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23.7 hrs • 10/4/2016 • Unabridged
A literary tour de force of a detective's ceaseless hunt for an elusive criminal By Gaslight is a deeply atmospheric, haunting novel about the unending quest that has shaped a man's life. William Pinkerton is already famous, the son of the most notorious detective of all time, when he descends into the underworld of Victorian London in pursuit of a new lead on the fabled con Edward Shade. William's father died without ever finding Shade, but William is determined to drag the thief out of the shadows. Adam Foole is a gentleman without a past, haunted by a love affair ten years gone. When he receives a letter from his lost beloved, he returns to London to find her. What he learns of her fate, and its connection to the man known as Shade, will force him to confront a grief he thought long-buried. A fog-enshrouded hunt through sewers, opium dens, drawing rooms, and séance halls ensues, creating the most unlikely of bonds: between Pinkerton, the great detective, and Foole, the one man who may hold the key to finding Edward Shade. Steven Price's dazzling, riveting By Gaslight moves from the diamond mines of South Africa to the battlefields of the Civil War, on a journey into a cityscape of grief, trust, and its breaking, where what we share can bind us even against our darker selves.Available Formats: CD, Download
By Gaslight23.7 hrs • 10/4/16 • UnabridgedCD
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18.1 hrs • 9/20/2016 • Unabridged
In The Four Swans, the sixth book in Winston Graham's legendary Poldark saga, Ross is faced with a new battlefield, one involving the women whose lives are intertwined in his own. Cornwall, 1795-1799: although Ross Poldark, now something of a war hero, seems secure in his hard-won prosperity, a new dilemma faces him in the sudden infatuation of a young naval officer for his wife Demelza. All four women—the four swans—whose lives touch Ross's, face a crisis in these years. For his wife Demelza, his old love Elizabeth, for his friend's new wife Caroline, and for the unhappy Morwenna Chynoweth, these are times of stress and conflict.Available Formats: Download
The Four SwansRead by Oliver J. Hembrough18.1 hrs • 9/20/16 • UnabridgedDownload
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14.5 hrs • 7/12/2016 • Unabridged
A sweeping saga about four generations of a family who live and love on an enchanting Mediterranean island off the coast of Italy—combining the romance of Beautiful Ruins with the magical tapestry works of Isabel Allende Castellamare is an island far enough away from the mainland to be forgotten but not far enough to escape from the world's troubles. At the center of the island's life is a café draped with bougainvillea called the House at the Edge of Night, where over generations the community gathers to gossip and talk. Amedeo Esposito, a foundling from Florence, finds his destiny on the island with his beautiful wife, Pina, whose fierce intelligence, grace, and unwavering love guide her every move. An indiscretion tests their marriage, and their children—three sons and an inquisitive daughter—grow up and struggle with both humanity's cruelty and its capacity for love and mercy. Spanning nearly a century, through secrets and mysteries, trials and sacrifice, this beautiful and haunting novel follows the lives of the Esposito family and the other islanders who live and love on Castellamare: a cruel count and his bewitching wife, a priest who loves scandal, a prisoner of war turned poet, an outcast girl who becomes a pillar of strength, a wounded English soldier who emerges from the sea. The people of Castellamare are transformed by two world wars and a great recession, by the threat of fascism and their deep bonds of passion and friendship, and by bitter rivalries and the power of forgiveness. Catherine Banner has written an enthralling, character-rich novel, epic in scope but intimate in feeling. At times, the island itself seems alive, a mythical place where the earth heaves with stories—and this magical novel takes you there.Available Formats: CD
The House at the Edge of NightRead by Edoardo Ballerini14.5 hrs • 7/12/16 • UnabridgedCD
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9.0 hrs • 3/15/2016 • Unabridged
From internationally bestselling author Tracy Chevalier, a riveting drama of a pioneer family on the American frontier 1838: James and Sadie Goodenough have settled where their wagon got stuck—in the muddy, stagnant swamps of northwest Ohio. They and their five children work relentlessly to tame their patch of land, buying saplings from a local tree man known as John Appleseed so they can cultivate the fifty apple trees required to stake their claim on the property. But the orchard they plant sows the seeds of a long battle. James loves the apples, reminders of an easier life back in Connecticut; while Sadie prefers the applejack they make, an alcoholic refuge from brutal frontier life. 1853: Their youngest child, Robert, is wandering through Gold Rush California. Restless and haunted by the broken family he left behind, he has made his way alone across the country. In the redwood and giant sequoia groves he finds some solace, collecting seeds for a naturalist who sells plants from the new world to the gardeners of England. But you can run only so far, even in America, and when Robert's past makes an unexpected appearance, he must decide whether to strike out again or stake his own claim to a home at last. Chevalier tells a fierce, beautifully crafted story in At the Edge of the Orchard, her most graceful and richly imagined work yet.Available Formats: CD
At the Edge of the OrchardRead by Mark Bramhall, Hillary Huber, Kirby Heyborne, and Cassandra Morris9.0 hrs • 3/15/16 • UnabridgedCD
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30.7 hrs • 3/8/2016 • Unabridged
Called "a Russian Thorn Birds," The Bronze Horseman by Paullina Simons is a sweeping saga of love and war that has been a monumental bestseller all over the world. The golden skies, the translucent twilight, and the white nights all hold the promise of youth, of love, and of eternal renewal. The war has not yet touched this city of fallen grandeur or the lives of two sisters, Tatiana and Dasha Metanova, who share a single room in a cramped apartment with their brother and parents. Their world is turned upside down when Hitler's armies attack Russia and begin their unstoppable blitz to Leningrad. Yet there is light in the darkness. Tatiana meets Alexander, a brave young officer in the Red Army. Strong and self-confident, yet guarding a mysterious and troubled past, he is drawn to Tatiana—and she to him. Starvation, desperation, and fear soon grip their city during the terrible winter of the merciless German siege. Tatiana and Alexander's impossible love threatens to tear the Metanova family apart and expose the dangerous secret Alexander so carefully protects—a secret as devastating as the war itself—as the lovers are swept up in the brutal tides that will change the world and their lives forever.Available Formats: Download, CD
The Bronze HorsemanRead by James Langton30.7 hrs • 3/8/16 • UnabridgedDownload
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23.4 hrs • 3/1/2016 • Unabridged
In a compelling, richly researched novel that draws from thousands of letters and original sources, bestselling authors Stephanie Dray and Laura Kamoie tell the fascinating, untold story of Thomas Jefferson's eldest daughter, Martha "Patsy" Jefferson Randolph—a woman who kept the secrets of our most enigmatic founding father and shaped an American legacy. From her earliest days, Patsy Jefferson knows that though her father loves his family dearly, his devotion to his country runs deeper still. As Thomas Jefferson's oldest daughter, she becomes his helpmate, protector, and constant companion in the wake of her mother's death, traveling with him when he becomes American minister to France. It is in Paris, at the glittering court and among the first tumultuous days of revolution, that fifteen-year-old Patsy learns about her father's troubling liaison with Sally Hemings, a slave girl her own age. Meanwhile, Patsy has fallen in love—with her father's protégé William Short, a staunch abolitionist and ambitious diplomat. Torn between love, principles, and the bonds of family, Patsy questions whether she can choose a life as William's wife and still be a devoted daughter. Her choice will follow her in the years to come, to Virginia farmland, Monticello, and even the White House. And as scandal, tragedy, and poverty threaten her family, Patsy must decide how much she will sacrifice to protect her father's reputation, in the process defining not just his political legacy, but that of the nation he founded.Available Formats: Download, CD
America's First DaughterRead by Cassandra Campbell23.4 hrs • 3/1/16 • UnabridgedDownload
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12.5 hrs • 2/16/2016 • Unabridged
With everyone onboard harboring dark secrets and at least one person determined to make sure the airship doesn't make the return trip, Flight of Dreams gives an utterly suspenseful, heart-wrenching explanation for one of the most enduring mysteries of the twentieth century. On the evening of May 3, 1937, Emilie Imhof boards the Hindenburg. As the only female crewmember, Emilie has access to the entire airship, from the lavish dining rooms and passenger suites to the gritty engine cars and control room. She hears everything, but with rumors circulating about bomb threats, Emilie's focus is on maintaining a professional air … and keeping her own plans under wraps. What Emilie can't see is that everyone—from the dynamic vaudeville acrobat to the high-standing German officer—seems to be hiding something. Giving free rein to countless theories of sabotage, charade, and mishap, Flight of Dreams takes us on the thrilling three-day transatlantic flight through the alternating perspectives of Emilie; Max, the ship's navigator who is sweet on her; Gertrud, a bold female journalist who's been blacklisted in her native Germany; Werner, a thirteen-year-old cabin boy with a bad habit of sneaking up on people; and a brash American who's never without a drink in his hand. Everyone knows more than they initially let on, and as the novel moves inexorably toward its tragic climax, the question of which of the passengers will survive the trip infuses every scene with a deliciously unbearable tension. With enthralling atmospheric details that immediately transport and spellbinding plotting that would make Agatha Christie proud, Flight of Dreams will keep you guessing till the last page.Available Formats: CD
Flight of Dreams12.5 hrs • 2/16/16 • UnabridgedCD
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9.5 hrs • 1/26/2016 • Unabridged
For a small-town girl with big-city dreams, there is no address more glamorous than New York's Barbizon Hotel. Laura, a patrician beauty from Smith, arrives to work at Mademoiselle for the summer. Her hopelessly romantic roommate, Dolly, comes from a working-class upstate town to attend secretarial school. Vivian, a brash British bombshell with a disregard for the hotel's rules, rounds out the trio of friends. Together, the girls embark on a journey of discovery that will take them from the penthouse apartments of Park Avenue to the Beat scene of Greenwich Village to Atlantic City's Steel Pier—and into the arms of very different men who will alter their lives forever.Available Formats: Download, Digital Rental
Searching for Grace KellyRead by Kristin Kalbli9.5 hrs • 1/26/16 • UnabridgedDownload
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11.0 hrs • 1/26/2016 • Unabridged
From the writings of Marie Nicolaevna Romanavna, age nineteen, July 17, 1918, midnight, in bed with her sister Anastasia (Shvybz), in the Ipatiev Mansion in Ekaterinburg, during the last night of their lives: "So much of my story unfolds by moonlight. This is a tale of midnight wakings and forced marches before dawn. Since this nightmare began, I do not dare undress, even to go to bed. I wear my dressing gown, my hair is prepared, and my shoes are set beside me. I have no idea when we will be summoned to rise. We have moved, as in the worst of dreams, slowly toward this place. There is no logic other than the sleepwalker's obedience—to follow instruction which we cannot resist: an actual lunacy. "Now, I have control only of this—my record of what happened to us, to me. I have committed a single sin, my one terrible transgression. I pray to be absolved. In this recording of memory lies all meaning to my life. Let my will prevail in this, my ultimate wish, to salvage something of value from this tragedy. The rest, as my mother says, is in God's hands." Here, in startling new historical detail, based on original diaries and letters, is the Romanov tragedy told from the point of view of the Tsar's third daughter, Marie, Anastasia's closest, older sister. Marie's story is unique—only Marie crossed the frozen Siberian river with her parents, and only Marie shared the full seventy-eight days and nights in "The House of Special Purpose".Available Formats: Download, Digital Rental
The Passion of Marie RomanovRead by Lillian Webb and Travis Smith11.0 hrs • 1/26/16 • UnabridgedDownload
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14.0 hrs • 1/12/2016 • Unabridged
From the bestselling author of Pompeii comes the third installment in the most provocative and brilliant saga of Rome and its power struggles since I, Claudius. With Dictator, Robert Harris brings the saga of Cicero's life to a time when some of the most epic events in human history occurred: the collapse of the Roman republic, the subsequent civil war, the murder of Pompey, and the assassination of Julius Caesar. Yet the question it asks is a timeless one: How is political freedom to be safeguarded against the triple threat of unscrupulous personal ambition, of an electoral system dominated by vested financial interests, and of the corrupting impact of waging ceaseless foreign wars? And in the very human figure of Cicero—brilliant, flawed, frequently fearful, and yet ultimately brave—Harris gives us a hero for both his own time, and for ours.Available Formats: CD
DictatorRead by David Rintoul14.0 hrs • 1/12/16 • UnabridgedCD
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21.5 hrs • 11/24/2015 • Unabridged
From the bestselling, acclaimed author of Tully and The Bronze Horseman comes the unforgettable love story between a college-bound young woman and a traveling troubadour on his way to war—a moving, compelling novel of love lost and found set against the stunning backdrop of Eastern Europe. Chloe is just weeks away from heading off to college and starting a new life far from her home in Maine when she embarks on a great European adventure with her boyfriend and two best friends. Their destination is Barcelona, but first they must detour through the historic cities of Eastern Europe to keep an old family promise. Here, in this fledgling post-Communist world, Chloe meets a charming American vagabond named Johnny, who carries a guitar, an easy smile—and a lifetime of secrets. From Treblinka to Trieste, from Karnikava to Krakow, from Vilnius to Venice, the unlikely band of friends and lovers traverse the old world on a train trip that becomes a treacherous journey into Europe's and Johnny's darkest past—a journey that jeopardizes Chloe's plans for the future and all she ever thought she wanted. But the lifelong bonds Chloe and her friends share are about to be put to the ultimate test—and whether or not they reach Barcelona, they can only be certain that their lives will never be the same again. A sweeping, beautiful tale that mesmerizes and enchants, Lone Star will linger long in the memory once the final words are read.Available Formats: Download, CD
Lone StarRead by Lauren Saunders21.5 hrs • 11/24/15 • UnabridgedDownload
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58.2 hrs • 9/8/2015 • Unabridged
James A. Michener's masterly chronicle of South Africa is an epic tale of adventurers, scoundrels, and ministers, the best and worst of two continents who carve an empire out of a vast wilderness. From the Java-born Van Doorn family tree springs two great branches: one nurtures lush vineyards, the other settles the interior to become the first Trekboers and Afrikaners. The Nxumalos, inhabitants of a peaceful village unchanged for centuries, unite warrior tribes into the powerful Zulu nation. And the wealthy Saltwoods are missionaries and settlers who join the masses to influence the wars and politics that ravage a nation. Rivalries and passions spill across the land of The Covenant, a story of courage and heroism, love and loyalty, and cruelty and betrayal, as generations fight to forge a new world.Available Formats: Download
The Covenant58.2 hrs • 9/8/15 • UnabridgedDownload
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37.5 hrs • 8/25/2015 • Unabridged
Already a renowned chronicler of the epic events of world history, James A. Michener tackles the most ambitious subject of his career: space, the last great frontier. This astounding novel brings to life the dreams and daring of countless men and women—people like Stanley Mott, the engineer whose irrepressible drive for knowledge places him at the center of the American exploration effort; Norman Grant, the war hero and US senator who takes his personal battle not only to a nation, but to the heavens; Dieter Kolff, Hitler's rocket scientist, whose specialty is a rare commodity in this new era; Randy Claggett, the astronaut who meets his destiny on a mission to the far side of the moon; and Cynthia Rhee, the reporter whose determined crusade brings their story to a breathless world.Available Formats: Download
Space37.5 hrs • 8/25/15 • UnabridgedDownload
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65.0 hrs • 8/25/2015 • Unabridged
Texas: a land of sprawling diversity and unparalleled richness; a dazzling chapter in the history of our nation, a place like no other on earth. Through the remarkable lives of four families, this epic saga spans four centuries and two continents and charts the dramatic formation of several great dynasties from the age of the conquistadors to the present day. A richly compelling novel of a proud people eager to meet the challenge of the land, Texas is James Michener's most magnificent achievement.Available Formats: Download
Texas65.0 hrs • 8/25/15 • UnabridgedDownload
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57.2 hrs • 8/4/2015 • Unabridged
In this sweeping epic of the northernmost American frontier, James A. Michener guides us through Alaska's fierce terrain and history, from the long-forgotten past to the bustling present. As his characters struggle for survival, Michener weaves together the exciting high points of Alaska's story: its brutal origins; the American acquisition; the gold rush; the tremendous growth and exploitation of the salmon industry; the arduous construction of the Alcan Highway, undertaken to defend the territory during World War II. A spellbinding portrait of a human community fighting to establish its place in the world, Alaska traces a bold and majestic saga of the enduring spirit of a land and its people.Available Formats: Download
Alaska57.2 hrs • 8/4/15 • UnabridgedDownload
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12.7 hrs • 8/4/2015 • Unabridged
Written to commemorate the Bicentennial in 1976, James A. Michener's magnificent saga of the West is an enthralling celebration of the frontier. Brimming with the glory of America's past, the story of Colorado—the Centennial State—is manifested through its people: Lame Beaver, the Arapaho chieftain and warrior, and his Comanche and Pawnee enemies; Levi Zendt, fleeing with his child bride from the Amish country; the cowboy, Jim Lloyd, who falls in love with a wealthy and cultured Englishwoman, Charlotte Seccombe. In Centennial, trappers, traders, homesteaders, gold seekers, ranchers, and hunters are brought together in the dramatic conflicts that shape the destiny of the legendary West—and the entire country.Available Formats: Download
Centennial12.7 hrs • 8/4/15 • UnabridgedDownload
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text:
The talk of taking the design of a desktop personal computer beyond a dull, beige box with a similarly boxy, beige monitor on top has been around for a few years. But with the proliferation of new technologies over the last year, that talk may soon become reality.
So say industry design executive and research analysts, who note the declining cost of flat-panel displays, increasing availability of high-speed Internet access and adoption of the Wi-Fi high-speed wireless networking technology by industry giants Intel and PC makers at large.
"My personal feeling on what we've been observing in the direction and design of the desktop PC is that it's going through a significant renaissance," said Chris Landry, design center manager, strategic design and innovation, at Hewlett-Packard's Personal Systems Group.
"And that's based on technologies that were available a couple of years ago but are now much more usable," Landry said. "The days of the CRT (cathode-ray-tube) sitting on top of a rectolinear box on your desk or under the desk on the floor and tethered to a mouse and keyboard are really, in our view, behind us."
Of course, the desktop PC with the CRT monitor will be around for some time yet, as corporations need computers for workers that are cheap and essentially commodities. Tens and tens of millions of traditional desktop PCs were sold last year, and more will be sold this year.
To be sure, so-called "all-in-one" PCs have been around for a few years, but with the exception of Apple Computer's iMac, introduced in 1998, none has been a smash hit. Apple has sold more than six million of the bulbous, translucent futuristic iMac computers.
"The thing about the CRT-based all-in-one unit is that, as a category, it's a dog. No one has had any success with it except Apple," said Roger Kay, an analyst at market researcher International Data Corp. "Typically, it's almost like a dumb idea, like a fish with wings."
"The concerns many buyers have with all-in-ones is you can't refresh elements, and you have very little upgrade flexibility with an all-in-one," Kay said.
The high-tech graveyard is full of futuristic designs, many spawned in the dot-com bubble and boom of the late 1990s. National Semiconductor unveiled a reference design for a Web-surfing tablet that wasn't picked up much by industry.
Networking company 3Com touted its Web-surfing gizmo, dubbed Audrey, designed to fit comfortably on a kitchen counter, but 3Com ultimately ditched Audrey and jettisoned its consumer electronics business, also spinning off handheld maker Palm.
There was also Apple's Newton, a cult hit with some die-hard Apple users and an early precursor to personal digital assistants such as H-P's iPaq or the Palm device, but Apple ultimately pulled the plug on that as well.
To be fair, these examples of failed new designs in an industry not generally lauded for its industrial design expertise, came before the technologies that could connect these devices to the Internet and other devices really took off, and at prices consumers and businesses would pay.
Take broadband, or high-speed Internet access. Leichtman Research Group says that, at the end of the third quarter of 2002, the leading cable and DSL providers in the United States had more than 15.6 million high-speed Internet subscribers. Leichtman says that broadband ranks as one of the most rapidly adopted products or services in U.S. history.
Couple broadband with Wi-Fi and the picture gets pretty compelling for new designs that may actually take off this time around, experts say.
A quickly growing segment of the PC market, spurred largely by Wi-Fi and broadband, is the "tablet PC," which typically comes in two forms — the convertible, which has a folding keyboard, or the slate, which uses a stylus, Kay said.
"Tablets are gaining in popularity," Kay said, noting that his firm believes the convertible form of a tablet PC will be more popular, because the general feeling is that users aren't ready to give up things like keyboards.
And one design that H-P's Landry believes shows promise is the Scout, a design known in the industry as a 'tweener, because it's bigger than a PDA but smaller than a thin-and-light notebook.
About the size of an old-fashioned day planner, the flat-panel screen tilts up and has a retractable keyboard.
In discussions with customers, Landry says people often say about H-P's popular iPaq that they wish it had a larger keyboard or a larger display.
"In my personal opinion, that's where I'd put my money right now," Landry said, declining to say when such a product might hit store shelves.

