (2006) the neurotransmitter hypothesis suggests that the dopamine over activity in the mesolimbic dopamine pathway, which is between the midbrain, is thought to cause the positive symptoms of schizophrenia and dopamine under activity in the mesocortical dopamine pathway is thought to result in the negative symptoms of schizophrenia. Positive symptoms represent a distortion of normal experience, such as delusions, hallucinations and thought disorder, whereas negative symptoms represent a loss or dimming of normal function and social norm, such as avoidance of social interactions (Baker, 2003). There are different types of schizophrenia such as paranoid, disorganised, catatonic, undifferentiated and residual (Issacs, 2006). However, Gillam (2002) claimed that the exact causes of schizophrenia remain unclear but genetic, environmental and social factors are all thought to influence its development. The risk for a child to develop schizophrenia is 46%, if both parents have the disorder (Kirk et al, 2006). Women who have certain viral illnesses during their pregnancy may be at a greater risk of giving birth to children who later develop schizophrenia and the 1957 influenza A2 epidemics in England resulted in an increase in schizophrenia in the offspring of women who developed this flu during their pregnancy (Frankenburg, 2007). 1 in 100 UK populations will develop schizophrenia in their lifetime and the world prevalence is about 2-4 in 1000, as it affects men and women equally (Rethink, 2008). However, the onset in men is about five years earlier than women with the peak age of incidence is between 16 and 25 and the presentation of the illness varies tremendously, not only between individuals, but also within the same individual at different stages of their illness (Magorrian, 2007). Schizophrenia seems to be more common in city areas and in some ethnic minority groups and premature mortality in people with schizophrenia is 2 to 3 times higher than that in the general population (Royal college of Psychiatrists 2008). The premature mortality might be due to poorer health care, physical health, unhealthy lifestyles and people with schizophrenia may be at greater risk of type 2 diabetes as a result of antipsychotic medications (Nash, 2005). Moreover, according to WHO (2008) schizophrenia is a treatable disorde r but many individuals remain untreated regardless of effective treatments. There has been an unresolved debate about how best to define patients engagement with medications and until the 1980s most work on patient engagement with medications regimes was described as compliance (Norman Ryrie, 2004). The term compliance is often used interchangeably with adherence or concordance (Snelgrove, 2005). According to Kikkert (2006) the term compliance has fallen out of favour in clinical practice because it carries an assumption that patients are the passive recipients of clinicians and implies unquestioning obedience with no opportunity for patients choice. To add to the complexity of this term, patients can be intentionally or unintentionally non-compliant such as a deliberate decision not to comply with treatment and patients may have misunderstood the guidance that they have been given or unable to open the medication container. Velligan et al (2006) claimed that in recent years there has been a shift from this paternalistic model of doctor-patient interactions with the consequent preference for the use of the term adherence. However, while adherence emphasises negotiation between clinician and patient, it still implies a degree of passivity and obedience (Snelgrove, 2005). Gray et al (2002b) assert that concordance may be a more acceptable term as it suggests a collaborative process of decision-making regarding medications regimes and acknowledges the importance of the two-way communication. The NHS Plan (2000) emphasises the importance of placing patients at the centre of services and the transformation of patients into consumers of the health service has changed the context of health care, as patients are expected to become more active and informed about their treatments (Jasper, 2006). Murray et al (2007) emphasise that shared decision-making between clinicians and patients has the potential to improve concordance with treatment plans. Furthermore, The Chief Nursing Officers review of mental health nursing (2006) recommends that building and maintaining positive interpersonal relationships with service users is essential to successful mental health nursing practice and person-centred values is helpful in building positive relationships. This indicates that by not agreeing to health professionals advice patients may be labelled as non-compliant. Nonetheless, compliance could also be problematic, for example if patients continue to take medication obediently, although it is causing adverse side effects. However, from the empirical knowledge the term compliance is still being used in clinical settings despite the paternalistic conception. Therefore, the term concordance is favoured here as it promotes the idea that medication treatment should be a collaborative process between clinicians and patients, which emphasises the patients rights. Ultimately, the term concordance corresponds with the current ethos of modern mental health care set out in the National Service Framework (1999), the NHS Plan (2000) and the Chief Nursing Officers review of mental health nursing (2006), which is concerned with working in partnership with patients and carers. However, according to the term concordance patients have the right to make t reatment decisions, for example, stopping medication even if health professionals do not agree with that decision. For decades researchers have worked to explain the causes of non-concordance with medication unfortunately there have been no valid way of measuring concordance (Velligan et al, 2006). Rates of concordance have been measured by using the subjective and objective methods. Subjective method includes patients` self report and direct interviews, although this method is less expensive, it tends to overestimate the degree of concordance, as patients may not admit non-concordance (Gray et al, 2002b). Snelgrove (2005) claims that objective method such as blood and urine analysis also pose problems as they do not account for individual metabolism and do not reflect inconsistencies in concordance over time. Moreover, from empirical knowledge blood test is effective in monitoring concordance with mood stabilisers such as lithium, but for schizophrenia it is the manifestation of symptoms can support the evidence of non-concordance. According to Gray et al (2002b) pill counts are more reliable, b ut it is impossible to tell whether patients have actually ingested the medication. Even expensive objective method such as electronic monitoring which records every occasion that a pill bottles is opened can also be problematic when patients choose not to swallow the medication that was removed or do not replace the caps and electronic prescribing is still fallible, just because medication is available does not mean that it is taken (Velligan et al, 2006). One of the major clinical problems in the treatment of people with schizophrenia is partial or complete non-concordance with medication and this limits the clinical effectiveness of the prescribed medications (Kikkert et al, 2006). Antipsychotics medication can only be effective if they are taken continuously over a sustained period of time (Norman Ryrie, 2004). Urquhart (2005) claims that partially concordant patients can be difficult to identify because they do not actively refuse to take their medication but the dosage deviations for different reasons and this may only be detected when psychotic symptoms re-emerge. Partial concordance creates significant problems for the treating physician as it creates difficulties in determining whether medications are working adequately, dosing is appropriate or concomitant medication is needed (Velligan et al, 2006). Therefore, this indicates that medication or dosage changes and the addition of concomitant medications are more likely to occu r among patients who are not fully concordant with prescribed medications. Non-concordance with prescribed medication is believed to be a significant factor to increasethe probability of relapse in patients with schizophrenia and relapse is one of the most costly aspects of schizophrenia (Almond et al, 2004). Knapp et al (2004) undertook a study of 658 patients receiving antipsychotics medication of whom 20% reported non-concordance with prescribed medication and concluded that non-concordance was one of the most significant factors in increasing service costs, predicting an excess annual cost per patient of  £2500 for inpatient services and an overall additional cost of  £5000 for total service use. In addition, Almond et al (2004) estimated that costs for relapse cases are four times higherthan those for non-relapse cases. Therefore, these two studies show that relapse in patients with schizophrenia as a result of non-concordance isa major factor in generating high hospitalisation rates and costs. This implies that patients who do not concord with the ir medication are likely to requiremore treatment and support from a range of services and given the high costs associated with relapse non-concordance is a key factor in the use ofin-patient and external services. Antipsychotic medication has proven efficacy in the treatment of schizophrenia and the prevention of relapse. In spite of vast evidence that antipsychotics can be effective in treating the symptoms of schizophrenia, almost 90% of patients will relapse within the first five years of treatment following an acute episode and in general the illness has a tendency to recur or become chronic (Velligan et al, 2006). According to White et al (2007) non-concordance with drug therapy is common in schizophrenia; approximately 50% of patients are non-concordant within one year and 75% within two years after being discharged from hospital. Such high rates of non-concordance with medication may initially seem alarming (Gray et al, 2002b). However, it is similar with other conditions such as asthma where maintenance treatment is required. A study of concordance with asthma medication conducted by Newell (2006) estimated that 70 % of asthma patients in the UK are non-concordant with medication and t he levels of non-concordance in long-term conditions, such as asthma are known to be high as many asthma sufferers will only take medicine when they feel they need it rather than as instructed by clinicians. Therefore, considering the Newell (2006) findings it can be argued that the rates of non-concordance with antipsychotics are not significantly different than those on non-psychiatric medications and the myth that non-concordance with medication is more common among mental disorders as compared to physical disorders needs to be dispelled. Several factors have been shown to increase the chance of relapse but probably the single most important cause of relapse is the discontinuation of effective antipsychotic medication regime. A large number of factors influence non-concordance with prescribed antipsychotic medications, however Gray et al (2002b) have identified the main factors as impaired judgement, negative beliefs about treatment, poor worker-user relationship and the side-effects of medication. Additionally, Kikkert et al (2006) conducted a study in four European countries exploring medication adherence in schizophrenia and identified insight, beliefs about treatment, side effects and treatment efficacy as factors that influence concordancewith medication in patients with schizophrenia. Urquhart (2005) suggests that the problem of non-concordance may be more prevalent among those with schizophrenia due to its nature, for example, lack of insight. Magorrian (2007) claimed that non-concordance with medication is often linked to the persons level of insight into his or her illness and lack of insight is a frequent concomitant of psychosis. In schizophrenia, insight has been defined as an awareness of illness and an ability to recognise symptoms as part of an illness (Gray et al, 2002b) According to Surguladze David (1999) between 50% and 80% of patients diagnosed with schizophrenia have been shown to be partially or totally lacking insight into the presence of their mental disorder and these individuals are often difficult to engage with treatments due to impaired insight. Recent conceptualisation has formulated insight as a continuum representing the combination of three factors; awareness of illness, need for treatment and attribution of symptoms. Lack of insight is continuously problematic but an emotional element can be associated with denial of symptoms or rejection of treatment at key points in the illness (Byrne, 2000). Mitchell Selmes (2007) claim that having a perception about the illness and the knowledge of medications are the key factors of concordance in mental health and patients who understand the purpose of the prescription are twice more likely to collect it than those who do not understand. A study by Cuesta et al (2000) reported that patients suffering from schizophreniashowed poorer insight than patients with affective disorders. Cuesta et al (2000) findings demonstrated that the severe disturbances of insight persisted over the time and the level of insight was not significantly improved in patients suffering from functional psychosis as between 29% to 49% of these patients continued to have fair to poor insight at the follow up assessment. This is consistent with the findings of Kikkert et al (2006), where poor insight was a strong predictor of non-concordance with medication. In contrast, Tait et al (2003) conducted a study to examine changes in insight and symptoms of psychosis on fifty participantswho met the ICD—10 diagnostic criteria for schizophrenia. The participants were interviewed and insight was measured duringacute psychosis using the Insight Scale with the score 0- 12 and all the participants were reinterviewed at 3 and6 months following the init ial interview. Tait et al (2003) findings indicated that duringthe acute episode, 48% of participants scored 9-12 on the InsightScale and the majority of participants (63%) werein the 9-12 range of scores. The study of Tait et al (2003) clearly indicated that level of insight was high among many participants. In considering the findings of both Cuesta et al (2000) and Tait et al (2003) it appears that some patients with psychosis are unaware of their illnesses and insight is a strong predictor of concordance with medications and a good indicator of prognosis. However, evidence