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Molema, Frederique MD; Koopmans, Raymond MD, PhD; Helmich, Esther MD, PhD
Dr. Molema is a former elderly care resident at Radboud University Nijmegen Medical Centre, Department of Primary and Community Care, Nijmegen, the Netherlands. She is currently working as an elderly care physician at Heijendaal, Arnhem, the Netherlands.
Prof. Koopmans is an elderly care physician and full professor at Radboud University Nijmegen Medical Centre, Department of Primary and Community Care, Nijmegen, the Netherlands.
Dr. Helmich is an elderly care physician and assistant professor at Amsterdam Medical Center/University of Amsterdam, Center for Evidence-Based Education, Amsterdam, the Netherlands.
Funding/support: None reported.
Other disclosures: None reported.
Ethical approval: Under Dutch law, educational research is exempt from formal ethics approval, but the authors took all necessary precautions to ensure study participants' well-being as described in more detail in the report.
Correspondence should be addressed to Dr. Helmich, Amsterdam Medical Center/University of Amsterdam, Center for Evidence-Based Education, PO BOX 22660, 1100 DD Amsterdam, the Netherlands; telephone: (+31) 20-566-1278; e-mail: firstname.lastname@example.com.
Purpose: Despite the imperative to develop adequate competence in caring for the growing demographic of elderly patients with complex health care problems, nursing homes are underused as learning environments for the education of future doctors; thus, the authors aimed to gain more insight into the characteristics of the nursing home as a learning environment.
Method: Approaching the nursing home as a learning environment from a predominantly sociocultural perspective, the authors carried out five focus group interviews (December 2011 through February 2012) with 36 family medicine and elderly care medicine residents during their nursing home placements. Data analysis was an iterative process following a grounded theory approach. The software ATLAS.ti supported data analysis.
Results: The authors identified 23 themes in five categories regarding the nursing home as a learning environment: organization, medical opportunities, communication, teamwork, and supervision. Working and learning in a nursing home was characterized by "dealing with less" (i.e., fewer resources), yet the residents reported that dealing with less resulted in "learning more." Family medicine and elderly care residents from different backgrounds differed in their perceptions and specific learning needs.
Conclusions: To the authors' knowledge, this study is one of the first to identify characteristics of the nursing home as a learning environment. The main challenge in the nursing home is dealing with less, which, according to the residents in the present study, often leads to learning more. To ensure that learning really happens, the authors call for high-quality supervision to support learners in the nursing home environment.
Despite the imperative for future doctors to develop adequate competence in caring for the growing demographic of elderly patients with complex health care problems, nursing homes and other geriatric care facilities continue to be underused as learning environments for the education of future doctors.1–3 As early as the 1990s, several authors advocated, both in this and another leading medical journal, employing the nursing home as a site for teaching the medical interview and physical diagnosis4,5; however, more than two decades later, a former editor of this journal must still wonder why students and residents do not learn and work in nursing homes throughout the United States.3
In general, medical schools and residency programs are placing increasing emphasis on geriatrics training.1 Recently, several authors have described initiatives to improve the quality of care provided to elderly people within internal medicine and family medicine residency programs.6 Another set of authors has detailed efforts to advance geriatrics education in medical schools and training programs by offering a faculty development program to nongeriatricians.7 Diachun and colleagues8 have written about the use of patient or caregiver feedback as a tool to cover for the lack of geriatricians supervising students or residents in the performance of comprehensive geriatric assessments, and Moran and colleagues9 have described a program to teach residents to apply geriatric knowledge and skills within a general internal medicine context. These initiatives are helpful; nevertheless, other research has shown that specific rotations in geriatric medicine are more effective in preparing students to care for the elderly compared with nonspecific clerkships.2 Further, additional research indicates that longitudinal rotations or internships in a long-term care facility increase internal medicine residents' knowledge of and attitudes toward geriatrics.10 However, almost no research provides evidence of, specifically, the pros and cons of the nursing home as learning environment. Recommendations to include nursing homes as core sites in medical education are based mostly on personal views or perceptions rather than on sound evidence.3,11,12
In the context of early clinical experience, we recently demonstrated that nursing home placements are highly suitable to enhancing medical students' personal and professional development because of the many opportunities they offer for active participation in patient care, the modeling of patient-centered behavior, and team spirit.13–15 Within the context of graduate medical education, Stok-Koch and colleagues16 carried out an exploratory study among elderly care residents and their supervisors; their results showed that social integration and a good atmosphere are the most salient factors influencing workplace learning in the nursing home. To our knowledge, no prior publications elucidate specifically how and what students or residents learn in the context of a nursing home. Therefore, we deliberately chose to focus solely on residents' concrete experiences of the nursing home as a learning environment. We were most interested in the factors in this unique sociocultural environment that hampered or facilitated learning, rather than in self-reported learning outcomes themselves.
In this study we aimed to answer the following questions:
1. Which factors characterize the nursing home as a learning environment?
2. What stimulates or hampers learning in the nursing home?
We carried out this study at the Radboud University Nijmegen Medical Centre (Nijmegen, the Netherlands), which offers two separate specialist training programs set partly in nursing homes: one in elderly care medicine and one in family medicine. The first year and the final six months of the three-year residency program in elderly care medicine take place in a long-term care facility (i.e., skilled nursing facility); the remainder of the program includes internships in different settings, such as general, rehabilitation, or psychiatric hospitals.17 The family medicine curriculum has a comparable structure; that is, trainees are in general practice during their first and third years and have different internships in the second year of the program. One of these second-year internships is a mandatory three-month internship in a long-term care facility.
As learning in medical practice necessarily takes place in interactions with patients, doctors, and other health care providers on the wards, we approached the nursing home as a learning environment from a predominantly sociocultural perspective. In other words, we conceptualized meaning and identity as negotiated and constructed through interactions with other individuals and artifacts (tools or organizational arrangements—e.g., electronic devices, patient charts, or ward rounds) while participating in communities of practice.18,19 In doing so, we emphasized the importance of both context (learning is situated) and process (learning is dynamic).20 We aimed to look at residents' experiences within their sociocultural environments (in this case, the nursing home), which means we were collecting data about context and process as perceived by residents.
We chose a focus group design, allowing for interactive discussions in which participants often query and have to explain themselves to one other, thus engaging in a collaborative sense-making process.21,22 Moreover, focus groups offer great opportunities for observing the extent of consensus and disagreement among participants.22 We approached residents in their training groups, units within which residents come together once a week for reflection and teaching sessions. We considered these naturally occurring groups the best suitable venue for gaining more insight into the learning processes taking place in nursing homes. Because members of training groups are familiar with discussing educational issues with one another, we supposed this approach would offer a relatively safe environment to share experiences, thereby leading to maximal depth of disclosure.23
From December 2011 through February 2012, we held five focus group interviews. Each group included 4 to 10 participants, and each session lasted about one hour. Of the five groups, four comprised first- or third-year elderly care residents, and one group comprised second-year family medicine residents during their long-term care internship.
A skilled moderator (E.H.) facilitated the discussion; the assistant moderator (F.M.) took notes. The first author (F.M.) audio-taped the sessions and then transcribed them verbatim. We used the following prompts to keep the discussions (held in Dutch) going:
* What was the most instructive experience you had in the nursing home, and what did you learn from it and why?
* What do you consider the main learning opportunities in the nursing home?
* What stimulates your learning in the nursing home, and what hampers the learning process? and
* What makes the nursing home unique as a learning environment?
Because qualitative research is based on experience and on the construction of meaning, we deliberately chose to have both an experienced elderly care physician (E.H.) and an elderly care resident (F.M.) run the groups. Their hands-on experience within the nursing home made it possible to pose in-depth questions and to ask for maximum clarification during the interviews.
Data analysis was an iterative process following a grounded theory approach.24 Directly after each focus group session, the moderator (E.H.) and assistant moderator (F.M.) conducted a first debriefing, sharing their initial thoughts and observations, and summarizing and reflecting on the session. We (E.H. and F.M.) used these reflections as entries for our research logs, which served as a first step in our process of making sense out of the data. Each of us then, independently, carried out a preliminary analysis of the session, allowing the evolving conceptual framework to inform the subsequent focus group discussions.
The two of us (F.M., E.H.) independently coded four interviews. We discussed differences and adapted codes until we reached full agreement about content and inclusion criteria.25 We renamed and rearranged codes into broader themes and eventually assigned these themes to more abstract categories. During this process, we constructed figures and diagrams to reach a better understanding of the meaning of the text. The use of the qualitative research software ATLAS.ti (ATLAS.ti GmbH, Berlin, Germany) supported our analysis. We believed we reached saturation after four interviews, and the analysis of a fifth focus group interview, conducted by F.M., confirmed that, indeed, further interviews would not produce further themes. To triangulate our findings, E.H. discussed the ultimate framework with two teams of elderly care physicians who approved it to be recognizable and trustworthy.
Under Dutch law, educational research is exempt from formal ethics approval. We discussed the aims and design of the study with the head of the Department of Elderly Care Medicine in order to take all necessary precautions to ensure our participants' well-being. F.M. informed all trainees in both the elder care and family medicine programs and asked them to participate in a group discussion about their learning in the nursing home. Thus, residents knew we would ask them to discuss their experiences and that we aimed to use our findings to further improve the nursing home as a learning environment. We emphasized that participation was fully voluntarily, that confidentiality was granted, and that participants could withdraw from the study at any time without consequences. We assured the participants that results would be presented only anonymously and at the group level, guaranteeing that participation would not have any effect on residents' positions or evaluations. At the start of each session, E.H. again explained the procedure and obtained written informed consent. As the interviews were scheduled during lunchtime, we offered a free lunch.
All elderly care residents in the first and third year of the program (N = 36) participated in the study. At the time of the study, only six family care residents were enrolled in a nursing home placement. Two of them were not able to participate because of time constraints. Response rate thus was almost 100% (95%; 40/42). We have summarized the information on the demographics of the participants in Table 1. The participants in our study were all assigned to different nursing homes located within a large educational area.
Our data set consists of almost five hours of group-discussion-generated data, to which we assigned more than 150 different codes during our first round of open coding. Later in the analysis, we rearranged this huge number of codes into 23 themes, which eventually led us to identify five broader categories: organization, medical opportunities, communication, teamwork, and supervision. Table 2 displays these themes, categories, and the related codes. We found we could divide each of the five categories into two subcategories: dealing with less (i.e., fewer resources) and learning more. There appeared to be one underlying construct: "dealing with less" was closely interrelated to "learning more."
Family medicine residents and elderly care residents from different backgrounds differed in their perceptions and specific learning needs.
Residents described the nursing home as an unstructured learning environment. They mentioned a lack of standard procedures, prescheduled activities, and instructions about how to carry out particular tasks. Residents needed to develop a daily routine on their own.
I had to initiate rounds myself, two times a week. (Family medicine resident)
Residents could not depend on the presence of adequately skilled nursing staff during rounds or in multidisciplinary meetings. They also reported a lack of support staff, resulting in spending a lot of time completing inappropriate, often administrative, tasks.
Residents perceived a lot of freedom and stated that organizing their own work was a valuable experience.
You have to structure your day by yourself and you are learning a lot by doing that. (Family medicine resident)
Other personnel at the nursing homes perceived the residents as readily accessible and asked them to complete nonmedical tasks. This accessibility required the residents to learn how to define and restrict their tasks and responsibilities, which they considered instructive. One family medicine resident, approached to provide computer support, felt as if others considered her to be a "handyman." She commented,
You need to set clear limits, getting to know what you think is important to do or not. (Family medicine resident)
One of the central features of working in the nursing home was the paucity of advanced diagnostic tools and medical procedures (e.g., blood testing and radiology). Residents considered this lack an obstacle for the learning and preservation of skills in the medico-technical domain. Residents were afraid they would lose skills in interpreting laboratory results or electrocardiograms, or that they would lose confidence in administering intravenous fluids or medications.
Sometimes you are not able to practice things just because they just are not there. Like having electrocardiograms available, providing you with the opportunity to keep up your interpretation skills. (Elderly care resident, Year 1)
For some residents, the limited technical or procedural possibilities reduced the attractiveness of working in a nursing home, hampering the development of a medical doctor identity. Trainees also described a lack of learning materials such as recent scientific publications or medical protocols.
I would like to have those technical opportunities … to feel a bit more like a doctor. (Elderly care resident, Year 1)
Residents described a large variety of medical conditions or patients' signs and symptoms prevalent in the nursing home. They were able to learn about chronic disease, end-of-life care, rehabilitation, and psychogeriatric diseases. Having limited access to advanced diagnostic or medical procedures resulted in a huge increase in clinical expertise, in the development of clinical skills, and in residents' confidence in the value of the medical interview and physical examination.
You really develop clinical expertise, reaching a diagnosis, without all those additional resources. (Elderly care resident, Year 1)
Trainees needed to think carefully about the different treatment options. This necessary consideration resulted in more deliberate decision making; residents learned to take into account perceived benefits and side effects, as well as financial aspects. This contrasted with the hospital, where treatment options are much more standardized.
The choices are made much more deliberately.… In the hospital you simply follow a protocol, without actually thinking about it. (Elderly care resident, Year 3)
Patients often were restricted in their ability to communicate because of medical or cognitive problems.
You are caring for frail elderly. Sometimes they are not able to communicate, for example due to aphasia or cognitive problems. So then you are confronted with specific barriers. (Elderly care resident, Year 3)
Residents, however, realized that patients' obstacles to communication encouraged them to advance their own skills instead. The third-year, elderly care resident above noted, "I think this demands even more of your communication skills." Further, residents described engaging in more frequent and more intense conversations. They described being more involved in the care of not only patients but also families than they would have been in hospitals.
What I really have learned to value are family meetings. I thought that, as a family doctor, you know, as a family doctor you only see individual patients. I never thought about, and neither did my supervisor, inviting the family to talk about the care for a patient. These are things I would like to do, next year, in a new family medicine placement, I plan do this more often. (Family medicine resident)
The level of education of the personnel in nursing homes in the Netherlands is quite low (nurses—many of them nursing assistants—in these Dutch facilities generally have only two or three years of vocational training). This discrepancy in education affected how residents and nurses communicated with each other.
People employed in the nursing home generally are lowly qualified. You are one of the highest educated in the nursing home, so you need to find other ways of communicating and working together. (Elderly care resident, Year 1)
Within the multidisciplinary team, residents frequently needed to discuss their treatment plans and reach an agreement with other health care professionals, which they considered to contribute highly to their learning process. The need to adjust to different levels of education and other ways of thinking offered great learning potential.
You should think carefully about what you are saying and you should check, without being disrespectful, if they understand what has been said. (Elderly care resident, Year 1)
In nursing homes a medical problem is often presented inadequately. You learn to ask in more detail, and to search for the underlying question. (Elderly care resident, Year 3)
Compared with in the hospital, residents in the nursing homes did not have many other doctors around. Working as a member of a multidisciplinary team, instead of communicating with predominantly other physicians, turned out to be very instructive.
Paying more attention to the social aspects of the care for patients, not only the medical stuff. (Elderly care resident, Year 3)
And also when you engage in a conversation with patients or families together with a nurse, then you can also learn from each other. You may complement each other and … yes, if I then, the next time, should have the conversation on my own, because the nurses don't have time for it, then … yes, … I know more about how they engage in such conversations. And then I will just use that, so, … yes, I think that actually is most instructive. (Elderly care resident, Year 3)
Within a nursing home you can also learn from other health care workers, the psychologist, the occupational therapist and the physiotherapist, who are all there. That's unique, you won't meet those disciplines that often in a hospital. You can also, with the social worker, talk about the many legal issues, and you see the psychological or psychiatric diseases.… Thus as a learning climate for a medical doctor, a learning environment, there is a lot to get out of it. (Elderly care resident, Year 3)
Trainees reported a lack of standardized supervision agreements. Feeling a strong urge to function as independently as possible, residents asked for supervision only when they faced difficult or unusual situations. As a consequence, care on the wards in the nursing home was not always supervised, leading to residents' uncertainties about their actual level of competence.
I'm not aware of what I don't know. And I am afraid I won't learn that in the nursing home as well. (Elderly care resident, Year 1)
In particular, when patients' conditions remained more or less stable for a long time and did not require additional, out-of-hours medical care, residents expressed concerns about medical errors remaining undetected for a long period. The relatively low educational level of the nursing staff further added to this feeling.
They [the nurses] will be less inclined to ask critically: "Why do you do that?" (Elderly care resident, Year 1)
Although formal supervisory agreements were limited, residents described a lot of opportunities for informal interaction with other colleagues.
I don't share a room with my supervisor, but with one of the other physicians, and then conversations arise naturally. That works fine. You realize that everybody sees things differently. That's of great value. (Elderly care resident, Year 1)
Trainees described the nursing home as a safe learning environment. The open atmosphere and the absence of hierarchy made it easy for them to ask for help. The lack of formal agreements offered opportunities for shaping supervision according to one's preferences. Being trusted to work quite independently resulted in a gain of confidence.
That you are allowed to do many things on your own, realizing "Yes, I can do that!" (Family medicine resident)
The topics that family medicine residents brought up differed from those that elderly care residents raised. Family medicine residents commented mostly on the lack of structure, which apparently was in great contrast with the working environments (i.e., primarily hospitals and family practices) they had previously experienced. We also observed differences in the concerns of younger and native residents compared with older, immigrant residents. Within focus group 2, for example, which was composed of both young native Dutch residents and older, more often immigrant residents, discussions arose around how the residents value the particular characteristics of the nursing home. The young, native Dutch residents highly favored the freedom they encountered in nursing homes, whereas the older, more often immigrant residents seemed to struggle with the lack of structure. The latter also noted, specifically, that they struggled with the paucity of learning materials and structured teaching moments or supervision agreements. Their younger, Dutch colleagues preferred the informal possibilities for sharing knowledge and experiences.
We found a striking consensus regarding communication and teamwork. Most residents appreciated the huge learning opportunities arising from the need to communicate with patients, families, and other caregivers about often-difficult or sensitive topics. They emphasized the benefits of frequently having to tune in to different levels of understanding.
Residents characterized working and learning in a nursing home as "dealing with less." Specifically, residents had to deal with a loosely structured organization and a nursing staff not as well trained as in other contexts (e.g., the hospital). They described a paucity of advanced diagnostic or treatment options. Patients were restricted in their ways and levels of communication. Formal supervision was minimal, sometimes causing the residents to feel uncertain.
Interestingly, this process of dealing with less led to learning more. Contending with fewer resources and formal parameters stimulated the development of communication and management skills. The absence of advanced diagnostic technologies resulted in the development of clinical skills, expertise, and confidence in the physical exam. The need to think carefully about treatment options led to more deliberate decision making. Being around so many different types of health care professionals (e.g., occupational therapists, mental health workers) offered large learning opportunities, and working quite independently in a complex environment led residents to develop a strong sense of confidence.
Although, to our knowledge, no prior published research directly addresses the nursing home as a learning environment, our findings do resonate with the pivotal role of participation in everyday activities described for workplace learning in medical education in general.26–28 In addition, our study provides a deeper understanding of one of the most important features of workplace learning—namely, informal learning.29,30 Our study offers many examples of how residents are learning to become members of communities of practice both by interacting with others and by learning to deal with specific arrangements or circumstances. Working together with other health care professionals stimulates the development of communication and collaboration skills. On the one hand, residents need to recognize and adapt to the lower educational attainment of some of their colleagues on the interprofessional team, but on the other hand, residents acknowledge the learning opportunities that arise from getting to know each others' roles and competencies. Because of the lack of structure or formal teaching arrangements, residents need to find their own ways of carrying out tasks and fulfilling responsibilities in a complex social environment. Being placed in a situation in which dealing with less is a central feature prompts residents to make use of the resulting freedom offered in order to take care of patients properly. Our findings clearly show how both contextual and socioemotional factors add to the learning processes taking place in the nursing home, extending previous empirical reports on the importance of "developmental space" as a prerequisite for "learning by doing."31
The residents in our study reported a strong urge to work independently, requesting help only in difficult or unexpected situations. In other words, "care-as-usual" in nursing homes remains largely unsupervised, which could affect the safety of the patients involved. The pressure on junior doctors to work independently32,33 and the resulting tensions between trainee learning and patient safety34 have been previously described for clinical care in hospitals; our findings suggest that these tensions may be the same in nursing homes. Medical trainees, whether in a hospital or nursing home, are obliged to secure direct assistance for any situation that their limited expertise precludes them from handling alone, but attendings and supervisors must be available to respond in a timely manner to these requests.35 Research indicates that trainees' decisions about seeking clinical support are influenced not only by the particular clinical situation but also by the availability and approachability of supervisors.35
Participants in our study explicitly describe the nursing home as a safe learning environment with no hierarchy, making it easy to approach more senior colleagues for help; however, the direct availability of senior staff may be limited, as elderly care physicians often attend the patients at different, geographically dispersed nursing homes. In addition, Kennedy and colleagues32 used Lave and Wenger's36 legitimate peripheral participation framework and the migration theory as described by Amalberti and colleagues37 to explain how identity and organization issues may explain the urge for residents in teaching hospitals to function independently. We suppose that the motivation to identify with the community of autonomous doctors32,36 is the same for residents in nursing homes as it is for residents in hospitals. Further, the pressures to increase productivity and to earn positive assessments that cause residents in hospitals to move beyond the boundaries of safe practice27,32 are not likely to differ for residents in a nursing home. However, in the chronic medical care context of the nursing home, defining the boundaries of safe practice might actually be more complex. Patients in nursing homes often reside in such facilities for an extended period of time and do not always experience acute illnesses, making the decision to consult a more senior physician particularly difficult. To support residents and ensure patient safety, it is important that both residents and supervisors understand these processes. To reach this goal, faculty development programs and explicit team discussions may be helpful.32
We used the full potential of a grounded theory approach to characterize the nursing home as a learning environment, which we consider a great strength of the study. We conducted the interviews within already-existing resident groups, enhancing disclosure. The moderator was unknown to the participants, which enhanced honesty, but she was easily able to relate to the groups because of her experience as an elderly care physician and clinical supervisor. The assistant moderator, however, was a member of one of the groups herself. As the discussion within this particular group was comparable to the other interviews, we do not think her role has influenced our findings.
Data analysis was rigorous: Two researchers were involved in the coding process and used discussions to negotiate meaning and arrive at a greater level of understanding. All of the researchers were working as medical doctors in nursing homes. Although this might seem to compromise independent analysis, we think having hands-on experience in a nursing home led to a far more in-depth understanding of the processes at hand.
The main questions concerning the outcomes of any qualitative study are whether the results can be trusted and applied to other settings. The present study was carried out in a single medical school; however, the participants in our study were assigned to a great number of nursing homes within a large educational area. Two groups of residents were in their first year of the residency program, and their work experience within a nursing home ranged from 4 to 36 months; two other groups comprised residents in their third year of the program, and their experience ranged from 16 to 48 months. Further, all of the third-year residents had experienced working in at least two different nursing home facilities. Therefore, we think our study covers a broad range of experiences in many different nursing homes over a longer period of time, increasing generalizability.
This study has revealed some unique characteristics of the nursing home as a learning environment, which may inform the current debate about providing internships or clinical placements in nursing homes. In the Netherlands, medical care for patients in nursing homes generally entails making an individual treatment plan, including advanced care planning (e.g., decisions about starting or withdrawing treatment in various circumstances). Treatment goals, however, whether related to rehabilitation, chronic medical care, or end-of-life care, are generally different from goals set for hospital care, which, in turn, influences the educational goals of residents. Moreover, one of the main challenges in the nursing home is dealing with less, which—according to the residents in our study—often leads to learning more. This greater learning suggests that the nursing home is a suitable context not only for gaining geriatric knowledge and improving attitudes about geriatric patients but also for the development of complex communication and collaborative skills and other general competencies regarding organization, time management, and boundary setting. Additional research is needed to further explore learning objectives and learning outcomes for clinical placements in the specific context of a nursing home and to explore how learning and practice in the nursing home translate to practice in other clinical contexts.
We recognize that dealing with less might pose a challenge to novice medical practitioners. Part of the uncertainties that may arise in nursing home practice are covered or addressed, at our institution, during the off-the-job learning sessions residents engage in one day each week. The specific curriculum they are following resembles the American Medical Directors Association's initiative as described by Swagerty and Tarnove.38 But, to address in real time the uncertainties residents face in the nursing home workplace, we need high-quality supervision which would allow residents to learn and practice safely in an unstructured learning environment with limited medical opportunities. Our study suggests that, at least early in the residency program, closer supervision of the daily work of residents may be needed, to ensure both patient safety and the gradual development of residents' level of competence. As we found large differences between family medicine residents and elderly care residents from different backgrounds, supervisors should try to align their supervision to the particular needs of individual residents. This might be a subject to further study.
Finally, working closely together with other health care professionals may sometimes be difficult or challenging, but at the same time doing so offers great learning potential; in the areas of, in particular, rehabilitation, chronic medical care, and end-of-life-care, collaborative practice and the role of the physician in the decision-making process may be different from what trainees have learned in medical school. In the current study, we have looked at residents' experiences within the specific sociocultural environment of the nursing home. To further characterize this particular context as a learning environment for both medical and other health care students, future research should also include the experiences and perceptions of other professionals in the nursing home.
To our knowledge, this study was the first to identify characteristics of the nursing home as a learning environment. The main challenge in the nursing home is dealing with less; however, according to the residents in our study, fewer resources and less structure often lead to learning more. To ensure that great learning really happens, we call for high-quality supervision to support learners and their patients in nursing homes.
© 2014 by the Association of American Medical Colleges
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[edit] Background
Asphalt: Urban GT brings the freshest rides to the N-Gage platform. Choose your favourite from a wide variety of real brands and models, including Lamborghini, Audi and Morgan. Customize the appearance and fine-tune the engine, then show your opponents what you've got on unique tracks based on actual locations around the world. Compete to earn money, more cars and access to new locations, or just race against your friends with the Bluetooth connection. You can even drive a police car and catch your opponents!
[edit] Features
- Brands include Lamborghini, Audi TT, Lotus, Morgan and TVR
- Visual and performance tuning
- Excellent 3D graphics with true high speed feeling
- Unique racing tracks based on actual locations include Miami, Las Vegas, New York, Paris, and Ukraine
- Local multiplayer with Bluetooth wireless technology for up to four players
- Multiplayer modes include Time Attack (2-4 players), Championship (2-4 players) and Cop Chase (2 players)