subset: commoncrawl


text:
Aims and objectives
To present the findings of a structured literature review that aimed to identify the influences on the health, safety and welfare of adults with learning disabilities in acute hospitals.
Correspondence: Caroline Bradbury-Jones, Research Fellow, University of Dundee, School of Nursing & Midwifery, 11 Airlie Place, Dundee DD1 4HJ, UK. Telephone: +44 (0)1382 384919.
E-mail: email@example.com
To present the findings of a structured literature review that aimed to identify the influences on the health, safety and welfare of adults with learning disabilities in acute hospitals.
There is increasing evidence regarding the inadequacy of care for people with learning disabilities in acute care settings. However, few studies have specifically addressed their health, safety and welfare in such contexts.
Four key electronic databases (Medline; PsycINFO; British Nursing Index and archive; Cumulative Index to Nursing and Allied Health Literature) were searched for relevant literature published between 2000 and 2011.
Publications assessed as meeting the inclusion criteria were retrieved in full. Data were extracted regarding methods used; primary aims of the study being reported; and key findings.
Of the 3505 papers identified in the initial search, eight met the inclusion criteria. Analysis revealed six areas of influence on the health, safety and welfare of adults with learning disabilities in acute hospitals: care provision (meeting health and personal needs); communication; staff attitudes; staff knowledge; supporters; and carers (valuing their role); physical environment.
We represent these six areas diagrammatically, as concentric rings. These influence on health, safety and welfare form an inner (direct) layer and an outer (indirect) layer consisting of liaison services and education/training. This new conceptualisation of influences as being multi-layered assists in the identification of similarly multi-layered improvement strategies.
Adults with learning disabilities can exert their own influence on health, safety and welfare and should be supported to make decisions about their own care. More broadly they should be involved with policy development, nurse education and research. This can be achieved through inclusive approaches, for example, inviting people with learning disabilities to input into nursing curricula or to engage in research as coinvestigators.
There is significant evidence that many people with a learning disability – an irreversible lifelong condition that starts at or around birth that comprises a significant global intellectual impairment with a functional IQ of < 70 and impairment of adaptive behaviour (Brown et al. 2010) – have greater health needs than the general population (Brown 2005, Disability Rights Commission 2006). Concurrent disabilities such as epilepsy, cerebral palsy and mental illness are common (Brown & Censullo 2008), which increase the likelihood of requiring contact with health services by almost twofold, compared to the rest of the population (Brown & MacArthur 2006). Paradoxically, however, people with learning disabilities are likely to have higher levels of unmet health needs (Campbell 2007, Kent 2008).
There is mounting empirical evidence regarding the inadequacy of secondary care for people with learning disabilities (Cumella & Martin 2004, Alborz et al. 2005, Mencap 2007, Gibbs et al. 2008, Backer et al. 2009, Webber et al. 2010). Indifference, ignorance and lack of education and training among doctors and nurses (Mencap 2011); systemic institutional discrimination (Michael 2008); and overall breaches of human rights (House of Commons & House of Lords: Joint Committee on Human Rights 2008) appear to be endemic.
The significant health needs of people with learning disabilities, coupled with enduring deficits in hospital care, make the need for further research more pressing (Brown & MacArthur 2006, Brown et al. 2010). However, this is an under-researched area that is only beginning to attract attention. Reviews of evidence have focussed on access, rather than provision of services (Alborz et al. 2005, Brown & Censullo 2008, Backer et al. 2009). Moreover, rather than focusing specifically on secondary care, many studies include community and non-health services, for example Alborz et al. (2005), Melville et al. (2005) and Jones et al. (2008). Serious injury and death, however, are also likely to occur when people with learning disabilities are admitted to hospital. To address the gap in knowledge, we undertook a review of empirical evidence regarding the promotion of health, safety and welfare of adults with learning disabilities in acute care settings. The purpose of this article is to report the findings of the review. Learning disability affects the people across the globe, and the issues we discuss are likely to transcend geographical boundaries. Thus, the article holds international relevance.
The aim was to understand the factors that influence the health, safety and welfare of adults with learning disabilities in acute care settings. The review questions were:
To address the research questions, we conducted a structured review of the empirical literature.
Relevant published literature was identified by searching four key electronic databases (Medline; PsycINFO; BNI and archive; CinAHL). Search strings were developed for each database according to the following search architecture (see Table 1 for a detailed example of the search string used to search PsycINFO and BNI):
|Search strings for PsycINFO and BNI and archive (number of publications)
|1 exp Safety Management/ or exp Safety/ (51,966)
|2 exp Risk Management/ (151,314)
|3 exp Patient Advocacy/ (23,998)
|4 exp 'Wounds and Injuries'/ (586,481)
|5 exp Self-Injurious Behavior/ (47,459)
|6 exp Accidents/ (131,852)
|7 exp Violence/ (103,931)
|8 exp Restraint, Physical/ (11,341)
|9 exp Accident Prevention/ (48,516)
|10 exp Abuse Reporting/ or exp 'Abuse of Power'/ or exp Emotional Abuse/ or exp Physical Abuse/ or exp Sexual Abuse/ or exp Patient Abuse/ or exp Verbal Abuse/ (40,237)
|11 exp Injuries/ (610,839)
|12 exp patient violence/ (901)
|13 exp Risk Assessment/ (130,822)
|14 exp Physical Restraint/ (11,341)
|15 exp Learning Disabilities: Abuse/ (59)
|16 exp Patients: Welfare/ (1803)
|17 exp 'Seclusion and Restraint'/ (446)
|18 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 (1,013,443)
|19 exp Learning Disorders/ (43,305)
|20 exp Mental Retardation/ (108,552)
|21 exp Developmental Disabilities/ (20,998)
|22 exp Special Education/ (31,684)
|23 exp Learning Disabilities/ (41,050)
|24 exp Mental Retardation/ (108,552)
|25 exp Special Needs/ (2363)
|26 exp Down's Syndrome/ (22,504)
|27 exp 'Mental Retardation (Attitudes Toward)'/ (690)
|28 exp Mild Mental Retardation/ (3741)
|29 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 (189,077)
|30 exp Hospitals/ (184,220)
|31 exp Inpatients/ (15,910)
|32 exp Hospitalization/ (141,089)
|33 exp Patients/ (124,297)
|34 inpatient.mp. (49,453)
|35 patient.mp. [mp=ps, rs, ti, ot, ab, nm, hw, ui, tc, id] (1,601,440)
|36 exp Hospitalized Patients/ (8917)
|37 exp Partial Hospitalization/ (5886)
|38 exp Hospitals, General/ (9443)
|39 exp Hospitals, Community/ (9320)
|40 exp Hospitals, Private/ (11,886)
|41 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 (1,901,480)
|42 18 and 29 and 41 (1535)
|43 remove duplicates from 42 (1502)
The search took place during March 2011. Where more than one database was searched simultaneously, results were de-duplicated. No limits or filters were applied. Titles and abstracts of the publications found by this search strategy were independently scrutinised by two of the authors (CB-J & SM). Decisions regarding whether to include or exclude each publication were made according to clearly formulated criteria (Table 2).
|Include if publication
|Exclude if publication
Those publications assessed as meeting the inclusion criteria were retrieved in full. The reference lists of these publications were searched to identify any further publications. Two members of the research team (CB-J & SM) independently examined full-text copies of all selected articles. Consensus was then reached by consultation with the rest of the team regarding the stepwise approach that led to the included article (See Fig 1).
Assessing the methodological quality of qualitative studies using composite scales has been hotly debated and contested (Emerson et al. 1990). We therefore performed a global assessment of study quality, dichotimised according to whether it appears to be 'strong' or 'weak' (see Table 4). Strong studies are likely to include, amongst other things, clear exposition of methods of data collection and analysis, triangulation of data, respondent validation and reflexivity. We also considered the nature of the evidence reported in the qualitative studies and assessed these in terms of the 'typologies' of their findings as described by Sandelowski and Barroso (2003). These authors suggest that findings of qualitative studies can be classified on a continuum of data transformation, from findings that are not qualitative (no finding, topical survey), to ones that are exploratory (thematic survey), descriptive (conceptual/thematic description) or explanatory (interpretive explanation). Given that the typologies are conceptualised as a continuum, it is possible for a study's findings to be rated at the junction between two categories (Table 3).
Key study parameters were examined and summarised in tabular form, focusing primarily on overall methodological rigour of the included studies. Data were extracted from included publications regarding the methods used; the primary aims of the study being reported; and key findings related to our research questions.
A synthesis of study data pertinent to each of the review questions was performed. The synthesis included the categorisation of relevant study findings.
Eight publications met all inclusion criteria. Details of the included articles are shown in Table 4. Two of these publications (Sowney & Barr 2006, 2007) report on the same study (although the two publications report selectively different findings). Thus, seven studies in total were included in this review. All seven studies adopted qualitative methods, although Iacono and Davis (2003) also conducted a questionnaire survey. Two studies (Cumella & Martin 2004, Brown & MacArthur 2006) collected data at a conference event. Five studies were conducted in the UK, with the remaining two conducted in Australia. Collectively, the articles reported a range of stakeholder perspectives, specifically, healthcare professionals (Hannon 2004, Brown & MacArthur 2006, Sowney & Barr 2006, 2007, Webber et al. 2010) and adults with learning disability and their parents, carers and supporters (Iacono & Davis 2003, Cumella & Martin 2004, Hannon 2004, Brown & MacArthur 2006, Gibbs et al. 2008).
|Study (first author)
|Country of study
|Study type/s
|Study participants
|Study purpose/aims
Qualitative and Quantitative:
Questionnaire survey with follow-up in-depth interviews
Questionnaire respondents: 328 inpatients from three Victorian style institutions, 119 of whom had attended a general hospital in the previous year
Follow-up in-depth interviews with nine people concerning eight patients; one with an intellectual disability; five with cerebral palsy; two mothers of people with cerebral palsy; and one support worker
|To determine whether needs of people with developmental disability were met during visits to emergency departments
Consensus development: plenary and small group problem-solving methods
|80 people, 40 participants each at two purposeful conferences. Participants were people with a learning disability; their supporters, family, professionals and managers
|To describe the problems faced by people with a learning disability when in a general hospital, and to attain consensus on possible solutions for these problems
Process evaluation using semi-structured interviews and focus groups
|20 participants: four with a learning disability; five family members/carers; six hospital staff; five learning disability nurses
|To identify key factors influencing the health care process and to evaluate the impact of a pre-admission assessment tool
Facilitated focus group at a conference event
|112 delegates of a conference event. Primarily from health services (including nurses, managers, AHPs, doctors, midwives) but also from the independent sector (including social services, higher education, carers and a service user)
|To identify a new research agenda focusing on improving the health care of people with learning difficulties in General Hospitals
|2006, 2007
Focus groups
|27 accident and emergency nurses
|To explore the experiences of nurses in accident and emergency units caring for people with intellectual difficulties
Focus groups
|25 participants: 11 adults with intellectual disabilities; nine parents and five paid carers
|To describe the experiences of adults with intellectual difficulties and their carers in general hospitals
In-depth longitudinal interviews
|Interviews with a range of individuals focused on 17 group home residents with intellectual difficulties from 13 group homes. In total, 55 participants were interviewed (17 family members; 16 house supervisors; 11 accommodation programme mangers; 11 staff in aged care facilities)
|To explore the hospitalisation experiences of older adults with intellectual disabilities
Whilst eight publications were included in this review, a further two (Glasby 2002, McMurray & Beebee 2007) were deemed to be of relevance. Although eligible for exclusion rather than inclusion (due to failure to fully report empirical methods), the studies provide useful information to help answer the review questions and are therefore integrated into the discussion. Similarly, the substantial grey literature (charters, reports and professional practice guidance) was excluded from the review. However, because of the pertinence of this literature, we have used it extensively in the discussion to triangulate against the review findings.
Analysis revealed six areas of influence: care provision (meeting health and personal needs); communication; staff attitudes; staff knowledge; supporters and carers (valuing their role); physical environment (see Table 5). The six areas are mapped to the research questions as represented in tabular form (Table 6). Findings can be represented as concentric layers of influence (Figure 2) that operate in an inward direction upon the person with learning disabilities.
|Care provision
|Staff attitudes
|Staff knowledge
|Supporters & carers
|Physical environment
|Sowney 2006
|Sowney 2007