for a relationship between insight and concordance with treatment is inconclusive as the discrepancies found between the two studies might be due to the methodological factors, such as selection of participants. In both studies all the participants had a diagnosis of schizophrenia and all of them gave informed consent to enter the study. According to Appelbaum (2006) several studies in America regarding the decisional-capacity of patients with schizophrenia to consent or participation to research have raise some concerns due to the cognitive impairments associated with schizophrenia and using the MacArthur Competence Assessment Tool for Clinical Research clearly indicated that patients with schizophrenia do lack und erstanding and reasoning of research ethics. McCann Clark (2005) emphasise that antipsychotic medications some of which have a sedating effect can also have an impact on the cognitive processes, such as illogical thinking and this can hinder the quality of responses. Moser et al (2005) argued that some studies have shown that a high percentage of individuals with schizophrenia have adequate decisional capacity to consent to research participation, however in a medication-free schizophrenia research, participants did not show a major decline in decisional capacity. In addition, Jeste et al (2006) claimed that there is a risk in assuming that decision-making capacity of individuals with schizophrenia is always impaired, when they are capable to make autonomous decisions and in considering their decision-making capacity as permanently impaired by virtue of their diagnosis. Consequently, in order to investigate factors associated with schizophrenia, it can be argued that only individuals with schizophrenia can provide the answers of their experiences and protecting vulnerable populations from research activity can also exclude them from its benefits. According to Gerrish Lacey (2006) there two key concepts that concern the quality of a research: validity and reliability. Roberts et al (2006) define reliability as how far a particular test will produce similar results in different circumstances, whereas validity is to ascertain the methods are actually measuring what is intended to measure. Both Cuesta et al (2000) and Tait et al (2003) had used structured interviews to gather the data and have chosen a quantitative approach. Structured interview provides the opportunities to change the words but not the meaning of the questions thus, Parahoo (2006) claimed that validity is enhanced because participants can be helped to understand the questions and interviewers can ask for clarifications and probe for further responses, if necessary and since all the questions are ideally asked in the same way, structured interview has a high degree of reliability. It seems that both Cuesta et al (2000) and Tait et al (2003) have adopted the appropriate approach to their research, as quantitative research is the conduct of investigations primarily using numerical methods. It infers that to examine correlations between insight and service engagement qualitative approach could not have produced the same data in this area of study. Moreover, in both studies purposive sampling were used as all the participants had a diagnosis of schizophrenia. According to Polit Beck (2006) all participants in a phenomenological study must have experienced the phenomenon under study and must be able to articulate what is like to have lived the experience. Johnson Orrell (1996 cited in Surguladze David, 1999 P 166) have argued that some patients may have their own explanations of their illnesses, such as religion or cultural beliefs which may not coincide with the Western medical model of mental disorders and this can be even more complicated if one tries directly to impose the models of insight on patients from non-Western cultures. Gamble Brennan (2006) claimed that different cultures in England perceive mental illness in different ways and this can have an impact on treatments as some cultures rather seek help from religious leaders than mental health services. Alternatively, religion or spiritual beliefs in the Western culture can have a positive impact on concordance with medication, as religious individuals with schizophrenia have a better social support compare to non-religious individuals with schizophrenia (Borras et al, 2007). Therefore, it can be put forward that awareness of illness is a crucial factor in the motivation to receive pharmacological treatment. Both cultures and religion can have a positive and negative influence on concordance with antipsychotics. Patients can have different levels of awareness into their illness and they may consciously or unconsciously avoid acknowledging that they are suffering from mental health problems because of their reluctance to bear the stigma of mentally ill (Surguladze David, 1999). Byrne (2000, p65) defined `stigma as a sign of disgrace or discredit, which sets a person apart from others and the stigma of mental illness although more often related to context than to a persons appearance, remains a powerful negative attribute in all-social relations`. Stigma of mental illness has become an indication for unpleasant experiences, such as bringing shame to the family or social exclusion. According to Phillips et al (2002), in some parts of china, schizophrenia is still considered as a punishmentfor an ancestors misbehaviour or for the familys currentmisconduct and the effect of stigmais greater if the patient had more prominent positive symptoms or highly educated. Moreover, a study by Lee et al (20 05) concluded that 60 % out of 320 patients with schizophrenia had experienced interpersonal stigma from p arents, siblings or close rel atives. This indicates that people with schizophrenia are more likely to experience stigma from family members than the general public. Having a diagnosis of schizophrenia does not only affect ones health but also carries all the prejudice, discrimination and social exclusion, for example many individuals are attacked on the streets, rejection in the society and denial of employments because they were known to have mental health problems (Gamble Brennan, 2006). According to Byrne (2000) in two identical UK public opinion surveys, 80% of participants claimed that most people are embarrassed by mentally ill people and about 30% agreeing `I am embarrassed by mentally ill persons`. There is also evidence that supports the concepts of stereotyping of mental illness. The power and influence of the media on mental illness has been a key issue of debate over many years as people with schizophrenia are frequently portrayed as violent and dangerous. In contrast, people with schizophrenia are more likely to be dangerous to themselves than to others, while the greater danger to the public is posed by people without mental health problems and people with mental health problems are six times more likely than the general public to be the victims of murder (Stickley Felton, 2006). Moreover, Gamble Brennan (2006) claimed that when the boxing champion Frank Bruno was admitted to hospital in 2003, one of the newspaper headlines was `Bonkers Bruno locked up`. This indicates that stigma has the grave potential to cause reluctance to seek treatments and this can be detrimental to the persons health. Therefore, as a mental health clinician, it