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When Does Osgood Start?
Posted 14 March 2010 - 09:50 PM
Posted 15 March 2010 - 11:06 AM
- T-bone likes this
Welcome to the playoffs....where the games get better and the officiating gets worse.
Posted 16 March 2010 - 04:50 AM
Posted 16 March 2010 - 06:53 AM
"All done? Five bucks." - Pavel Datsyuk after an interview
"Very few cities in the NHL have the history or the following of the Detroit Red Wings." - Steve Yzerman
Be sure and check out my writing on Detroit Sports Nation
#25 Guest_mindfly (Guest)
Posted 16 March 2010 - 09:07 AM
Posted 16 March 2010 - 09:17 AM
To me Howard's last two starts againt Vancouver will pay a factor in the decision for sure. That being said, those starts can be used to make an argument for either Osgood or Howard to start. The poor performances in the last two games should light a fire under Howard's (and the rest of the roster's) ass to get some redemption and they should come out firing. On the other hand maybe you try to change things up and you go with Osgood.
No matter how you spin it you absolutely need to get every single point out of Edmonton and Columbus the rest of the way. Plus, the two remaining games against Nashville are huge so you need a minimum 3 of 4 points in those two games. Plus, you have games against teams like St. Louis and Minnesota so it's really anyone's guess as to when Osgood starts.
In all honesty, that Minnesota game on March 26 might be a half way decent game for Osgood to start. It's the first of a back-to-back game. It's in Detroit before they head on the road to travel to Nashville. It'd give Howard an extra night off to rest before a big game.
- zettie85 likes this
Posted 16 March 2010 - 09:30 AM
during warm-ups
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Texas Woman Makes Roster On Men's Professional Football TeamJennifer Welter is a doctor, a two-time Olympic gold medalist, and is now the first woman to be on the season opening roster of a men's professional football team.
Terrell Owens Released From Allen WranglersThe Allen Wranglers Indoor Football League team announced on Tuesday that co-owner and WR Terrell Owens has been officially released.
Terrell Owens Makes Allen Wranglers DebutTerrell Owens caught three passes, all for touchdowns, in his debut for the Allen Wranglers Saturday. Owens and the Wranglers defeated the Wichita Wild 50-30 to open the Indoor Football League season.
T.O. Will Play In The NFL AgainOwens signed a new deal to be a partial owner of the Allen Wranglers of the IFL as well as their starting wide receiver. Is he back?