|Influences that promote or compromise health, safety and welfare
|Strategies to promote health, safety and welfare
|Implications for research, policy and practice
|Care provision
|Degree to which personal and healthcare needs are met
|Availability of appropriate equipment and aids
|Fiscal investment in such resources
|Use of relevant assessment tools
|Provision of education and training
|Ability to communicate own needs
|Availability of resources such as videos, accessible booklets, augmentative and alternative communication and pictures/symbols
|Fiscal investment in such resources
|Ability to be understood
|Use of communication passports
|Provision of education and training
|Staff attitudes
|Extent to which care is provided in non-discriminatory, non-stigmatising way
|Under-graduate curricula that bring students into direct contact with people with learning disabilities
|Provision of education and training in a range of learning disability contexts
|Staff knowledge
|Degree of knowledge regarding learning disabilities among nurses and other healthcare professionals
|Under-graduate curricula that bring students into direct contact with people with learning disabilities and learning disability services
|Provision of education and training in a range of learning disability contexts
|Provision of learning disability liaison services
|Fiscal investment in learning disability services
|Supporters and carers
|Presence of supporters and carers
|Valuing carers' contribution to care and using the information they provide
|Fiscal investment in resources to support carers
|Supporting carers and providing them with information and respite
|Provision of education and training
|Physical environment
|Extent to which the hospital environment is de-alienated
|Preliminary visit to hospital and preadmission assessments
|Fiscal investment in creating improved physical environments
|Appropriate signage and relaxed environment
|Future research into aspects of safety
Six studies highlighted the issue of care provision, with significant emphasis on inadequate care. Iacono and Davis (2003) reported that people in their study did not get enough to eat (13%) or drink (18%), and almost half of the people who needed special eating utensils did not have access to these. Similarly, patients had not been given fluids (Gibbs et al. 2008), had been presented with a written menu that they did not understand (Cumella & Martin 2004), or had food removed uneaten (Webber et al. 2010). Neglect of toileting needs was also highlighted. Thirty-nine per cent of patients in the study by Iacono and Davis (2003) could not get to the toilet when needed, and similarly, Webber et al. (2010) reported that continent adults with learning disabilities were given continence pads, rather than taken to the toilet.
Failing to obtain help moving from bed was experienced by 11% of people in the study by Iacono and Davis (2003). Such lack of assistance may explain why one person in the study by Gibbs et al. (2008) was reported to have been injured by bed sides. Lack of adapted facilities meant that one patient in the study by Cumella and Martin spent six weeks in hospital without a bath. Moreover, unresponsive staff resulted in inadequate management of bed sores and failure to feed patients (Cumella & Martin 2004). However, among these largely negative experiences, there were some positive practices. For example, a woman with learning disability recounted how a nurse stayed with her while she was having a bath in case she slipped (Iacono & Davis 2003).
In terms of treatment, care of adults with learning disabilities in hospitals is often suboptimal. Cumella and Martin (2004) reported that people with learning disability in their study received inferior quality of medical treatment including lack of attention to epilepsy and failure to prescribe appropriate medication. Similarly, 12% of people in the study by Iacono and Davis (2003) did not obtain the correct medication, and 22% did not obtain their medication on time. Overall, most articles highlighted a picture of neglected treatment needs. However, this needs to be tempered by the findings of Hannon (2004) who reported that service users in their study had all received appropriate treatment.
There are strategies to overcome such challenges. Brown and MacArthur (2006) argue that specialist equipment aids and adaptation are necessary to ensure appropriate care. Hospitals could consider a central store of such equipment (Cumella & Martin 2004). Assessment of specific issues or problems such as pain and distress for such patients can be challenging, but assessment tools such as the Disability Distress Assessment Tool are being developed and validated (Brown & MacArthur 2006). Similarly, pain scales can be used, particularly in combination with information provided by carers or relatives (Sowney & Barr 2006).
Communication was highlighted as a core issue in all but one of the articles. There are a number of concerns. People with learning disabilities frequently have difficulty communicating their needs. For example, of the 119 people with recent hospital experiences in Iacono and Davis' (2003) study, 51 were unable to convey their needs to staff. Similarly, they do not always understand healthcare professionals (Gibbs et al. 2008), and the use of jargon exacerbates this problem (Hannon 2004). From the perspective of nurses, Sowney and Barr (2007) report that many have difficulty understanding non-verbal communication of people with learning disabilities, particularly when assessing pain. Factors associated with poor communication include a rushed environment (of an emergency department); time constraints; and inadequate documentation accompanying the patient (Sowney & Barr 2007). Yet again, the situation is not solely negative. Iacono and Davis (2003) report that most people in their study were given an explanation for why they had been in hospital and what to do after discharge. Similarly, Hannon (2004) reported on the largely positive aspects of communication.
Cumella and Martin's study (2004) highlighted several strategies regarding the preparation of people with learning disabilities for admission (where possible) using resources such as videos and accessible booklets. Improving information about choices whilst in hospital was also discussed using, for example, a communication passport (Cumella & Martin 2004, Brown & MacArthur 2006), augmentative and alternative communication (AAC) or pictures/symbols to help with decisions such as meal choice (Cumella & Martin 2004). Similarly, participants in the study by Brown and MacArthur (2006) suggested several aids to communication, such as health advice sheets, books, CDs and a key ring with symbols. In relation to emergency department attendance, Sowney and Barr (2007) suggest that where possible carers should make contact, outlining any special needs or circumstances. It is then incumbent upon nursing staff to develop appropriate plans for the assessment and care of the person's needs (Sowney & Barr 2007).
It is clear from this review that discrimination towards people with learning disabilities is endemic. Gibbs et al. (2008) reported that carers had heard negative comments about those they care for and suspected that this was discrimination. Similarly, participants in Iacono and Davis' (2003) study experienced problematic attitudes of staff, particularly towards patients with communication difficulties. Cumella and Martin (2004) described an awkwardness and embarrassment among staff when dealing with people with learning disabilities. However, by the way of explanation for such attitudes, Sowney and Barr (2006) reported that nurses in their study experienced fear and vulnerability. They were confused over terminology and did not know whether to use 'mental handicap' or 'learning disability'. They were also afraid of being unable to deal with potential complexities of caring for a person with a learning disability. Ironically, they were also afraid of discrimination – being criticised for perceiving people with learning disabilities as being 'different' (Sowney & Barr 2006). Such findings illustrate that discrimination; anxiety; and fear are often underpinned by lack of knowledge and awareness of 'Others'.
This review has highlighted a tripartite relationship of anxiety among (1) patients with learning disabilities; (2) hospital staff; (3) carers. For example, Gibbs et al. (2008) reported that patients with learning disabilities are fearful of investigations, injections, white coats and procedures. Conversely, in the same study, some hospital staff were perceived as being afraid of people with learning disabilities. Carers were also anxious about the level of care and protection provided for the person with learning disabilities (Gibbs et al. 2008). The problem with this pervasive context of anxiety is that people with learning disabilities pick up on it and become agitated (Gibbs et al. 2008), thus creating a cyclical pattern of events. However, it is important to temper these largely negative findings with the more positive experiences reported by Hannon (2004).
In terms of strategies, being exposed to a preregistration experience in a learning disability context was associated with the perceptions of more competent caring among some nurses in the study by Sowney and Barr (2006). Similarly, Iacono and Davis (2003) reported that education in undergraduate curricula that brings students into direct contact with people with learning disability can address attitudinal problems.
Staff knowledge was highlighted by most studies in the review. The study by Sowney and Barr and the two articles arising from it highlight the lack of knowledge among many nurses regarding the issue of learning disability. Most nurses had no preregistration education in learning disabilities (Sowney & Barr 2006). Lack of basic understanding reduced nurses' ability to pick up on cues, and they recognised the impact of this on their competence and confidence in 'caring'. The articles shed light on the complex relationship between learning disability and consent. Many nurses believed that people with learning disabilities cannot consent to treatment and had a misguided understanding that this was the role of carers (Sowney & Barr 2006, 2007). This is an issue that will be discussed later.
Training programmes for healthcare staff in communication are shown to be beneficial (Cumella & Martin 2004), along with mentoring by more experienced, confident practitioners (Hannon 2004). Additionally, learning disability liaison services provide a crucial role. According to Gibbs et al. (2008), learning disability liaison nurses can improve care for people with learning disabilities. They form an important contact point (Cumella & Martin 2004) and source of advice/support (Sowney & Barr 2006). There are different models of liaison services (Brown & MacArthur 2006), but overall, they play an important role that includes coordinating care between community and hospital and increasing staff awareness of learning disability (Sowney & Barr 2007).
Supporters and carers featured highly in this review. Most people with learning disabilities like a parent or carer with them on admission, and many chose to spend up to 24 hours per day in hospital (Iacono & Davis 2003, Hannon 2004, Gibbs et al. 2008). They attend to care and help with communication. Nurses value the presence of carers. They perceive that it increases their ability to assess and provide care to ill patients with learning disabilities (Sowney & Barr 2006). However, there are tensions regarding the presence of carers and issues of overreliance. Carers often feel taken-for-granted by hospital staff and are rarely offered a break or assistance with care (Cumella & martin 2005, Gibbs et al. 2008).
A key strategy for supporting parents and carers is highlighted by Gibbs and colleagues. The fundamental principle is to value their significant contribution to care. Implicit within this is to use information they provide; listen to their opinions; and give practical support and respite (Gibbs et al. 2008). With reference to personal and healthcare needs, Iacono and Davis (2003) found a positive association between having someone stay with the person with learning disabilities and getting enough to drink. Yet again Hannon's (2004) study brought a positive slant to the review, with most carers feeling satisfied with the support they received.
Of the six areas identified in this review, the physical environment was the least well documented, but it still featured in five articles. In many respects, acute care settings are 'alien environments'. Hospitals are often busy, and as already discussed, this can impact negatively on adequate assessment (Sowney & Barr 2007) and means that adults with learning disabilities fear getting lost (Gibbs et al. 2008). There are mixed views among people with learning disabilities regarding the preference of a single room or a larger ward environment. Most parents who stay in hospital with their adult children prefer a side room to ensure privacy (Gibbs et al. 2008). However, as Hannon (2004) points out, although a side room may be preferred by some, they should not be given as a matter of course. It is a matter of individual choice for the person with leaning disability and their carer.
Numerous simple, yet effective strategies can promote the safety of adults with learning disabilities in hospital. Hannon (2004), Cumella and Martin (2004) and Gibbs et al. (2008) highlight the benefits of a preliminary visit to hospital. Indeed, preadmission assessment has been found to improve experience of admission (Hannon 2004), and carers find it helpful (Gibbs et al. 2008). The assessment provides the opportunity to identify individual health needs; increase staff awareness of the needs of people with learning disability; overcome problems with communication; give carers more confidence in staff (and staff more confidence in working with people with learning disability) (Hannon 2004). Conducive environments can also be created by the provision of symbols or pictures to assist those who find reading difficult (Cumella & Martin 2004, Gibbs et al. 2008).
Despite the insight provided by this review, it has some limitations. Included studies come from the UK and Australia, which potentially limits transferability of findings to other countries. Findings should thus be tentatively applied to different countries and contexts. Also, included studies are all qualitative: we found no quantitative studies that met the inclusion criteria, yet such studies may have contributed significantly to answering our research questions. We suggest this as a focus for future research. Finally, we found limited evidence regarding the physical safety of adults with learning disabilities in acute care settings. As reported, most studies are concerned with matters of patient experience and welfare. Again, this has highlighted an important area for research development. Overall, however, despite its limitations, the review has provided new insight into an under-researched area.