will be vital to assist people wit h mental health problems to rebuild their lives and this requires moving beyond the traditional focus on symptoms and medication by exploring alternatives in reducing stigma of mental health that avert people from social inclusion. It has been predicted that families with high expressed emotion compared to low expressed emotion can contribute towards the relapse rate in symptoms of schizophrenia and this can also be a triggering factor for non-concordance with medication. High expressed emotion carers appear to perceive their caring situation as more stressful and this could be conceptualised as a catastrophic appraisal of the role of caring (Raune et al 2004). Kuipers et al (2006) identifies the components of expressed emotion as emotional over-involvement, hostility, critical comments, warmth and positive remarks. A study by Kuipers et al (2006) indicates that patients whose carers showed high expressed emotion had considerably higher levels of anxiety and lower self-esteem due to the components of expressed emotion. However, a significant amount of data from western cultures suggests that high expressed emotion subjects who were not on medication are three times likely to relapse than those who were on medic ation (Bhugra McKenzie, 2003). This clearly signifies that despite being concordant, high expressed emotion subjects are vulnerable to relapse. The interactions between patient and the carers are crucial, especially cross-culturally as in some cultures for example, in some parts of India, emotional over-involvement is the norm and if carers do not show emotional over-involvement, this can be seen as lack of care (Bhugra McKenzie, 2003). Hashemi Cochrane (1999) conducted a study in UK on expressed emotion and they observed that 80% of the British Pakistani, 45% of the White and 30% of the British Sikh families exhibited high levels of expressed emotion and emotional over-involvement was notably higher among the British Pakistani group. The findings concluded that White patients with high expressed emotion relatives were significantly more likely to relapse than those from low expressed emotion families, whereas for both Asian groups high expressed emotion did not predict relapse. The study of Hashemi Cochrane (1999) also indicated that that Pakistani families in the UK were more likely to be rated as high expressed emotion than White families, indicating that components such as emotional over-involvement may be cultural rather than pathogenic traits. Conversely, low expressed emotion families who are not over-anxious in their response to the patients illness may tend to perceive stigma in less threatening ways whereas, families with high expressed emotion, who respond to the patients illness in a highly anxious may experience stigma more intensely (Phillips et al 2002). Therefore, it appears that family members levels of expressed emotion could influence their perception and response to stigma of mental health and concordance with medication is essential for patients irrespective of the expressed emotion status in the family. Thus, family interventions need to improve in order to lower the levels of anxiety and to increase self-esteem among families with hig h expressed emotion. As a clinician it will be vital to acknowledge the cultural aspect of expressed emotion status in the family to facilitate concordance with medication. There is overwhelming evidence for patients with schizophrenia, who misuse illicit drugs and alcohol to have an increased rate of re-hospitalisation (Sokya, 2000). According to Barnes et al (2006) the higher relapse rate in people with established schizophrenia who usesubstances may be partially explained by non-concordant tothe medication regimen. Evidence suggests that the substance used most frequently by people with schizophrenia is cannabis (Gamble Brennan, 2006). Arseneault et al (2004) emphasise that rates of cannabis use in UK are higher among people with schizophrenia than among the general population and patients detained under the MHA (1983) have even higher rates of lifetime use of cannabis. Substance misuse in schizophrenia may be explained as a form of self-medication to alleviate the symptoms of schizophrenia, to improve the side effects of antipsychotics and to respond to social pressures (Sokya, 2000). There has been little evidence to support the self-medication hypothesis despite its popularity with users and in contrast, substance misuse can aggravate the symptoms of schizophrenia and can also trigger psychotic episode particularly in people with a pre-exis Factors Affecting Antipsychotic Medication Compliance Factors Affecting Antipsychotic Medication Compliance INTRODUCTION The aim of this dissertation is to explore the factors affecting concordance with prescribed antipsychotic medications. The rationale for selecting this topic is derived from personal working experience with mental health service users. Having worked as a nursing assistant for the past eight years on acute admissions wards and as a student nurse for the past three years it was observed that a large proportion of compulsory re-hospitalisation under the Mental Health Act 1983 occurs due to relapse of mental illness as a result of non- concordance with medications, particularly service users with a diagnosis of schizophrenia. This led to believe that concordance with antipsychotic medications plays a crucial role in managing psychosis as it positively contributes towards the effective management of the illness in the community. In support to this view, Gray et al (2002a) assert that prophylactic use of antipsychotic medication reduces the risk of relapse among individuals with schizophr enia and non-concordance with medication has the potential for frequent re-hospitalisations. This has been recognised as the revolving door syndrome. During most mental health placements it was noted that non-concordance with medication has become significant, as this has been identified as a risk factor within the risk assessment checklist. Furthermore, despite the well-documented therapeutic effect of antipsychotic medications, some patients are reluctant to accept treatments and some may even wish to cease taking medications altogether. Therefore, this empirical knowledge has reinforced the desire to examine the factors associated with non-concordance with antipsychotic medications. According to Brimblecombe et al (2005) medication is one of the major therapeutic tools available to help people with schizophrenia. There is also growing evidence that schizophrenia can be treated effectively with a range of psychological and social interventions together with antipsychotic medications. Norman Ryrie (2004) emphasised that antipsychotic medication has been the mainstay of treatment for schizophrenia since the 1950s when it was discovered that the dopamine antagonist haloperidol and chlorpromazine exerted antipsychotic effects. The National Institute for Clinical Excellence (NICE) (2002) recommends that atypical antipsychotic drugs such as amisulpride, aripiprazole , olanzapine, quetiapine or risperidone must be considered in the choice of first-line treatments for individuals with newly diagnosed schizophrenia or to promote recovery for those who have experienced unacceptable side-effects on conventional antipsychotics, as atypical