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Added by AnyClip Subscribe 2 726
Published 28 Nov 2011
The clip taking a car from Bobby (2006) a lot of people are gonna be intimidated by this thing because it'...
The clip taking a car from Bobby (2006) a lot of people are gonna be intimidated by this thing because it's new, all right? So I'm counting on all of you to reassure them that it's perfectly legitimate, it's easy... Just-just for one minute, please. It's easy, and it makes voting simpler and quicker, all right? All you have to do is turn the plastic pages. Names and offices appear on the left. Simply make your choice and push down firmly in the proper place with the steel stylus attached to the vote recorder. All right? Now, when you're finished with that, take out the paper ballot. And I want you all to check, check the back of it, all right, to make sure that there are no stray bits of punched-out paper called "card-hole-aggregate debris." Or what the, uh, what the folks down at IBM like to call "chads." If I'd have worked this hard in school, I'd be on the honor roll. Hey, you think your brother will loan us his car again? Ah, I don't know. He was cool with it the first couple times, but now, I don't know. I can't do another day on this awful bus, Coop. -Me neither. -I hate it. Maybe if I was stoned. Well, yeah, stoned would be good whether we're on the bus or not. -Fellas. -Wade. -Wade. You guys are on the Glendale-Pasadena bus today. Well, no, uh, we were actually gonna come over here to tell you, we got a car today, Wade. Uh, Coop's brother comes through again. Really? Um, just think of the number of elderly we can help get to the polls with a car. I think we're much more valuable on our own. Yeah. Well, that's great. Maybe you can persuade them to go along with you. Every little bit counts, right? Uh, what precincts are you guys covering? Actually, Dwayne and I won't be in the field today. We're gonna stay here at campaign headquarters. That way, we can take care of any problems that come up. Yeah, we already received a call about stolen voting machines down in Precinct 180. I'm not familiar with that area. It's a black neighborhood. Oh, is it? Yeah, I guess busing doesn't really agree with you fellas, huh? I guess we got more in common than you think. Good luck. Ladies and gentlemen, if we could get...