The six areas presented in the findings can be conceptualised as having direct influence – thus, in Fig 2, they form the closest layer to the person. However, the review has illuminated some less direct influences that in turn, influence the six areas, namely education/training and support/liaison services (as indicated by the inward direction of the arrows in Fig 2). Importantly, adults with learning disabilities are not passive recipients of care. As indicated by the arrows, they should be active agents, capable of exerting outward influence in relation to healthcare. To show the relationship between the different layers of influence, the discussion is organised with reference to Fig 2.
The review findings are supportive of the wider literature; indicating that people with learning disabilities are less likely than others to obtain the healthcare they need (Disability Rights Commission 2006). In the healthcare system, they are perceived as low priority (Mencap 2007). Illness is often misdiagnosed or undiagnosed because many staff have limited knowledge of the healthcare needs of this group of people (Kent 2008). Moreover, people with learning disabilities are likely to have significantly higher mobility problems than the general population (van Schrojenstein Lantman-de Valk 2005), and falls-related injuries are common (Finlayson et al. 2010, Willgoss et al. 2010). Much of this is preventable. Understanding the unique needs of individual patients with learning disabilities can be achieved through listening to them and their carers and through using the available resources such as communication aids and passports (Sowney et al. 2006).
Findings regarding communication are unsurprising, and an important, related issue is that of consent. Effective communication underpins any assessment of capacity to consent (Brittle 2004), but many nurses and other healthcare professionals do not understand the laws around capacity (Mencap 2007). Many people with learning disabilities do have capacity to consent, but inappropriate assumptions are often made regarding incapacity (National Patient Safety Agency 2004, Brown & MacArthur 2006). This has a direct influence on the person's autonomy and agency. Again, direct discussion with the patient and the use of communication aids and passports can inform a more accurate assessment of an individual person's capacity to consent. It is noteworthy that with the exception of Gibbs et al. (2008), all included articles were published pre- or circa-implementation of the Mental Capacity Act in England and Wales (Parliament of the United Kingdom 2005). The purpose of the Act is to protect people who lack mental capacity and allow adults to make as many decisions as they can for themselves. Time will illuminate the extent to which the Act has impacted positively on the issues of consent highlighted in this review.
Consistent with the wider literature, the review highlighted healthcare professionals' limited knowledge about learning disability (Michael 2008). Melville et al. (2005) identified a clear knowledge gap among healthcare practitioners, and only 8% of nurses in the study had received learning disability-related training. A recent study conducted in Belgium found that staff sometimes felt negative emotions such as depression or anger in reaction to challenging behaviour among people with learning disabilities (Lambrechts et al. 2009). Overall, widespread ignorance results in institutional discrimination (Mencap 2007), and people with learning disabilities are often misunderstood and misinterpreted.
As indicated in Fig 2, carers have a direct influence in supporting their relative with learning disabilities. However, carers' own needs are often inadequately met. Many healthcare professionals do not properly consult and involve them (Mencap 2007), and their opinions and assessments are frequently ignored (Michael 2008, Backer et al. 2009). At a physical level, there are often inappropriate facilities for families and carers in hospital, and they spend hours without being spoken to or offered a drink and spend nights sleeping in chairs, spare wheelchairs or on the floor (Mencap 2011). They can be expected to be ever present and provide physical nursing care (National Patient Safety Agency 2004, Backer et al. 2009). These factors combine to cause considerable stress for carers. It is clear that carers need support. They should not be expected to be present 24 hours per day (Cumella & Martin 2004), and provision of breaks is important (Glasby 2002, Backer et al. 2009). At an organisational level, additional nursing staff should be provided if needed, and carers should not be used as substitutes (Royal College of Nursing 2011).
In terms of physical environment, people with learning disabilities often have difficulty adapting to new situations, and therefore, admission to hospital may be an ordeal (Glasby 2002, Brittle 2004). Backer et al. (2009) detailed a spectrum of factors that can lead to people with learning disabilities becoming bored, distressed, anxious or angry while in hospital. These include fear of hospital, long waiting times, being ignored and poor communication from staff. They highlighted how signage and maps may be confusing and cluttered clinical environments can hinder accessibility. However, the challenge of physical environments can be thoughtfully modified. Decluttering, appropriate signage and using colour codes are helpful. Ensuring that lighting is not too bright and that noise is minimised is also important (Royal College of Nursing 2011).
As indicated in Fig 2, the areas as discussed do not stand in isolation. They are influenced by other factors, particularly education and support. Training in learning disabilities has been found to increase confidence and reduce anxiety, fear and ignorance among staff (Glasby 2002, McMurray & Beebee 2007). Historically, however, nurses and other healthcare staff have received insufficient education and clinical experience in working with people with learning disabilities (Brown 2005, Michael 2008). Together with ignorance and fear, these factors reinforce negative attitudes towards people with learning disabilities (Michael 2008). To care for people with learning disability more effectively, nurses must overcome any prejudices and develop an understanding of learning disability (Brittle 2004). Education and training is one way to achieve this (Backer et al. 2009). Education is also critical in ensuring patients' healthcare needs are met, because lack of training means that healthcare staff may overlook the seriousness of symptoms (National Patient Safety Agency 2004). Improvements in treatment can be facilitated by health professional training to tackle 'diagnostic overshadowing' (Disability Rights Commission 2006); that is, failing to recognise the severity of a person's condition due to their learning disability. Specifically, staff should be trained to communicate with people with learning disabilities (Mencap 2011).
Disability liaison nurses are crucial in supporting and educating staff (McMurray & Beebee 2007). It is several years since the National Patient Safety Agency (2004) advocated the appointment of learning disability liaison nurses in all general hospitals to ensure the safety of patients with learning disabilities. There has been subsequent support from non-governmental and healthcare organisations (Royal College of Nursing 2010, Mencap 2011). Moreover, since that time there has been mounting empirical evidence regarding the benefits of the role (Backer et al. 2009, MacArthur et al. 2010).
Central to the care of adults with learning disabilities is the patient themselves, with their own individual needs. This is reflected in Fig 2, which places the person at the core. Thus, people with learning disabilities can directly influence all six areas such as care provision, staff attitudes etcetera. It is incumbent upon nurses to ensure that this is achieved. Moreover, there is potential to influence outer layers such as education and policy. There is congruence between our views and those of others regarding the involvement of people with learning disabilities in activities such as: design and modernisation of hospital services (Brown & MacArthur 2006); research (Brown et al. 2010); healthcare education programmes (NHS Health Scotland 2004); and service evaluation (Campbell & Martin 2009).
Policies that support a healthcare environment in which optimal care is likely to be delivered are essential. A number of countries have augmented the chances of this happening at a legislative level. The 2010 Equality Act in the UK; Affordable Care Act in the USA; and the forthcoming Disability Act in Australia are such examples. The recently published good practice framework in Wales recommends several practices that align with the findings of this review, such as assessing for indicators of pain; taking time to provide accessible information; and developing robust communication systems (Tomlinson 2011). Again, nurses have a crucial role. Overall, as indicated by the feint markings in Fig 2, the broader context of care was not reported in our findings per se, but indirectly can have a significant impact on the person with learning disabilities at the centre of care.
Influences on the health, safety and welfare of adults with learning disabilities in acute care settings are multi-layered, and thus, improvement strategies need to be similarly multi-layered. Diagrammatic representation shows these relational elements – as direct and indirect influences – and highlights the areas for strategy development. Situating the findings within a broader, political and socio-economic context is important because through appropriate policies and fiscal support, improvements to nursing and healthcare can be made.
Findings of this review largely mirror the recommendations of published grey literature for strengthening quality, safety and clinical practice in relation to care of adults with learning disabilities. However, as a result of the review, evidence from individual empirical studies has been synthesised to develop new perspectives. Unique contribution to nursing knowledge and practice is made by explicating the multiple, layered influences and associated strategy development, as articulated in Fig 2 and Table 6. These have potential as pedagogical tools in nursing and healthcare programmes and as leverage for political and strategic influence.
Several factors including staff attitudes and knowledge and communication and physical environment have a direct influence on the health, safety and welfare of adults with learning disabilities in acute care settings. Education and training along with nursing support/liaison services have an indirect influence, and therefore, fiscal investment in these areas is important. Crucially, through many of the mechanisms discussed, adults with learning disabilities should be supported to make decisions regarding their own care based on their unique, individual needs and preferences. Moreover, they should be involved with policy development, education, service evaluation and research. This can be achieved through inclusive approaches, for example, inviting people with learning disabilities to input into nursing curricula or engage in research as coinvestigators. This only becomes a reality, however, in the presence of genuine desire to improve the health, safety and welfare of adults with learning disabilities.
We acknowledge NHS Tayside, Scotland for funding the study (of which this structured review formed a part). We would also like to thank Kristi Herd from the University of Dundee for helping to produce the figure 2 representation.
Study design: CB-J, MJ, SM, JR; data collection and analysis: CB-J, SM and manuscript preparation: CB-J, MJ, SM, JR.
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text:
My SIL is renting one of ours at the moment and just adopted 4 puppies as they were about to be put down if no one took them. We said yes.
I trust the property manager, and if anything needs to be fixed they are liable to fix it. thats what rent inspections are for!
Im sure kids (I know, I have one and one on the way) make way more 'mess' than pets do (as do some adults!!!!)
I feel sorry for renters who have pets.. most landlords don't make it easy for you! My Brother is looking for a place at the moment - its not cheap in Perth and even harder when you have a pet!
The flaw in saying that there are cheap properties (for example in 4152, as I can comment on this area) is the houses ofter require work, like restumping, rewiring, extensive asbestos throughout (we have it), reroofing. I can also tell you that at least 2 of the properties that showed up on domain for 4152 are in streets that have flooded at least twice in 4 years. Others are on very busy roads which is not nice for sleeping babies, not to mention the very heavy dust (containing god knows what) that settles on every surface of our home. So a domain search doesn't give the full story, there is a whole range of other issues to consider.
ETA - removing an asbestos roof and replacing with zincalume cost us $10000. Other quotes were as high as $17000.
i found plenty of houses in a VERY family friendly area.. So cheap
CMF (09-01-2013),FindMyLunch (10-01-2013)
There is often a very good reason house prices are way way lower than the average.
Actually in some of our places I wouldnt allow more than 2 children due to space.
It is hard to buy, but you can't expect your dream house the first time you buy or be in the best area. It's about getting into the housing market.
Not all rent covers my mortgages and I don't live in a house I own because we move for hubby's work. Everyone has different requirements and it's about making your money work in your situation.
Renting a house to someone is a business transaction it is not and should not be an emotional thing and it's why you are covered by agents and insurances.
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text: Seller: lostintimeantiquesvintage (8,618) 100% , Location: Stroudsburg, Pennsylvania, Ships to: US & many other countries, Item: 371796287316 I'm a honest seller so please contact me if not happy with transaction .Thank you for buying from me. Feel free to ask any questions. Condition: As Pictured, Color: Dark Brown, Maker: Leviton, Material: Bakelite