antipsychotics appear to have less extrapyramidal symptoms (side effects) than the conventional antipsychotics such as haloperidol and chlorpromazine. The care and treatment of individuals with schizophrenia have advanced considerably over the past ten years, since the introduction of atypical antipsychotics and medication continues to be the first line treatment for schizophrenia (Walker MacAulay, 2005). However, Gray et al (2002b) claim that despite the effectiveness of these atypical antipsychotic drugs, non- concordance with prescribed antipsychotic medications is observed in around 50% of people with schizophrenia and is a major preventable cause of psychiatric morbidity. In addition, Mitchell Selmes (2007) claim that over the course of a year, about 75% of patients will discontinue prescribed antipsychotic medications, often coming to the decision themselves and without informing a health professional. According to Gray et al (2006) relapse rates is five times higher among individuals with schizophrenia, who are non-concordance with medication compared with concordance. Non-concordance during acute treatment of psychosis le ads to chronic symptomswhereas non-concordance after remission increases the risk ofrelapse and both may have serious consequences; re-hospitalisation (Hamer Haddad, 2007). Furthermore, the impacts of non-concordance with medication not only affect the individuals with schizophrenia, as each relapse causes a stepping down of cognitive functioning which is rarely retrieved but also their carers and the costs of treatments (Institute, 2007). To facilitate this project as a literature review, an analysis of secondary sources only will be use. Secondary sources were mainly obtained from nursing journals such as Nursing-Standard, Nursing-Times, Advances in Psychiatric Treatment, Mental health practice, Schizophrenia Bulletin and The British Journal of Psychiatry, containing the key words: schizophrenia, oral antipsychotic, medication management and non-concordance. An Internet search of Google was also done with the same keywords to access any relevant documents. To address the factors affecting concordance with prescribed antipsychotic medications, these will be divided into patient-related factors, medication-related factors and clinician-related factors. LITERATURE REVIEW According to White (2007) schizophrenia is a debilitating psychiatric disorder characterised by a range of positive and negative symptoms and these symptoms were first described in detail by the British neurologist Hughlings-Jackson in the late 1800s. There is no physical test for schizophrenia rather it is diagnosed by the presence of certain positive and negative symptoms over a period of time (Brennan, 2001). According to Issacs (2006) the neurotransmitter hypothesis suggests that the dopamine over activity in the mesolimbic dopamine pathway, which is between the midbrain, is thought to cause the positive symptoms of schizophrenia and dopamine under activity in the mesocortical dopamine pathway is thought to result in the negative symptoms of schizophrenia. Positive symptoms represent a distortion of normal experience, such as delusions, hallucinations and thought disorder, whereas negative symptoms represent a loss or dimming of normal function and social norm, such as avoidance of social interactions (Baker, 2003). There are different types of schizophrenia such as paranoid, disorganised, catatonic, undifferentiated and residual (Issacs, 2006). However, Gillam (2002) claimed that the exact causes of schizophrenia remain unclear but genetic, environmental and social factors are all thought to influence its development. The risk for a child to develop schizophrenia is 46%, if both parents have the disorder (Kirk et al, 2006). Women who have certain viral illnesses during their pregnancy may be at a greater risk of giving birth to children who later develop schizophrenia and the 1957 influenza A2 epidemics in England resulted in an increase in schizophrenia in the offspring of women who developed this flu during their pregnancy (Frankenburg, 2007). 1 in 100 UK populations will develop schizophrenia in their lifetime and the world prevalence is about 2-4 in 1000, as it affects men and women equally (Rethink, 2008). However, the onset in men is about five years earlier than women with the peak age of incidence is between 16 and 25 and the presentation of the illness varies tremendously, not only between individuals, but also within the same individual at different stages of their illness (Magorrian, 2007). Schizophrenia seems to be more common in city areas and in some ethnic minority groups and premature mortality in people with schizophrenia is 2 to 3 times higher than that in the general population (Royal college of Psychiatrists 2008). The premature mortality might be due to poorer health care, physical health, unhealthy lifestyles and people with schizophrenia may be at greater risk of type 2 diabetes as a result of antipsychotic medications (Nash, 2005). Moreover, according to WHO (2008) schizophrenia is a treatable disorde r but many individuals remain untreated regardless of effective treatments. There has been an unresolved debate about how best to define patients engagement with medications and until the 1980s most work on patient engagement with medications regimes was described as compliance (Norman Ryrie, 2004). The term compliance is often used interchangeably with adherence or concordance (Snelgrove, 2005). According to Kikkert (2006) the term compliance has fallen out of favour in clinical practice because it carries an assumption that patients are the passive recipients of clinicians and implies unquestioning obedience with no opportunity for patients choice. To add to the complexity of this term, patients can be intentionally or unintentionally non-compliant such as a deliberate decision not to comply with treatment and patients may have misunderstood the guidance that they have been given or unable to open the medication container. Velligan et al (2006) claimed that in recent years there has been a shift from this paternalistic model of doctor-patient interactions with the consequent preference for the use of the term adherence. However, while adherence emphasises negotiation between clinician and patient, it still implies a degree of passivity and obedience (Snelgrove, 2005). Gray et al (2002b) assert that concordance may be a more acceptable term as it suggests a collaborative process of decision-making regarding medications regimes and acknowledges the importance of the two-way communication. The NHS Plan (2000) emphasises the importance of placing patients at the centre of services and the transformation of patients into consumers of the health service has changed the context of health care, as patients are expected to become more active and informed about their treatments (Jasper, 2006). Murray et al (2007) emphasise that shared decision-making between clinicians and patients has the potential to improve concordance with treatment plans. Furthermore, The Chief Nursing Officers review of mental health nursing (2006) recommends that building and maintaining positive interpersonal relationships with service users is essential to successful mental health nursing practice and person-centred values is helpful in building positive relationships. This indicates