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Remove Unnatural Link Penalty from Google
This project received 17 bids from talented freelancers with an average bid price of $667 AUD.Get free quotes for a project like this
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Project Description
Our website got an "unnatural link" penalty one week ago (a manual one I think). I will send you the link on request.
We need a company or individual who has the following skills, knowledge, and experience:
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Latest News
Mastery of Times Tables Competition
14 June 2016
On Tuesday 14th June 2016 a Year 5 team of four children and a Year 6 team of four children entered the Mastery of Times Tables Competition, which was held at Christ the King Catholic Academy.
Paul Maynard Visit
27 May 2016
On Friday 27th May, local MP Paul Maynard visited Years 5 and 6 to answer questions impartially about the EU referendum. His responses were informative and he was very impressed with the children's level of interest.
Choir of the Year 2015
31 March 2015
Some images from our performance at the annual Choir of the Year compeition at Blackpool Tower Ballroom in March.


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Rent Primary Mathematics and the Developing Professional 1st edition today, or search our site for other textbooks by Margaret Brown. Every textbook comes with a 21-day "Any Reason" guarantee. Published by Springer London, Limited.
Need help ASAP? We have you covered with 24/7 instant online tutoring. Connect with one of our Math tutors now.


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John Salvi
John C. Salvi III (March 2, 1972 – November 29, 1996) was an abortion opponent who carried out fatal shootings at two Planned Parenthood reproductive health clinics in Brookline, Massachusetts, on December 30, 1994, killing two and wounding five. These were the subject of intense media coverage. He was convicted, and later died in 1996 of an apparent suicide.
Planned Parenthood shootings[edit]
On December 30, 1994, John Salvi walked into a Planned Parenthood clinic in Brookline, Massachusetts. He shot and killed receptionist Shannon Lowney. In the second attack security guard Richard Seron returned fire. Salvi then dropped a bag containing a second gun and 700 rounds of ammunition and fled. Police were able to identify him from a gun shop receipt in the abandoned bag.[1]
John Salvi was captured in Norfolk, Virginia, after another Planned Parenthood shooting. On March 19, 1996, he was found guilty of murdering receptionists Lee Ann Nichols and Shannon Lowney. After an unsuccessful defense strategy related to Salvi's mental state, he was convicted in both killings.
The shooting at the Hillcrest clinic, in Norfolk Virginia, was also a clinic picketed by Donald Spitz, a known supporter of anti-abortion terrorism. It was reported by the Boston Globe that Salvi had Spitz's name and unlisted phone number on his person at the time of his arrest.[2][3] Spitz was never charged in connection with Salvi's activities. Spitz held a rally in support of Salvi outside of Norfolk City Jail.[4] Because of Spitz's support of Salvi, Spitz was told he was not welcome in Massachusetts.[5]
During Salvi's trial, the defense argued that Salvi suffered from schizophrenia. Several expert witnesses, including noted forensic psychiatrist Phillip J. Resnick, M.D., testified that Salvi exhibited schizophrenic behavior and was not competent to stand trial.[6] John's mother Anne Marie Salvi testified that her son had told her that he, "was the thief on the cross with Jesus."[7] The defense argued that Salvi told his parents that "...the mafia and KKK are out to get me".[8] The prosecution utilized the testimony of Bridgewater State Hospital psychologist Joel Haycock, who spent eleven days with Salvi out of his sixty days under observation at Bridgewater State Hospital. Haycock claimed Salvi purposefully chose not to give a narrative of the events of December 30, 1994, and concluded that Salvi had no mental disease at the time of the crime and was competent to stand trial. Salvi was found competent to stand trial and was found guilty.
Salvi's conviction was ultimately overturned by the sentencing judge. Judge Barbara Dortch-Okara invoked the legal principle that a conviction may not stand if the accused dies before his appeals are exhausted.[9]
John Salvi had extensive beliefs in a number of conspiracy theories. While considered by his defense as evidence of severe mental illness, many elements of his conspiracy beliefs reflected those of others on the extreme end of anti-abortion activism : "Shortly after his arrest he released a handwritten note alleging conspiracies of Freemasons, conspiracies to manipulate paper currency, and conspiracies against Catholics. ... He has talked about the Vatican printing its own currency and a specific conspiracy of the Ku Klux Klan, the Freemasons, and the Mob."[10]
Salvi was found dead in his prison cell at MCI Cedar Junction in Walpole, Massachusetts with a garbage bag over his head tied around his neck on November 29, 1996. The official report states that Salvi's death was a suicide.[11]
- ^ "An Armed Fanatic Raises the Stakes". Time. January 9, 1995.
- ^ Wrath of Angels, James Risen, p.368, ISBN 978-0465092734, 1999, Basic Books
- ^ *Christopher B. Daly (March 19, 1996). "Salvi Convicted of Murder in Shootings". The Washington Post.
- ^ Extremist groups: information for students, Volume 1 - Thomson/Gale, 2006
- ^ "Don Spitz unwelcomed in Massachusetts". Armyofgod.com. Retrieved 2016-06-15.
- ^ PBS Frontline. (1995). Salvi's Hearing Transcripts. Retrieved February 7, 2007.
- ^ PBS Frontline. (1996). Murder on "Abortion Row" - Transcript. Retrieved February 7, 2007.
- ^ "Salvi's Hearing Transcripts | Murder On Abortion Row | FRONTLINE". Pbs.org. Retrieved 2016-06-15.
- ^ The New York Times. (1997). Conviction in Killings at Clinics Is Overturned. Retrieved February 7, 2007.
- ^ "The Website of Political Research Associates". PublicEye.org. Retrieved 2016-06-15.
- ^ "Abortion clinic gunman dies John Salvi, who killed two at Mass. facilities, commits suicide in cell". Baltimore Sun. 30 November 1996. Retrieved 25 July 2015.
External links[edit]
- The John Salvi papers, 1994-1996 are located in the Northeastern University Libraries, Archives and Special Collections Department, Boston, MA.
- 1972 births
- 1996 deaths
- Murderers who committed suicide
- American spree killers
- American Roman Catholics
- Pro-life violence in the United States
- American conspiracy theorists
- American people who died in prison custody
- Attacks in the United States in 1994
- Prisoners who died in Massachusetts detention
- Perpetrators of religiously motivated violence in the United States
- Christian terrorism in the United States
- American people convicted of murder
- Deaths by firearm in Massachusetts
- Terrorist incidents in Massachusetts
- 1994 murders in the United States
- Spree shootings in the United States
- Attacks on Planned Parenthood facilities