text:
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Posted in thread: Soda / beerline equation.. on 03-29-2013 at 12:57 AM
It depends on the pressure, but I dispense soda at 30 psi and it needs about 25' of 3/16" line.
With 1/4" line, you may need at least 50 feet per tap, but I"m not sure about that because the
1/4" line...
Posted in thread: Can I use a beer or wine tap/faucet for dispensing soda? on 03-29-2013 at 12:53 AM
I can get beer taps to give good soda pours as long as I have the serving pressure set really,
really low.Lower it to about 5psi or lower. Just enough to push the beer out. Regular serving
pressure fo...
Posted in thread: Johnson Controls Dig. Temp. Control Not Working? on 10-24-2011 at 12:31 AM
Just tried the lamp test, and it didn't turn it on.When I plugged it in it displayed "C03" or
"CO3" then did the thing where it flashes "Asd" and the temperature, and then seemed to operate
normally, ...
Posted in thread: Johnson Controls Dig. Temp. Control Not Working? on 10-23-2011 at 10:54 PM
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Posted in thread: Johnson Controls Dig. Temp. Control Not Working? on 10-23-2011 at 07:37 PM
Hey guys,I bought a Johnson Controls digital temperature controller from Northern Brewer about
three months ago. Worked great when I got it, but suddenly stopped working in the last week or
so. :( se...
Posted in thread: Danby 10.2 (DCFM289WDD) Keezer Build Thread on 10-07-2011 at 05:19 PM
The radiuses were done with a table belt sander and then finish work with a palm sander.
Basically:1) Butt join the boards - drill and temporarily screw together.2) Draw the radiuses
on top for each c...
Posted in thread: Danby 10.2 (DCFM289WDD) Keezer Build Thread on 09-02-2011 at 11:08 PM
Hey, looks great! I can't wait to see it finished and hooked up!The metal paint did a great job
of hiding the screw holes and joinery. It looks like a totally solid piece now. Really cool.I'm
Posted in thread: Why brewing kits? on 08-31-2011 at 03:53 PM
I started out using kits when I started brewing, because nobody I knew had ever done any
brewing and I was a complete novice. Since I had never done it before and didn't know about all
the internet fo...
Posted in thread: Danby 10.2 (DCFM289WDD) Keezer Build Thread on 08-29-2011 at 07:05 PM
Awesome! I look forward to seeing more pics of your build.I picked up one of these freezers
over the weekend from someone who was selling it on Craigslist for $190.They dropped it so one
of the feet i...
Posted in thread: Just bought Perlick 525SS Faucet Shank Combo w/ Knob $25ea on 08-28-2011 at 11:37 PM
Got my faucets & shanks in the mail yesterday.Order was 100% correct, everything about the
order went great. I only wish I'd bought more! :cross:Massive thanks to jetmac and everyone
else for bringing...