that by not agreeing to health professionals advice patients may be labelled as non-compliant. Nonetheless, compliance could also be problematic, for example if patients continue to take medication obediently, although it is causing adverse side effects. However, from the empirical knowledge the term compliance is still being used in clinical settings despite the paternalistic conception. Therefore, the term concordance is favoured here as it promotes the idea that medication treatment should be a collaborative process between clinicians and patients, which emphasises the patients rights. Ultimately, the term concordance corresponds with the current ethos of modern mental health care set out in the National Service Framework (1999), the NHS Plan (2000) and the Chief Nursing Officers review of mental health nursing (2006), which is concerned with working in partnership with patients and carers. However, according to the term concordance patients have the right to make t reatment decisions, for example, stopping medication even if health professionals do not agree with that decision. For decades researchers have worked to explain the causes of non-concordance with medication unfortunately there have been no valid way of measuring concordance (Velligan et al, 2006). Rates of concordance have been measured by using the subjective and objective methods. Subjective method includes patients` self report and direct interviews, although this method is less expensive, it tends to overestimate the degree of concordance, as patients may not admit non-concordance (Gray et al, 2002b). Snelgrove (2005) claims that objective method such as blood and urine analysis also pose problems as they do not account for individual metabolism and do not reflect inconsistencies in concordance over time. Moreover, from empirical knowledge blood test is effective in monitoring concordance with mood stabilisers such as lithium, but for schizophrenia it is the manifestation of symptoms can support the evidence of non-concordance. According to Gray et al (2002b) pill counts are more reliable, b ut it is impossible to tell whether patients have actually ingested the medication. Even expensive objective method such as electronic monitoring which records every occasion that a pill bottles is opened can also be problematic when patients choose not to swallow the medication that was removed or do not replace the caps and electronic prescribing is still fallible, just because medication is available does not mean that it is taken (Velligan et al, 2006). One of the major clinical problems in the treatment of people with schizophrenia is partial or complete non-concordance with medication and this limits the clinical effectiveness of the prescribed medications (Kikkert et al, 2006). Antipsychotics medication can only be effective if they are taken continuously over a sustained period of time (Norman Ryrie, 2004). Urquhart (2005) claims that partially concordant patients can be difficult to identify because they do not actively refuse to take their medication but the dosage deviations for different reasons and this may only be detected when psychotic symptoms re-emerge. Partial concordance creates significant problems for the treating physician as it creates difficulties in determining whether medications are working adequately, dosing is appropriate or concomitant medication is needed (Velligan et al, 2006). Therefore, this indicates that medication or dosage changes and the addition of concomitant medications are more likely to occu r among patients who are not fully concordant with prescribed medications. Non-concordance with prescribed medication is believed to be a significant factor to increasethe probability of relapse in patients with schizophrenia and relapse is one of the most costly aspects of schizophrenia (Almond et al, 2004). Knapp et al (2004) undertook a study of 658 patients receiving antipsychotics medication of whom 20% reported non-concordance with prescribed medication and concluded that non-concordance was one of the most significant factors in increasing service costs, predicting an excess annual cost per patient of  £2500 for inpatient services and an overall additional cost of  £5000 for total service use. In addition, Almond et al (2004) estimated that costs for relapse cases are four times higherthan those for non-relapse cases. Therefore, these two studies show that relapse in patients with schizophrenia as a result of non-concordance isa major factor in generating high hospitalisation rates and costs. This implies that patients who do not concord with the ir medication are likely to requiremore treatment and support from a range of services and given the high costs associated with relapse non-concordance is a key factor in the use ofin-patient and external services. Antipsychotic medication has proven efficacy in the treatment of schizophrenia and the prevention of relapse. In spite of vast evidence that antipsychotics can be effective in treating the symptoms of schizophrenia, almost 90% of patients will relapse within the first five years of treatment following an acute episode and in general the illness has a tendency to recur or become chronic (Velligan et al, 2006). According to White et al (2007) non-concordance with drug therapy is common in schizophrenia; approximately 50% of patients are non-concordant within one year and 75% within two years after being discharged from hospital. Such high rates of non-concordance with medication may initially seem alarming (Gray et al, 2002b). However, it is similar with other conditions such as asthma where maintenance treatment is required. A study of concordance with asthma medication conducted by Newell (2006) estimated that 70 % of asthma patients in the UK are non-concordant with medication and t he levels of non-concordance in long-term conditions, such as asthma are known to be high as many asthma sufferers will only take medicine when they feel they need it rather than as instructed by clinicians. Therefore, considering the Newell (2006) findings it can be argued that the rates of non-concordance with antipsychotics are not significantly different than those on non-psychiatric medications and the myth that non-concordance with medication is more common among mental disorders as compared to physical disorders needs to be dispelled. Several factors have been shown to increase the chance of relapse but probably the single most important cause of relapse is the discontinuation of effective antipsychotic medication regime. A large number of factors influence non-concordance with prescribed antipsychotic medications, however Gray et al (2002b) have identified the main factors as impaired judgement, negative beliefs about treatment, poor worker-user relationship and the side-effects of medication. Additionally, Kikkert et al (2006) conducted a study in four European countries exploring medication adherence in schizophrenia and identified insight, beliefs about treatment, side effects and treatment efficacy as factors that influence concordancewith medication in patients with schizophrenia. Urquhart (2005) suggests that the problem of non-concordance may be more prevalent among those with schizophrenia due to its nature, for example, lack of insight. Magorrian (2007) claimed that non-concordance with medication is often linked to