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Best route map between Webster City, IA and Iowa Falls, IA. This route take about 35 Miles.
The distance and estimated time is placed on the right depending on the status of the road.
, 17:35
* You can see Webster City, IA and Iowa Falls, IA photos above. We provide this photos from Google Panoramio service.
* Webster City, IA weather as celsius: °C
* Iowa Falls, IA weather as celsius: °C
* Weather information on route, provide by Open Weather Map.
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You must have a pretty high opinion ofyourself!I'd say riding this piece of s---- for 3 yrs at nogain is long enough. The 3 yrs stagnation speaks foritself regardless of the investor. Everyone's investmentscenario/objectives/methods are different. If I'm so stupid and irresponsiblethen how'd I manage a 1300 % gain in my net positionover the last 15 months?


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Northside Christian Warriors dominate 6-C All-District selections
Northside Christian catcher Nicholas Zaunbrecher and pitcher Joseph Trahan talk in between innings during the Class C state championship game in Sulphur.
CROWLEY – To say the Northside Christian Warriors were dominant during their 8-0 march through District 6-C play this year would be an understatement.
The Warriors, who played just seven league games due to a forfeit by Singer, limited their opponents to just eight runs. Those eight runs all came late in the games when the Warriors had emptied their bench.
More impressively, the Warriors averaged just fewer than 20 runs per game in their league slate, posting a total of 137 runs in seven games.
That said, it was no surprise that the Warriors were rewarded with seven slots on the 6-C All-District team that was recently announced by the league's coaches.
Northside's Lane Marceaux and Nicholas Zaunbrecher topped the list of honorees by being named the Coach of the Year and the Most Valuable Player, respectively.
Marceaux led his squad to an impressive 24-5 record overall and guided his team to their first ever state championship two weeks ago when they defeated nemesis Claiborne Christian, 7-6, in nine innings.
Zaunbrecher, a senior catcher, hit for a district average of .600 with three doubles and 11 RBI. Overall, he hit .536 on the season with 16 doubles, seven triples and 25 RBI.
Joseph Trahan was named to the first-team as a utility player. The senior hit .523 in district with two doubles, one triple, two home runs and 12 RBI despite being walked numerous times. On the year, the University of Louisiana at Lafayette signee led the Warriors with a .667 average. Despite being walked 27 times, 13 intentionally, he logged 22 doubles, eight triples, eight home runs and 35 RBI.
Trahan also logged 48 innings on the mound this season where he posted a 5-2 record with a 3.07 ERA. He struck out 52 and walked 15.
Northside also nailed down three spots in the infield: second baseman Jordan Monte, shortstop Bradley Ancelet and third baseman Christian Morgan.
Monte hit .549 in league play with two doubles and eight RBI. The senior, who drove in the winning run in the championship game, hit .544 on the year with 17 doubles, three triples, one home run and 29 RBI.
Ancelet, a junior, hit for a .579 clip during the seven league games with two doubles, two triples and 12 RBI. On the year, he hit .536 with 16 doubles, seven triples and 25 RBI.
Morgan, a sophomore, hit .533 in league and .432 overall. He finished the year with nine doubles, one triple, one home run and a team-leading 42 RBI.
Dylan King grabbed a spot in the outfield and Nicholas Martin rounded out Northside's first-team selections at pitcher.
King, a senior, hit .533 in league and .350 overall. He six doubles and 16 RBI on the year.
Martin, a junior, went 3-0 in district play on the mound with a 2.30 ERA. He also hit .471 (.306 on the year) with one double and seven RBI.
Also making the first team at pitcher were Hackberry Samuel Ducote and Singer's Matthew Spears.
Hackberry's Kory Kyle made the team at catcher and Eric O'Banion of Starks got made the unit at first base.
Joining King in the outfield were Starks' Zack Dupre and Johnson Bayou's Garen Romero.
Utility players included Singer's Jonah Cavazos, Johnson Bayou's Derek Storm and Hackberry's Bret Bird.
Northside freshman Dillon Hayes and eighth grader Bryce Gatte were named to the second team.


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Acacia acinacea
Acacia acinacea is a flowering shrub growing to 2m in height. It is native to Australia and lives for 15 years (on average). They are tolerant of drought and frost. It is also a species of wattle, and is commonly known as Wreath Wattle, Gold Dust Wattle or Round-leaf Wattle.
They are a hardy, free-flowering species with very specific soil requirements. The requirements are that the soil is well-drained and non-saline, although it can tolerate many different types.
- ^ "Acacia acinacea". Australian Plant Name Index (APNI), IBIS database. Centre for Plant Biodiversity Research, Australian Government, Canberra. http://www.anbg.gov.au/cgi-bin/apni?TAXON_NAME=Acacia+acinacea. Retrieved 4 December 2012.
EOL content is automatically assembled from many different content providers. As a result, from time to time you may find pages on EOL that are confusing.
To request an improvement, please leave a comment on the page. Thank you!


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Makro deephunter Pro Metal Detector System
Makro deephunter is everything you need in one single device! Ideal for deep treasure & relic hunting, coin shooting, gold prospecting and more.List Price: $7,999.95Special: $5,700.00 (Save over $2200)
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Clarence Darrow defended 104 men who faced the death penalty. Not one was ever hanged. He defended the weak and the strong, but never the strong against the weak. The play touches on the most famous Darrow cases such as the Scopes trial, his defence of Leopold and Loeb, and the bombing of the Los Angeles Times.
Presented in-the-round.
Spacey returns to Old Vic in 'barnstorming' Clarence Darrow - 6 Jun 2014
Video: Kevin Spacey discusses Richard III, Clarence Darrow and his new documentary - 5 Jun 2014
Clarence Darrow (Old Vic) - 5 Jun 2014
Theatre highlights of the week: Clarence Darrow opens and Blithe Spirit closes - 2 Jun 2014Read more related articles