text:
The Library Board provides oversight and guidance to the library.
Gay Guthrie - Chair
Mort Seymour - Vice Chair
Mason Ainsworth - City Council Representative
Lisa Avery - Trustee
Barbara Dickson - Trustee
Ted Duncan - Trustee
Joe Fecht - Trustee
Victoria Shelep - Trustee
Sarah Valiquette-Thompson - City Council Representative
Suzanne Campbell (Library CEO) - Secretary
*There is currently one vacant Trustee position.
The Library Board of Trustee meetings are held on the fourth Wednesday of every month at 3:30 p.m. (except July and August) at the Orillia Public Library. The meetings are open to the public.
The Orillia Public Library Board has eleven members who serve for a four year term concurrent with Orillia City Council The Board is composed of:
Mailing Address
Orillia Public Library Board
36 Mississaga Street West
Orillia, ON
Email the Library Board
Phone: Suzanne Campbell, CEO, 705-325-2338


text:
Shadow Coasters
Who knows what evil lurks in the hearts of men?
- Set of 6 coasters (2 each of 3 designs)
- They read "Happy Halloween" where you put your beverage
- Really, they should read "happy table"
Who knows what evil lurks in the hearts of men?Shadows have an incredible morphing ability. One minute, this shadow is two hands. The next minute, it's a bunny rabbit. But as anybody who's been home alone watching a scary movie knows, shadows can also be terrifying. Everything's twisted and distorted. The darkness itself seems to be moving. Is that a broom or someone standing around the corner...?
Don't let the shadows spook you! These shadows are here to help, because they're coasters. Made from water-resistant cardboard, this set of 6 coasters shaped like shadows is ready to protect your table from sweating beverages. You're on your own for other sweat-related problems.
Product Specifications
- Shadow Coasters
- Set of 6 coasters (2 each of 3 designs)
- Read "Happy Halloween" where you put your beverage
- Materials: Water-resistant cardboard
- Dimensions: 9 1/2" x 6 1/2"
- Ages 14+
Wanna chat about it?
Have questions about Shadow Coasters or your order? We monitor these comments daily, but it may be faster to email us directly or call us at 1-888-GEEKSTUFF.