the persons level of insight into his or her illness and lack of insight is a frequent concomitant of psychosis. In schizophrenia, insight has been defined as an awareness of illness and an ability to recognise symptoms as part of an illness (Gray et al, 2002b) According to Surguladze David (1999) between 50% and 80% of patients diagnosed with schizophrenia have been shown to be partially or totally lacking insight into the presence of their mental disorder and these individuals are often difficult to engage with treatments due to impaired insight. Recent conceptualisation has formulated insight as a continuum representing the combination of three factors; awareness of illness, need for treatment and attribution of symptoms. Lack of insight is continuously problematic but an emotional element can be associated with denial of symptoms or rejection of treatment at key points in the illness (Byrne, 2000). Mitchell Selmes (2007) claim that having a perception about the illness and the knowledge of medications are the key factors of concordance in mental health and patients who understand the purpose of the prescription are twice more likely to collect it than those who do not understand. A study by Cuesta et al (2000) reported that patients suffering from schizophreniashowed poorer insight than patients with affective disorders. Cuesta et al (2000) findings demonstrated that the severe disturbances of insight persisted over the time and the level of insight was not significantly improved in patients suffering from functional psychosis as between 29% to 49% of these patients continued to have fair to poor insight at the follow up assessment. This is consistent with the findings of Kikkert et al (2006), where poor insight was a strong predictor of non-concordance with medication. In contrast, Tait et al (2003) conducted a study to examine changes in insight and symptoms of psychosis on fifty participantswho met the ICD—10 diagnostic criteria for schizophrenia. The participants were interviewed and insight was measured duringacute psychosis using the Insight Scale with the score 0- 12 and all the participants were reinterviewed at 3 and6 months following the init ial interview. Tait et al (2003) findings indicated that duringthe acute episode, 48% of participants scored 9-12 on the InsightScale and the majority of participants (63%) werein the 9-12 range of scores. The study of Tait et al (2003) clearly indicated that level of insight was high among many participants. In considering the findings of both Cuesta et al (2000) and Tait et al (2003) it appears that some patients with psychosis are unaware of their illnesses and insight is a strong predictor of concordance with medications and a good indicator of prognosis. However, evidence for a relationship between insight and concordance with treatment is inconclusive as the discrepancies found between the two studies might be due to the methodological factors, such as selection of participants. In both studies all the participants had a diagnosis of schizophrenia and all of them gave informed consent to enter the study. According to Appelbaum (2006) several studies in America regarding the decisional-capacity of patients with schizophrenia to consent or participation to research have raise some concerns due to the cognitive impairments associated with schizophrenia and using the MacArthur Competence Assessment Tool for Clinical Research clearly indicated that patients with schizophrenia do lack und erstanding and reasoning of research ethics. McCann Clark (2005) emphasise that antipsychotic medications some of which have a sedating effect can also have an impact on the cognitive processes, such as illogical thinking and this can hinder the quality of responses. Moser et al (2005) argued that some studies have shown that a high percentage of individuals with schizophrenia have adequate decisional capacity to consent to research participation, however in a medication-free schizophrenia research, participants did not show a major decline in decisional capacity. In addition, Jeste et al (2006) claimed that there is a risk in assuming that decision-making capacity of individuals with schizophrenia is always impaired, when they are capable to make autonomous decisions and in considering their decision-making capacity as permanently impaired by virtue of their diagnosis. Consequently, in order to investigate factors associated with schizophrenia, it can be argued that only individuals with schizophrenia can provide the answers of their experiences and protecting vulnerable populations from research activity can also exclude them from its benefits. According to Gerrish Lacey (2006) there two key concepts that concern the quality of a research: validity and reliability. Roberts et al (2006) define reliability as how far a particular test will produce similar results in different circumstances, whereas validity is to ascertain the methods are actually measuring what is intended to measure. Both Cuesta et al (2000) and Tait et al (2003) had used structured interviews to gather the data and have chosen a quantitative approach. Structured interview provides the opportunities to change the words but not the meaning of the questions thus, Parahoo (2006) claimed that validity is enhanced because participants can be helped to understand the questions and interviewers can ask for clarifications and probe for further responses, if necessary and since all the questions are ideally asked in the same way, structured interview has a high degree of reliability. It seems that both Cuesta et al (2000) and Tait et al (2003) have adopted the appropriate approach to their research, as quantitative research is the conduct of investigations primarily using numerical methods. It infers that to examine correlations between insight and service engagement qualitative approach could not have produced the same data in this area of study. Moreover, in both studies purposive sampling were used as all the participants had a diagnosis of schizophrenia. According to Polit Beck (2006) all participants in a phenomenological study must have experienced the phenomenon under study and must be able to articulate what is like to have lived the experience. Johnson Orrell (1996 cited in Surguladze David, 1999 P 166) have argued that some patients may have their own explanations of their illnesses, such as religion or cultural beliefs which may not coincide with the Western medical model of mental disorders and this can be even more complicated if one tries directly to impose the models of insight on patients from non-Western cultures. Gamble Brennan (2006) claimed that different cultures in England perceive mental illness in different ways and this can have an impact on treatments as some cultures rather seek help from religious leaders than mental health services. Alternatively, religion or spiritual beliefs in the Western culture can have a positive impact on concordance with medication, as religious individuals with schizophrenia have a better social support compare to non-religious individuals with schizophrenia (Borras et al, 2007). Therefore, it can be put forward that awareness of illness is a crucial factor in the motivation to receive pharmacological treatment. Both cultures and religion can have a positive and negative influence on concordance with antipsychotics. Patients