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Milwaukee's Fatty Acids, Sat. Nite Duets join forces for new music video
Individually, the Fatty Acids and Sat. Nite Duets deliver some of the city's most interesting shaggy rock and quirky music videos. But with their forces combined, the two bands are a force to be reckoned with.
To celebrate the release of a new split seven-inch "Torrential Zen," the bands have come together for a nearly 10-minute, two-song music video that debuted today on AOL's music blog Spinner, titled "Riverwest Side Story." (It was naturally filmed in Riverwest.) »Read Full Blog Post
Actor John C. Reilly brings character to concert at Miller Caves
The Miller Caves, underneath the brewery that not only made Milwaukee famous but also helped define the city itself, apparently never seemed, until Sunday night, like a place to hold a concert.
In retrospect, after the very first such event courtesy of John C. Reilly and Friends, the historic location was a small club waiting to happen: The painted backdrop of cavorting (presumably) Germans had retro style, as did the overhead lamps and the high-arched ceiling. »Read Full Article(4)
What does strange press release from 'Mad Men' mean?
Two minutes after the end of Sunday's "Mad Men" episode - filled with personal drama, some of it involving, Pete, Bob, Ted and Peggy - AMC, I presume sent out this press release.
With Peggy listed as the contact, it is presumably the press release Peggy was told to prepare a few weeks ago on the show, announcing the new name of the merged advertising agency. »Read Full Blog Post(3)
Central Bark Fido Fest unleashes the fun
A fine time for canines
This may be the warmest and fuzziest festival of all. »Read Full Article
Museum fundraiser; 'Fondy Soulbration' market; 'Walk, Run and Wag' 5K
Take a seat
Milwaukee's historic house museums are offering patrons a seat at their annual fundraising event Wednesday. And, afterward — guests can take the chairs with them. The Villa Terrace Decorative Arts Museum and the Charles Allis Art Museum have been blessed with chairs — or artistic riffs on chairs — created by local artists for this auction at 6 p.m. at the Villa Terrace. The seats range from an old easy chair dressed as a cozy grandmother to a pew made from doors to a partial-chair that's now totally sculptural. Other seats for auction are ones at theatrical productions, sporting events or a table in a local fine dining establishment. The evening also features live music, hors d'oeuvres and a cash bar. Tickets are $25. Making a reservation would be appreciated and can be done by calling Ann Steinbach at (414) 278-8295 Ext. 5, but it isn't mandatory. Visit www.charlesallis.org/cavtgalleryofchairs.html »Read Full Article


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Banana Cream Pie Smoothie & Pinkberry Founder's Kitchen
Today's Delicious Links• Banana Cream Pie Smoothie - from Cooking Light. • Fresh Produce Farmers Market Letterpress Card Pack - from YeeHaw. We have some of these cards and we love them. • Curly Maple Natural edge Cosmic cheeseboard / trivet and cutting board - From Wook Woodworking. • Pinkberry's sleek look...in a home kitchen - At the Wall Street Journal. (via Tastespotting)
Found a new product? Made a great recipe? Have a delicious link to share?
Send us a tip!
Send us a tip!


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Top Definition
When you sit between two guys in fubu jackets on the subway
I forgot my jacket, so I got on in a subway sleeping bag to warm up.
作者 kurt cosmic 2011年5月07日
Trending Now
Can you define these popular missing words?
Sitting between two guys in FUBU jackets on the subway. (Saturday Night Live, 5/7/11)
I got a nice nap on my way home because Jerome and Tyrone made a nice subway sleeping bag for me.
作者 funkypeepz 2011年5月08日


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The Wisdom of Charlie Munger
Global investing expert Nicholas Vardy explains the wisdom of Charlie Munger, vice chairman of Berkshire Hathawa.y and long-time partner of Warren Buffett.
Why It's Time to Invert Tax Inversion
Global investor Nicholas Vardy discusses how America could deter companies that seek to leave its shores by offering them more favorable tax plans.
You'll Never Guess the Top-Performing Stock Markets of 2015
Global investing expert Nicholas Vardy reveals the nations that have performed the best in 2015 and examines promising stocks for each country.
Why You Should Never Let a Hedgehog Manage Your Money
Investment guru Nicholas Vardy explains the "hedgehog" and "fox" investing styles and why one of these strategies is dangerous for investors' portfolios.
Why I Think Commodities May Have Bottomed
Global investment expert Nicholas Vardy examines the history and trends of the global commodities market to determine whether it has bottomed.
What is Factor Investing?
Global investment expert Nicholas Vardy explains factor investing and the secrets behind the strategy's success.
The World's Top Global Cities Today and Tomorrow
Cities play a central role in the global economy. And their importance is growing by the day. The leading global cities in the world are the centers of innovation, commerce, media, culture and politics that are the drivers of human progress.
A Global Q3 Slaughterhouse
When it came to bombed-out sectors during Q3, there was plenty of structural damage to go around.
The Sweet-Tasting Success of Irish Austerity
Ireland-based food giant Kerry Group Plc (KRYAF) is well known for its ingredient and flavors business. This week, the company celebrates the opening of a €100 million global technology and innovation center near the town of Naas, just outside of | Read More »
Three (Relatively) Bullish Views on the U.S. Stock Market
After experiencing its first technical correction of 10% since 2011, the U.S. stock market has bounced back from the lows it reached on Aug. 24. Since then, volatility has eased and the S&P 500 has recovered almost 7%. I already | Read More »
The Global Stock Market Washout
Last week, I discussed how BRIC investing went bust. Well, as it turns out, I may have unfairly picked on the BRICs. After all, investors everywhere on the planet are having a rough time. In the past, it has been | Read More »
How the BRICs Came Down to Earth
The popularity of the acronym "BRICs" — which stands for the fast-growth economies of Brazil, Russia, India and China — spread like wildfire in the post-financial-crisis world. Coined by ex-Goldman Sachs economist Jim O'Neill in 2003, the BRICs came to | Read More »
Why This May Be the Best Week of the Year to Pile into Stocks
What a week it has been… During the course of the past five sessions, the S&P 500 has corrected by 10%. Yesterday, it suffered its worst day of trading since 2011. And the Shanghai stock market tumbled 19% during the past | Read More »
Profit from the Cable-Cutting Mega Trend
The way in which Americans are consuming media is undergoing a revolution. Early 2015 marked the first time in history that the number of pay-TV subscribers in the United States dropped. During Q2, 566,000 customers "cut the cord" to pay | Read More »
Is the Bull Run in Biotech over?
In a bull market that's six-plus years old, bull runs in hot sectors become increasingly scarce commodities.
What's That Got to Do with the Price of a Big Mac in China?
I've written about The Economist magazine's "Big Mac Index" many times in The Global Guru. But if you're new to this quick and dirty but useful method of measuring the relative values of global currencies, then here's the basic idea. | Read More »
2015: How to Make Money in this Lousy Year
It is turning out to be a tough 2015 for stock market investors. The U.S. S&P 500 is trading where it was back on March 31. Fundstrat's Thomas Lee recently noted that this has been only the second time since | Read More »
The 'Soft Power' of Donald Trump
**************************************** Note from the Publisher For all of you dividend fans out there, I am thrilled to announce that we have added www.DividendInvestor.com to the Eagle family of products. With screening tools, an all-star ranking of dividend stocks, the best | Read More »
The Global Market First-Half Scorecard
We are now just past the halfway mark of 2015. And as the French say: "plus ça change, plus c'est la même chose." Loosely translated, this means "the more things change, the more things stay the same." And looking at | Read More »
Investing in the Jewel of Southeast Asia
I can't say what made me fall in love with Vietnam — that a woman's voice can drug you; that everything is so intense. The colors, the taste, even the rain. Nothing like the filthy rain in London. –Graham Greene, | Read More »


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Your link to Wisconsin's land, air and water resources
Walker tells Senate to get going on mining
Gov. Scott Walker prodded the Republican-controlled state Senate to take up mining legislation on Thursday in his weekly radio address, saying that Wisconsin "should not have to wait for many months for action."
Walker commended the Assembly for holding a hearing today in Hurley on mining, with members of that house saying this week that they will move forward on drafting legislation that would give mine developers more regulatory certainty.
"I believe they recognize and are ready to address that the current process is unreasonable and is costing our state thousands of good-paying jobs," Walker said, referring to the Assembly. »Read Full Blog Post(259)
Bad River tribe opposes iron ore mine near Hurley
Madison - Hours before leaders were slated to meet this afternoon with Gov. Scott Walker in Madison, the Bad River band of Lake Superior Chippewa said Wednesday that it opposes the development of a proposed iron ore mine near Hurley.
The tribe said that it believes an open pit mine in a range of hills in the same watershed as the tribe can't be developed without harming the surrounding environment.
"The Bad River watershed is one of those places that should not be mined. It's that simple," Michael Wiggins Jr., the tribal chairman, said at a capitol news conference." »Read Full Blog Post(214)
Walker to meet with tribal leaders on mine
Gov. Scott Walker is scheduled to meet on Wednesday with leaders of the Bad River band of Lake Superior Chippewa, and possibly other Wisconsin tribal leaders, to discuss mining legislation.
Meanwhile, the Bad River tribe will hold a news conference in the Senate parlor of the Capitol at 10:30 a.m. before its meeting with Walker to stake out its position on the proposed iron ore mine near Hurley.
The tribe has previously gone on record as opposing the project. »Read Full Blog Post(4)
DNR secretary weighs in on mining, deer and climate change
Natural Resources Secretary Cathy Stepp said Tuesday the state's mining laws are "very old" and need to be updated.
Stepp also said the agency is close to naming a new "deer trustee" to advise the Department of Natural Resources on deer policy. She also declined to state her beliefs about climate change.
The Republican appointee told Steven Walters of WisconsinEye that her agency would play only a technical role in new mining legislation - it will be up the Legislature to decide whether mining laws needs to be rewritten. »Read Full Blog Post(94)
Four Republicans oppose Walker's bid to end reycling mandate
Four Republican lawmakers have criticized Gov. Scott Walker's proposal to end the mandate on local governments to run recycling programs.
The Republicans all said the mandate is needed to assure that waste is recycled and not thrown into landfills.
They are: Senate President Mike Ellis (R-Neenah,) Sen. Rob Cowles (R-Green Bay,) and Reps. Robin Vos (R-Burlington) and John Nygren (R-Marinette.) »Read Full Blog Post(80)
Walker's wetlands bill getting fast-tracked
Gov. Scott Walker's legislation to side-step environmental reviews of projects involving small wetlands in Brown County is getting fast-tracked in the Legislature.
The legislation is widely believed to help a proposed commercial development near Lambeau Field favored by the Green Bay Packers.
The Assembly Natural Resources Committee will hold a hearing on the bill on Wednesday and plans to vote on the measure Thursday, the office of Rep. Jeffrey Mursau, the committee chairman says. Mursau is a Republican from Crivitz. »Read Full Blog Post(14)