text:
How do you get the name of the current virtual directory using ASP Classic? In ASP.NET you can use
Request.ApplicationPath to find this.
For example, let's say you have a URL like this:
In ASP.NET,
Request.ApplicationPath would return /virtual_directory
Try using: Request.ServerVariables("SCRIPT_NAME")
or try using Request.ServerVariables("INSTANCE_META_PATH") if that does not work for you.
For a list of other server variables try this link:
You can get the virtual path to the file from one of several server variables - try either:
(but not
INSTANCE_META_PATH as previously suggested - this gives you the meta base path, not the virtual path you're expecting).
Either server variable will give you the virtual path including any sub-directories and the file name - given your example, you'll get "/virtual_directory/subdirectory/file.asp". If you just want the virtual directory, you'll need to strip off everything after the second forward slash using whatever method you prefer for plucking a directory out of a path, such as:
s = Request.ServerVariables("SCRIPT_NAME")
i = InStr(2, s, "/")
If i > 0 Then
s = Left(s, i - 1)
End If
s = "/" & Split(Request.ServerVariables("SCRIPT_NAME"), "/")(1)
Similar Questions


text: From the New York Times. Sales of firearms to Baghdad civilians are said to be rising sharply on rising prices. The ever-popular, rugged, dependable AK-47 assault rifle has risen from $112 to $290 in the past month. Automatic pistols and revolvers are selling briskly. Strong sales of hand grenades although the price recently doubled to $95@. Possession of hand grenades by civilians is contrary to Iraqi "law." The Iraqi "government" professes concern about the enthusiasm of the public for arming itself. Mr. Hussein Abdul-Khaliq, a satisfied Kalashnikov purchaser, less than the legal minimum of twenty-five years for firearms ownership, and on the street in possession of more than the legal maximum of twenty-five rounds, is quoted as commenting "let them try to take it from me." "Sectarian Strife Fuels Gun Sales In Baghdad" by Jeffrey Gettleman. 3 April 2006 http://fairuse.100webcustomers.com/sf/nyt4_03_06.htm


text:
Graphic Designer for a Non-Profit
Cause Areas
WhenIt's flexible! We'll work with your schedule.
WhereThis is a Virtual Opportunity, with no fixed address.
We are looking for a strong graphic designer to help us build some basic marketing materials for our non-profit educational institution. We have a logo and colors established already, but need trifolds, a crest, marketing packets, admissions packets, etc.
- Graphic Design / Print
- Graphic Design/Visual Identity
Good Match For
Requirements & Commitment


text:
Prices, specials, features and availability subject to change.
Contact for details
From convenience to luxury we have everything you are looking for at Versailles Apartment Homes in Towson, MD. Conveniently located in the residential part of West Towson, you will find dining, some of the best shopping in Baltimore County, excellent private and public schools and universities, renowned medical facilities just around the corner, with easy access to downtown Baltimore's sports and entertainment venues. We offer the best apartment living in Towson, and with one, two and three bedroom options we are sure to have the perfect floor plan to fit your lifestyle. We'd love to welcome you home, come see the lifestyle we have to offer at Versailles!
Lease terms are variable. Please inquire with property staff.
Dogs Allowed. Cats Allowed. Pets Accepted. Call for service animal policy.
173 units
Contact Propertyor call
We are very happy living here. The community is excellent and very well managed.
February 01, 2017
Dear Residents;
The staff and management appreciate you taking the time to share your thoughts. We are grateful for the opportunity you have given us to provide a home for you!
Should you have any concerns please contact us at our office at your convenience. We look forward to your continued residency at Versailles!
Olga Jovanovic
Versailles Apartment Homes is a hidden treasure.
January 18, 2017
It is wonderful living here. Safety, green, clean and all the people here including the offcie staff and neigh Read Moreours are friendly.
November 04, 2016
Dear Resident:
Thank you for your kind comments!
We appreciate the opportunity you are giving us to provide a home for you! Please do not hesitate to contact us should you have any concerns!
Olga Jovanovic
I strongly recommend this community- great time, great value, beautiful community! Love it!
November 04, 2016
Dear Resident:
Thank you for taking the time to share your thoughts with us. We appreciate the opportunity you have given us to provide a home for you! Should you have any concerns please contact us at our office at your convenience. We look forward to your continued residency with us!
Sincerely, Olga Jovanovic
Property Manager
Wonderful management and staff! Very spacious and well appointed apartments, with continual property improvem Read Moreent. Fantastic pet policy and general atmosphere of community.
November 04, 2016
Dear Resident;
Thank you very much for your feedback! We value our residents and strive to provide a great service and a nice place to live. Your positive comments mean a great deal to us because we truly love what we do!
Should you ever need anything please do not hesitate to let us know!
Olga Jovanovic, Community Manger
Monday-Friday: 9:00am-5:00pm
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Israel News
Business & Innovation
Middle East
American Politics
Smoke rises in Gaza after IAF air strike 370 (R).
(photo credit:Amir Cohen/Reuters)
Five members of Hamas's Kassam Brigades were killed in an explosion in a tunnel in the Gaza Strip on Thursday, Palestinian news agency Ma'an reported.The explosion in the Tuffah neighborhood of Gaza City was first reported on Thursday morning, however reports of multiple casualties came hours later.
By ADAM RASGON
By REUTERS
Promoted Content
By JPOST.COM STAFF
By ZVI MAZEL
By ADAM RASGON
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text:
- Price: $99.00
- Exclusive Price: $8500.00
Magestic Studio Flash CMS Template 33052
This demo will open in a new window.
Please make sure you have disabled popup blockers!
Click Here to start the live demo
Description, Sources, Software & Requirements
Art and Photography site template with a simple minimalistic theme. There is a white background with a photo of divers looking at a manta ray under the surface of the ocean in the demo screen. The various category bars beep and when clicked have page slides of new photos come into view. There is a jazzy soundtrack playing in the background.
Magestic Studio Flash CMS Template 33052 has a width of 1400 pixels and is available in the following sources: .SWF, .PSD, .FLA, .PHP, .XML, and .XFL. Software required includes Winzip 9+ (Windows) or Stuffit Expander 10+ (Mac) for uncompressing .zip files, and Hosting Requirements: PHP Version 5.2, 5.3, or 5.4; Zend Optimizer Version 3.3 (for PHP 5.2) or Zend Guard Loader (PHP 5.3 & 5.4). It has had a total of total of 4 downloads since it first appeared.


text:
Country: Philippines
Genres: Asian Comedy Drama, Asian Movie Drama, Asian Romance Drama
Date aired: November 21, 2012
Jane (Kathryn Bernardo), a die-hard fan, wants to win tickets to Billy Fernandez's (Daniel Padilla) concert. To do this she must answer the question, "What would you do if it was the end of the world?" In search for this answer she meets different people with different love stories: a 40-year-old virgin named Virginia (Pokwang) who meets a gigolo named Charles (Sam Milby); a hopeless romantic secretary, Barbara (Maja Salvador) who is helping her boss, Ken (Diether Ocampo) with "personal issues"; Belle (Bea Alonzo) who is in love with her gay best-friend, Butch (Zanjoe Marudo), an active-executive; Verna (Angelica Panganiban) who falls in love with a waiter named Elvis (John Lloyd Cruz) in Vietnam; Jomar (Zaijan Jaranilla) who is trying to court Ayie (Xyriel Manabat) with the help of a 35-year-old mentally-challenged man named Pipoy (Piolo Pascual); Patty (Kim Chiu) who traces her first love, Alvin (Gerald Anderson) to become a model for her company.
Hot on KissAsian:


text:
Status: Open
Know more about this business than we do? Cool! Please submit any corrections or missing details you may have.Help us make it right
Great location, beautiful apartment homes and a commitment to providing a quality lifestyle make Regency Park a retirement community you can rely on for Assisted Living and Memory Care. Our philosophy of service at Regency Park Assisted Living encourages an active and independent senior lifestyle that supports residents' privacy and dignity. Our senior apartments are considered the premier...
Regency Park Assisted Living & Memory Care is based in Portland, Ore. The center offers a wide range of assisted living services for senior citizens. It also organizes a variety of activity programs, special events and entertainment options for residents. The center assists individuals with several activities, such as cooking, cleaning and household maintenance. It also assists with other...
Welcome to Regency Park Assisted Living in Portland, Oregon.
Our philosophy of service at Regency Park Assisted Living encourages an active and independent senior lifestyle that supports residents' privacy and dignity. Our senior apartments are considered the premier Portland, Oregon senior retirement community. Regency Park provides Assisted Living, Memory Care, and Respite and Adult Day Care...
Be the first OregonLive.com user to add photos or videos of Poppe Karl J Md
I was able to visit Regency Park, and it was a very beautiful building -- very nice and progressive looking -- but it wasn't the right place for my mom. The staff seemed nice and lovely.
I was very pleased with Regency Assisted Living. The hallways were nice and wide. The staff was extremely friendly. The people that lived there were extremely happy. I felt like people got more personal because they weren't quite as large. The kitchen and dining area was clean. The rooms were very clean as well.
Regency Park, Memory Care, Assisted Living
Regency Park Assisted Living and Memory Care can be found at Sw Barnes Rd 8300. The following is offered: Hospice Care. The entry is present with us since Sep 9, 2010 and was last updated on Nov 14, 2013. In Portland there are 6 other Hospice Care. An overview can be found here.