can have different levels of awareness into their illness and they may consciously or unconsciously avoid acknowledging that they are suffering from mental health problems because of their reluctance to bear the stigma of mentally ill (Surguladze David, 1999). Byrne (2000, p65) defined `stigma as a sign of disgrace or discredit, which sets a person apart from others and the stigma of mental illness although more often related to context than to a persons appearance, remains a powerful negative attribute in all-social relations`. Stigma of mental illness has become an indication for unpleasant experiences, such as bringing shame to the family or social exclusion. According to Phillips et al (2002), in some parts of china, schizophrenia is still considered as a punishmentfor an ancestors misbehaviour or for the familys currentmisconduct and the effect of stigmais greater if the patient had more prominent positive symptoms or highly educated. Moreover, a study by Lee et al (20 05) concluded that 60 % out of 320 patients with schizophrenia had experienced interpersonal stigma from p arents, siblings or close rel atives. This indicates that people with schizophrenia are more likely to experience stigma from family members than the general public. Having a diagnosis of schizophrenia does not only affect ones health but also carries all the prejudice, discrimination and social exclusion, for example many individuals are attacked on the streets, rejection in the society and denial of employments because they were known to have mental health problems (Gamble Brennan, 2006). According to Byrne (2000) in two identical UK public opinion surveys, 80% of participants claimed that most people are embarrassed by mentally ill people and about 30% agreeing `I am embarrassed by mentally ill persons`. There is also evidence that supports the concepts of stereotyping of mental illness. The power and influence of the media on mental illness has been a key issue of debate over many years as people with schizophrenia are frequently portrayed as violent and dangerous. In contrast, people with schizophrenia are more likely to be dangerous to themselves than to others, while the greater danger to the public is posed by people without mental health problems and people with mental health problems are six times more likely than the general public to be the victims of murder (Stickley Felton, 2006). Moreover, Gamble Brennan (2006) claimed that when the boxing champion Frank Bruno was admitted to hospital in 2003, one of the newspaper headlines was `Bonkers Bruno locked up`. This indicates that stigma has the grave potential to cause reluctance to seek treatments and this can be detrimental to the persons health. Therefore, as a mental health clinician, it will be vital to assist people wit h mental health problems to rebuild their lives and this requires moving beyond the traditional focus on symptoms and medication by exploring alternatives in reducing stigma of mental health that avert people from social inclusion. It has been predicted that families with high expressed emotion compared to low expressed emotion can contribute towards the relapse rate in symptoms of schizophrenia and this can also be a triggering factor for non-concordance with medication. High expressed emotion carers appear to perceive their caring situation as more stressful and this could be conceptualised as a catastrophic appraisal of the role of caring (Raune et al 2004). Kuipers et al (2006) identifies the components of expressed emotion as emotional over-involvement, hostility, critical comments, warmth and positive remarks. A study by Kuipers et al (2006) indicates that patients whose carers showed high expressed emotion had considerably higher levels of anxiety and lower self-esteem due to the components of expressed emotion. However, a significant amount of data from western cultures suggests that high expressed emotion subjects who were not on medication are three times likely to relapse than those who were on medic ation (Bhugra McKenzie, 2003). This clearly signifies that despite being concordant, high expressed emotion subjects are vulnerable to relapse. The interactions between patient and the carers are crucial, especially cross-culturally as in some cultures for example, in some parts of India, emotional over-involvement is the norm and if carers do not show emotional over-involvement, this can be seen as lack of care (Bhugra McKenzie, 2003). Hashemi Cochrane (1999) conducted a study in UK on expressed emotion and they observed that 80% of the British Pakistani, 45% of the White and 30% of the British Sikh families exhibited high levels of expressed emotion and emotional over-involvement was notably higher among the British Pakistani group. The findings concluded that White patients with high expressed emotion relatives were significantly more likely to relapse than those from low expressed emotion families, whereas for both Asian groups high expressed emotion did not predict relapse. The study of Hashemi Cochrane (1999) also indicated that that Pakistani families in the UK were more likely to be rated as high expressed emotion than White families, indicating that components such as emotional over-involvement may be cultural rather than pathogenic traits. Conversely, low expressed emotion families who are not over-anxious in their response to the patients illness may tend to perceive stigma in less threatening ways whereas, families with high expressed emotion, who respond to the patients illness in a highly anxious may experience stigma more intensely (Phillips et al 2002). Therefore, it appears that family members levels of expressed emotion could influence their perception and response to stigma of mental health and concordance with medication is essential for patients irrespective of the expressed emotion status in the family. Thus, family interventions need to improve in order to lower the levels of anxiety and to increase self-esteem among families with hig h expressed emotion. As a clinician it will be vital to acknowledge the cultural aspect of expressed emotion status in the family to facilitate concordance with medication. There is overwhelming evidence for patients with schizophrenia, who misuse illicit drugs and alcohol to have an increased rate of re-hospitalisation (Sokya, 2000). According to Barnes et al (2006) the higher relapse rate in people with established schizophrenia who usesubstances may be partially explained by non-concordant tothe medication regimen. Evidence suggests that the substance used most frequently by people with schizophrenia is cannabis (Gamble Brennan, 2006). Arseneault et al (2004) emphasise that rates of cannabis use in UK are higher among people with schizophrenia than among the general population and patients detained under the MHA (1983) have even higher rates of lifetime use of cannabis. Substance misuse in schizophrenia may be explained as a form of self-medication to alleviate the symptoms of schizophrenia, to improve the side effects of antipsychotics and to respond to social pressures (Sokya, 2000). There has been little evidence to support the self-medication hypothesis despite its popularity with users and in contrast, substance misuse can aggravate the symptoms of schizophrenia and can also trigger psychotic episode particularly in people with a pre-exis