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Cowboy Bebop
Season 1
Toys in the Attic
There's an intruder on the Bebop! A strange organism roams the ship and its touch causes great illness. One by one, the members of the crew fall prey to it. Is it an alien invader? A disease? Soon, only Spike and Ed are left to deal with this dangerous creature.
Bohemian Rhapsody
Tollbooths at the interstellar travel gates have become the scene of high-tech robberies, and there's a large bounty for the culprit. The Bebop's crew pools its information and tries to track down the mastermind behind all this, but their only clue is a seemingly worthless chess piece.


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Fred Katz
His scores for cult movie classics such as Little Shop of Horrors (Rhino, 1984), backing tracks for Ken Nordine's offbeat Word Jazz series (Dot, 1957) and holy grail novelties like Harpo in HiFi (Mercury, 1957) and Sidney Poitier reading Plato, Journeys Inside the Mind (Warner Brothers, 1970) make Katz a giant among collectible musical obscurities. A child prodigy on both piano and cello and a professor of anthropology for 22 years, there is much more to him than historical footnote. Katz is also a serious musician and superb composer who studied with the great classical cellist Pablo Casals and he continues to maintain contemporary insight into a myriad of topics both musical and philosophical. The recent release of his prescient ethnic/poetic/jazz journey Folk Songs for Far Out Folk (Warner Bros.-Reboot) on CD for the first time, nearly a half-century after it was recorded, served as an initial entré into his current doings and as fodder for some looks backward.
As Katz remembers, "The record was released in 1958 so it's going back a few years. I was known as a writer and an arranger, they knew me as a player, but my arranging and writing was getting out there. So Warner Bros. found out about me somehow and asked me to do an album on Brigitte Bardot but for some reason it didn't go through I don't know why because I would have loved to have met her. So instead [guitarist] Alvino Rey came over the house and he asked me if I would like to do an album for Warner Bros. and then it suddenly occurred to me, because I have always been interested in different cultures, the jazz experience, which to us means the improv experience, was indigenous to every culture, so I decided to pick the American and the African and then eventually the Hebrew."
Hamilton's group had some of the finest musicians of the time in it and several like Collette and saxophonist/flutist Paul Horn appear on these cuts. Three separately recorded sessions present folk tunes in a very contemporary jazz format as the camaraderie among disparate tunes like "Sometimes I Feel Like a Motherless Child" and "Mate'Ka" are exposed through jazz. In addition, Katz enlisted beat poet Lawrence Lipton to write a poem representing each culture. Katz remembers a young pianist in the studio who would go on to greatness as a composer: "I walked into the studio and there was this guy Johnny Williams playing the piano. I wrote this arrangement on "Sometimes I Feel Like a Motherless Child" and I left room for improv and as Johnny was playing he said, Fred, there is no bass part. I said, I did this on purpose because I want you to make your own bass part as you play so there would be more polyphony going on and he did itforgetting his composing he was a wonderful jazz player and, if you follow the piece, he is playing these wonderful beautiful lines without any bass and that's quite interesting."
The Hebraic session features a piece entitled "Rav's Nigun" which, upon mention, sets Katz off onto multiple topics. "I was teaching Anthropology and I had in my class this woman who used to bring her husband who happened to be a Rabbi. One day he invited me to the house for a real Friday night dinner. We had a wonderful time, he did the prayers in Hebrew and sang and it was absolutely a night of magic. At the end of the evening he gave me this book on Hasidic and Chabad melodies of the 17th and 18th century. The first one goes sort of andante (singing the tune). I wondered how would that sound fast (singing the tune); You can hear it on the album and the reason why I made it fast is because I want the Rabbi to really dance...I wanted to express the feeling of dancing with ecstasy...dancing with the Holy Spirit to achieve a moment of unity, a sense of wonder, a sense of magic."
About Fred Katz
CD/LP/Track Review
- Folk Songs For Far Out Folk by Michael P. Gladstone
- Folk Songs for Far Out Folks by Eyal Hareuveni
CD/LP/Track Review
- Folk Songs for Far Out Folk by Dan McClenaghan
- Folk Songs For Far Out Folk by Troy Collins


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The very kind staff at the Aquatic Center went above and beyond the call of duty by walking with me to a deputy sheriff outside monitoring the parked cars. The deputy called her supervisor, and another deputy was at the facility to assist me within 20 minutes. What could have been a disastrous ending to a weekend of great swimming was graciously and quickly resolved by their hospitality, and we were on our way home.
"Thank you" seems inadequate. I could not have been more pleased. The city of Augusta should be very proud.
Debbie Kosater, Macon