text:
Theo Walcott believes Arsenal will be feared in the Champions League after their 5-2 demolition of Fenerbahce in Istanbul which ended the Turkish club's unbeaten home run of 16 European matches.
The England international, who scored his team's second goal, hopes that victory has laid down a marker for the rest of Europe. "All the teams will look and see the win, Arsenal away, with a young team and I think the other teams will be scared to play us," Walcott said. "That's the impression we want to give out to all the other teams. We do that and we


text:
AASHE Award Winner Webinar - Using a Design Competition to Expand Bee Habitat On and Off-Campus
Webinar Date:
March 1, 2017, 3:00-4:00PM ET
Description: BEE / HOUSE / LAB was an international design competition at the University of Manitoba that resulted in innovative bee houses built, installed around campus and used for research. The reasons for the competition were to help bees in a time of rapid decline due to habitat loss and severe weather brought on by climate change. Partnerships were what made this project a success. In this webinar, you will learn more about the process of this project and see the winning designs.
Anna Weier, University of Manitoba (Winner of 2016 Campus Sustainability Achievement Award).


text: From where I stand, I am seeing more and more Churches do away with "Wednesday night prayer meeting & Bible study". Well our Church hasn't given it up yet. -------------------------------------------------- This last Wednesday, I started a series of lessons; And I thought that I would share with all of you, what is being taught behind my pulpit on Wednesday nights. Here are my lesson notes; Hope you enjoy them... ============================================ June 15, 2011 -THE DOCTRINE OF PRESERVATION- (1) ============================================ -Tonight......we start a series of lessons on ❝the Bible's preservation❞! =========================================== LETS GO TO....... Genesis 3:1-4 ========================================= Genesis 3:1A Now the serpent was more subtil than any beast of the field which the LORD God had made. -SATAN'S CHOICE OF BEASTS- (Choosing an animal that suited his nature Satan's are ever-so subtle: -------------------------------------------------- They don't even look like attacks! ==================================== Genesis 3:1B And he said unto the woman, -SATAN'S CHOICE.....FOR HIS FIRST ATTACK- (The weaker sex -------------------------------------------------- God's promise to the strong Christian..... James 4:7 "Submit yourselves therefore to God. Resist the devil, and he will flee from you." ========================================= Genesis 3:1C Yea, hath God said, Ye shall not eat of every tree of the garden? -A METHOD OF ATTACK.....THAT HE STILL USES TODAY- (Casting doubt upon it -------------------------------------------------- If Satan had slithered up and said..."God's a liar": Eve might have turned away! ======================================= Genesis 3:2 And the woman said unto the serpent, We may eat of the fruit of the trees of the garden: -MANKIND'S FIRST MISTAKE- (Giving an ear to words of doubt -------------------------------------------------- We should never give our ear to anyone saying.... "Hath God really said?" ------------------------ Listening to people cast doubt on God's Word: Can be very dangerous! =========================================== Genesis 3:3 But of the fruit of the tree which [is] in the midst of the garden, God hath said, Ye shall not eat of it, neither shall ye touch it, lest ye die. -?WAS THIS.....MANKIND'S SECOND MISTAKE?- i.e. (Not quoting God's Words exactly?) ------------------------ That is a good question. -------------------------------------------------- God's instructions in Genesis 2:16-17 seem clear enough; But here in Eve's mouth...they got kind of mixed up. ------------------------ This is what happens....when we give our ear to DOUBT! ===================================== Genesis 3:4 And the serpent said unto the woman, Ye shall not surely die: -PRESERVATION DOESN'T MEAN...GOD'S WORD WON'T BE ATTACKED- (We just need to be aware of this attack ------------------------ Some might say... "See...God didn't preserve His Word": Because Satan was able to change it: -------------------------------------------------- But God's word Was still preserved! It's just that Eve....was tricked away from it! =======================================


text:
Watch Opal TV live stream online
- TV Channel Name: Opal TV
- Broadcast country: France
More info about Opal TV, program guide and shows can be found on the Opal TV website.
Opal TV Stream is not hosted by our site, it is provided by the tv station itself. So please wait to connect to Opal TV broadcast. Opal TV Channel can be offline sometimes.
If you search for precise channels, please visit the Internet TV website where you will find a complete list of streams for all channels. If you encounter difficulties with watching live streams, please first check our detailed How to Watch guide. And most importantly, all streams you can find in our website are completely free - Internet connection is all you need!
Please Check Here to proceed to the destination page.


text:
Arts, Music, Society & Culture, TV & FilmFollow
|TV & Film
|Top 200
Pop Culture Happy Hour is a lively chat about books, movies, music, television, comics and pretty much anything else that strikes a nerve, all in a weekly roundtable from NPR. Features "Monkey See" blogger Linda Holmes and an occasionally rowdy cast of characters. Join the club at NPR.org/pchh.
September 9th, 2009
Episode 23 of 604 episodes
This week in Culturetopia: the new dolphin doc The Cove; musician Imogen Heap; music for monkeys; LA's comedy scene of the 1970s and a violent book for teenagers about reality shows of the future.
You'll need to sign in to write a comment.
Welcome to the daily audio workout for your head.


text:
The Show Radio - Video Games ~ Life Hacks ~ Interviews
About This Show
Show Info: Life Hacks with a dash of Tech, Video Games and probing Interviews. Ready?
Show Info: Life Hacks with a dash of Tech, Video Games and probing Interviews. Ready?
Kodi is a free and open-source media player software application developed by the XBMC Foundation. In recent weeks the open source media organizer has been making rounds in the media while dodging defamation and copyright infringement allegations. Is Kodi a clean or pirated application? ------------------------------------------- Social Media ------------------------------------------- BLOG: http://bit.ly/2iNN1jk INSTAGRAM: http://bit.ly/2jCuq9X TWITTER: http://bit.ly/2jCB4Nf FACEBOOK: http://bit.ly/2jpYNRk Videos: http://bit.ly/2inuNnB ----------------------- About The Podcast ------------------------ The Show Radio is one of the top internationally recognized indie podcasts with over 330 episodes in over 100 countries enjoying more than 293 hours of content including Video Games, Life Hacks, and interviews. Subscribers can listen to as much as they want, anytime, anywhere, on Itunes, Google Play, Stitcher, TuneIn, IHeartRadio, and YouTube. If you're looking for Video Games and Life Hacks simplified, look no further than The Show. PODCAST on ITUNES: http://apple.co/2j6zO6c PODCAST on GOOGLE PLAY: http://bit.ly/2jdRkI1


text: Posted November 21, 2007 It's been awhile since I've fished leech through the ice...have had fairly good success with whitefish on the main lake, but had always stumbled upon them accidentally. Now I'd actually like to target them specifically...what locations/depths/tactics usually work for them? I've caught them both day and night as well, does 1 time work better than the other? Share this post Link to post Share on other sites


text:
Bible School Prayer
"One of our five daughters was taught this prayer during kindergarten Bible school. After that, the entire family always said it together at mealtime," notes Josephine Creswell of Kilmarnock, Virginia.
Dear God, we thank Thee for this food, for milk and water, too. Help us to be most kind and good in everything we do. Amen.


text:
Alternative websites for 480hay.net
1. Result for 480hay.net
Hay Street is a major road through the CBD of Perth, Western Australia, and adjacent suburbs. The street was named after Robert William Hay, the Permanent ...
Alternative for en.wikipedia.org
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Ashley Hay is a writer who lives in Brisbane, Australia. Her latest novel, The Railwayman's Wife, was first published in Australia in 2013 by Allen and Unwin.
Alternative for ashleyhay.com.au
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Perth - E S & A Bank. At 938 Hay Street, on the corner of Milligan Street is the former English Scottish and Australian Bank (later ANZ) which was constructed in ...
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Featuring the council, the local area including a demographic profile and a map and tourist information.
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Get chemist advice and health care you can trust. See opening hours and pharmacy services at Friendlies chemist Perth Hay St. Online bookings available.
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Alternative for friendliespharmacies.com.au


text:
Insights/Case studies/Newsroom/Careers/About us/Contact us Global locations
Office Locations
"Our proposals for GP commissioning and the NHS Commissioning Board mark a fundamental break with the past."
GP consortia's new commissioning responsibilities require healthcare organisations to develop new skills and new ways of working. As the NHS white paper proposals for GP commissioning states, the reforms represent the biggest change to the NHS for 60 years "not just in structure but in culture and ways of working." PA's health team give some practical advice on where to begin.
For healthcare organisations, there is no existing model to reference how the workforce should be arranged and one might view the 'safe' option for taking on this new role as transitioning across existing PCT commissioning staff to the new GP commissioning operations. However, PCTs have had mixed experiences at commissioning so simply transitioning the same team may not deliver the improvements in healthcare or value for money required.
This is the opportunity for your GP commissioning consortium to create the right workforce that will underpin a successful, and potentially different, commissioning function.
As a GP commissioning consortium, you need to ask 'What capabilities do we need?' To execute GP commissioning successfully requires not just new systems and processes but also a new approach to developing the right organisational cultures and workforce capabilities – and these will be different from those already in place within the PCT.
Once you know what your GP commissioning consortium will look like, the next question is 'where do we get our capabilities from?' The options are to build commissioning capabilities, buy them or rent them – and the three are not mutually exclusive. You can mix and match to build the commissioning organisation that meets the needs defined:
The role that GPs will play in commissioning and the range of roles that the consortium will to accommodate will have a significant impact upon the prevailing culture. So with the team in place, you should then ask, 'How do we develop the collaborative culture to ensure effective commissioning?'
The opportunities to deliver a more effective and efficient commissioning system are here for the taking. GP commissioning consortia have the opportunity to be innovative and create the workforce that is right for them.
GP commissioning consortia will need to model, plan for and recruit the right people into the right roles in order to ensure they have the necessary skills to manage the commissioning function.
To learn how PA can help your GP commissioning consortium develop the right capabilities, please contact us now.
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text:
NYC Psychotherapist
Website: http://www.nycpsychotherapist.org
Contact: 646 770 1603
For a free half hour psychotherapy consult, leave a message at 646-770-1603. In this half hour we will work together to: •Create a crystal clear vision for what you want. •Uncover hidden challenges that may be sabotaging your success. •Let you leave the session renewed and re-energized
UNHCR Your generous support to the UN Refugee Agency will provide protection, shelter, clean water ...