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Best Car I ever owned
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USD-JPY had been showing a gain of over 0.5% versus the Japanese currency, before the yen rebounded from intraday weakness. There seemed to a relief rally at play in currency and global asset markets, with investors deeming Clinton to have got the better of Trump in the first presidential debate by the two (markets not liking Trump's protectionist view on trade). Rebounding stock markets had aided the yen lower in the Tokyo session, in ... Read More ►
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Markets decided that Clinton had the edge in the first presidential debate of the campaign, which prompted rallies in the Mexican peso and Canadian dollar given Trump's anti-NAFTA stance and generally protectionist views on trade. The peso was off its highs but was showing just over a 1.5% advance on the dollar as of the early European PM session. The Canadian buck was showing a fractional gain, having given back intraday gains. The greenback, ... Read More ►
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The Mexican peso and the Canadian dollar rallied on what appears to be a generally perceived victory, at least from the perspective of financial markets, for Clinton in the first presidential debate of the campaign. Trump's protectionist views on trade (he said during the debate that NAFTA was the worse trade deal that the U.S. had ever signed) doesn't sit too well with markets. The peso rallied by over 1.5%, driving USD-MXN to an eight-day lows below ... Read More ►
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Risk-off conditions weighed on the dollar through the N.Y. morning session on Monday, though the unit bounced some following the London close. USD-JPY remained heavy into the close however, printing 100.25 lows. EUR-USD topped at 1.1279, though eased back under 1.1260, with the announcement of Italy's constitutional referendum (December 4) prompting some position squaring. USD-CAD pulled back from the 1.3200 level to base at 1.3136, as oil prices rallied, ... Read More ►
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HOME Miami Hurricanes Gear Miami Hurricanes Womens Miami Hurricanes Womens Accessories Miami Hurricanes Womens Accessories Travel (6 items) Product ID: 1722980
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- Padded laptop and tablet compartments
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LIMA, Peru (AP) - When the smoke and tear gas cleared after President Alberto Fujimori's inauguration, key government buildings smoldered, six people lay dead and dozens were injured.
But the long-term effects appeared to be both a new blot on Fujimori's already tarnished record and a setback for the opposition, which failed to keep its promise of a nonviolent demonstration.
"If what we seek is to build a democratic society we must proceed in an orderly way, with prudence and without veering from the path," Fujimori told Congress on Friday during his inaugural speech for an unprecedented third five-year term.
"The armed forces and police should reconcile themselves to the new period of peace that characterizes our nation," he said.
Meanwhile, seven blocks away, hundreds of protesters chanting "There is no president!" fought with riot police, who fired tear gas directly into the crowds.
As the street fighting spread, three air force fighter jets in formation swooped low over Lima's historic center.
Six bank guards died in a blaze, allegedly started by demonstrators, that destroyed the state-run Banco de la Nacion.
Alejandro Toledo, the former opposition candidate, boycotted the May 28 presidential runoff, claiming it was rigged in Fujimori's favor. He laid most of the blame for Friday's violence on infiltrators from the National Intelligence Service.
"I can tell you that our program has been peaceful. Nevertheless, we were met with brutal repression," Toledo said. "We have received information that the intelligence service penetrated the marchers with 100 agents who provoked acts of violence."
Gen. Fernando Dianderas called Toledo's accusations "an insult to the intelligence of the Peruvian people."
"I deny it emphatically," he said during a news conference confirming the deaths of the bank guards.
Julio Carrion, a Peruvian political scientist at the University of Delaware, said he believed the intelligence service likely had "a hand" in some of the violence.
"But it would be disingenuous to blame everything on the intelligence service," said Carrion, speaking by telephone from the United States.
In any case, he said, the violence could signal a resurgence of "heavy-handed tactics" by Fujimori to retain his grip on power.
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Happy Birthday To The Blog!
Today is the 2nd birthday of the Texas Agriculture Law Blog. When I began this project in June 2013, I never imagined the growth, support, and contacts that this website would generate! As of June 1, we nearly 750 subscribers and nearly 18,000 page views per month. Last year, this blog was named one of the Top 100 Legal Blogs (Blawgs) by the American Bar Association. My favorite accolade, however, is when readers let me know that something they found here was useful for their operation and family! As always,… Read More →
Texas Landowner Liability Part II: Premises Liability – Legal Status and Duty Owed
As we discussed in Part I of this series, when a plaintiff is injured due to a condition on the defendant's land, he or she may recover only under a premises liability claim. In analyzing this type of claim, the first question to ask is what duty was owed by the landowner. The answer to this question generally depends on which of the three the legal categories the plaintiff fits: invitee, licensee, or trespasser. Invitee A person who enters the land with the owner's knowledge and for the mutual… Read More →
Question from Tiffany's Desk: Forum Selection Clauses
Question: Recently I got a question asking whether Texas law recognizes contractual provisions requiring claims to be brought in a certain place. For example, is a contractual term that provides, "any dispute arising under this contract shall be heard in the courts of the state of Colorado" valid? Answer: These clauses, known as "forum selection clauses" are generally enforceable in Texas so long as certain conditions are met. The purpose of enforcing these clauses is to protect the legitimate expectations of the contracting parties and to further the interests… Read More →
Questions from Tiffany's Desk: How Do I Select an Attorney?
People frequently ask my advice on how to select an agricultural law attorney. Having been in private practice for four years, I understand the importance of finding the right attorney for your legal issue. Importantly, there is no one-size-fits-all plan to selecting the right attorney for you, and, as you might expect, the right attorney for one farmer's issue may not be the right attorney for the farmer down the road. Here are a few important points to consider when you are selecting an attorney. 1. Can you have… Read More →
Top 100 Legal Blog Award
I am excited and honored to announce that the Texas Agriculture Law Blog has been named a Top 100 legal blog by the American Bar Association. To view the Top 100 list, click here. Thank you to those who nominated us! Now, the competition continues. The 100 winners have been divided into 13 separate categories. This blog is in the "Niche" category. The ABA is allowing people to vote for their favorite blog in each category and will name a winner for each in December. I need your… Read More →
Questions from Tiffany's Desk: My Neighbor Wants to Build a Fence…
Question: My neighbor wants to build a fence on the property line dividing our land because he wants to run cattle on his property. I do not object to his desire to have livestock on his land or his building the fence. He insists that I pay for half of the fence. Do I have a legal responsibility to help finance this fence that will be built on the property line? Answer: No, Texas case law makes clear that a landowner has no legal obligation to help finance… Read More →
New Mexico Green Chile Advertising Act
As a native New Mexican, the fall means that it is my favorite time of the year….green chile season. My home state is famous for our flavorful green chile crop and for good reason! New Mexico recently passed an interesting law to ensure that only green chile that is truly New Mexican may be advertised as such within the state. This law illustrates the importance of this agricultural crop to the State of New Mexico and helps to ensure truth in advertising. Because numerous other states have similarly… Read More →
Registration Open for the American Agricultural Law Association Annual Symposium
Attention to all you agricultural attorneys out there! The American Agricultural Law Association will be holding our annual AALA symposium in Albuquerque, New Mexico, October 19-21, 2014. I've been attending this CLE for 5 years now and always find it very informative and a great opportunity to meet with ag attorneys from across the country. I am a member of the planning committee and can tell you that there are great sessions and presenters planned for the program, including topics like The 2014 Farm Bill, Water Law Hot… Read More →
ABA Blawg 100 Nominations
It's that time of year again when the American Bar Association is seeking nominations to help it decide on the Top 100 law blogs ("Blawgs"). The ABA is accepting nominations from now until August 8, 2014. To nominate the Texas Ag Law Blog, just click here and fill out the quick nomination form. And for your reading pleasure, here are a list of the Top 100 Blawgs last year!


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Vibia, headquartered in Barcelona, Spain, designs and manufactures modern and contemporary lighting and living accessories. The entire Vibia line features works by prominent designers known for superb European lighting.
The Tree Outdoor Lamp is available with the following:
- White UV-resistant polythene diffuser
- White lacquered base
- Tree is bolt mounted to surface (hardware not included)
- 70" Black power cord
- ETL Listed for Wet locations
- Made in Spain
- Designed by Pete Sans
Size: Small, Large
- Large option utilizes two 36 Watt 120 Volt PL-L 2G11 Base Fluorescent lamps (not included).
- Small option utilizes two 24 Watt 120 Volt PL-L 2G11 Base Fluorescent lamps (not included)
Compare Brightness:
LumensThe amount of light that comes from a bulb, which has commonly been measured in watts. The more lumens, the brighter the bulb.
WattageA measurement of the power delivered to a component of an electric circuit (allowing a one-ampere current to flow through the component under the pressure of 1 volt.)
Bulb ShapeBulb shapes are denoted with a letter, which describes the shape, and a number, which indicates the size. The number indicates the diameter of the light bulb at its widest part in eighths of an inch.
BaseThe part of the bulb that connects to the fixture and its power supply. Bulb bases are denoted with the letter E, and a number which indicates the diameter of the bulb base at its widest part in millimeters.
VoltageIndicates how much voltage a bulb can accept via the fixture it's installed in.
Light Color TemperatureThe relative color from a light source, measured on the Kelvin temperature scale. Warm light is lower in color temperature (2700-3000 K) and cool, blue light is higher (5000 K).
Average Rated LifeThe average amount time that a bulb is expected to last.
CRICRI = color rendering index. This number, which can go from 0 to 100, measures the ability of a light or bulb accurately renders colors. The higher the number, the better, with most quality bulbs these days measuring at least in the 80s.
- Small Option Fixture: Height 72.5", Diameter 17"
- Large Option Fixture: Height 102", Diameter 23.5"
- Small Option Base: Diameter 14.25"
- Large Option Base: Diameter 19.75"
Manufacturer IDs: view
Need help with some of our terminology? Check out Lumens' Lighting & Design Glossary.
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text: P . A . T . Pat Jones OPELOUSAS P.A.T. is from Opelousas, Louisiana and has been seriously doing music since '02 traveling just about everywhere in the nation building up the awareness of his presence in the music world! With his 1st BIG project just recently hitting the masses(NO ROOFTOPS Pt.1 FUN-DA-MENTAL TRILL~O.G hosted by DJBEDTYME357), you would thank that even if he wasn't looking for another family, someone has to be ringing their phones off the hook for features and the option of making a major move here in the Music World! Couldn't believe this guy worked for SoSo Def/Virgin Records or did shows all over NYC,Fla,Vegas,Cali, Texas,Various other places & of course Louisiana? Well if not check into it on his myspace and youtube pages -/WHATCHAKNO- and you will see Louisiana's Finest on the stage with Snoop Dogg, Dougie Fresh, Jazze Pha, Lil Wayne, Slim Thug, David Banner, JadaKiss, JD and Nelly and im sure you get the drift that somethings bound to happen! The music is witty and nothing short of AMAZING, "if it sounds UnBELIEVEable just Believe ME it is, No Rooftops is just saying im here, WATCH WHEN I TAKE YOU INSIDE YOU WILL KNOW THAT YOU HAVE A DIFFERENT KIND OF ARTIST THAT YOU'VE BEEN WAITING FOR A LONGTIME!!" P . A . T .'s tracks Soul For Real [BONUS] Feat. KXNG Crooked I by P . A . T . published on 2016/04/02 23:35:09 +0000 Horrible Dreams by P . A . T . published on 2015/10/05 11:22:28 +0000 Urban Trends Radio Commercial by P . A . T . published on 2015/07/19 23:12:47 +0000 MADE IN SOUTH DROP by P . A . T . published on 2015/03/09 03:00:24 +0000 BIG BANK - #WESTCOAST FLAVOR by P . A . T . published on 2015/01/30 10:24:06 +0000 REALEST LYRICAL "HISTORY LESSON" OK COOL!!! by P . A . T . published on 2014/12/17 13:00:19 +0000 BET Cypher ReCap & Rap by P . A . T . published on 2014/12/03 10:51:50 +0000 Flyest ONE feat K-Chill by P . A . T . published on 2014/10/14 04:14:30 +0000 Judgement Come by P . A . T . published on 2014/10/10 23:09:07 +0000 MILLION BUCKS prod by Chris Prythm by P . A . T . published on 2014/05/29 07:17:27 +0000