Study On Hand Hygiene In Optometry Nursing Essay

Study On Hand Hygiene In Optometry Nursing Essay Hand hygiene is a term used to describe any act of hand cleansing. There are various methods of decontamination each with their own level of efficacy (Lucet et al., 2002; Kampf, Là ¶ffler and Gastmeier, 2009). It is an essential practice among health care workers (HCWs) to prevent the transmission of microorganisms and spread of nosocomial infections in a clinical setting. Despite this knowledge, compliance among HCWs remains low averaging 40% which increases the risk of patients contracting hospital acquired infections (Boyce and Pittet, 2002). The World Health Organisation (2005) recognise hospital acquired infections as being a major cause of death and mortality in hospital bound patients, averaging 5000 deaths a year in England. Improving hand hygiene practice among HCWs is the cornerstone in reducing nosocomial infections such as methicillin-resistant Staphylococcis aureus (MRSA) and Clostridium difficile (C. diff.). However, implementing this change in behaviour is complex and difficult to achieve. An integral factor for improved hand hygiene compliance relies on HCWs educational training and the introduction of motivational programmes designed specifically to influence behaviour. Monitoring and encouragement will be necessary for these procedures to be successful (Boyce, 2008; Saint et al., 2009). 1.2 Hand hygiene in Optometry There is an apparent lack of research into hand hygiene practice in a primary and community care setting; optometric practice included. Currently there are no evidence based studies directly linked with Optometry to support the recommended guidelines set out by The College of Optometrists. Instead these guidelines are based on expert opinion with little conclusive evidence of efficacy in primary care. The importance of effective hand hygiene in the prevention and control of infection is stressed. They have adopted recommendations set by The National Institute for Health and Clinical Excellence (NICE 2003), which are for the use of professionals in primary and community care. A minimum standard of hand hygiene practice would be to decontaminate hands before each and every episode of patient contact and after any procedure or contact that would cause hands to become contaminated. The College of Optometrists (2009) expand upon this stipulating that there is no set regularity in hand was hing episodes and that instead it should be adhered to in circumstances such as contact lens insertion and removal, after going to the toilet, when hands appear visibly unclean, before and after contact with ocular surfaces or the adnexa, before and after administering topical ointments or drops, after any possible microbial contamination, after handling soiled or contaminated materials and before wearing and after removing gloves. Furthermore, an instruction of appropriate hand hygiene technique in clinical practice is suggested: Wet hands under running water. Dispense soap/antiseptic into cupped hand (N.B. bar soap should not be used). Rub hands vigorously and thoroughly for 10-15 seconds without adding more water. Ensure all surfaces of the hands are covered. Rinse hands thoroughly under warm running water. Dry hands with a disposable paper towel. The use of non disposable towels is not good practice. Advisory recommendations for optometrists regarding hand hygiene in the community setting remains at a robust level. To improve standards, further research must be conducted as it is widely regarded that sound clinical practice requires conclusive clinical evidence (Smith, 2009). Optometrists in a primary care setting could benefit from adopting higher standards of hygiene expected in hospital environments. 1.3 Hand hygiene guidelines and technique Due to the clinical and economic implications of health-care associated infection the World Health Organisation (WHO) and the US Centers for Disease Control and Prevention (CDC) have formulated guidelines to promote improved hand hygiene adherence among health care workers (Boyce and Pittet, 2002; Pittet, Allegranzi and Boyce, 2009; Sax et al., 2009). These guidelines include specific indications for hand washing and hand antisepsis episodes. A detailed description of appropriate hand hygiene technique is also included. The recommendations are categorised on the basis of published scientific data, theoretical knowledge, applicability in a clinical setting and economic involvement. The CDC/HICPAC created a system for categorising hand hygiene recommendations. These categories are shown in Table 1 Table 1 showing the CDC/ HICPAC categorisation of guidelines (Boyce and Pittet, 2002) Category Criteria IA Strongly recommended for implementation and strongly supported by well-designed experimental, clinical or epidemiologic studies IB Strongly recommended for implementation and strongly supported by certain experimental, clinical, or epidemiologic studies and a strong theoretical rationale. IC Required for implementation, as mandated by federal or state regulation or standard II Suggested for implementation and supported by suggestive clinical or epidemiological studies or a theoretical rationale or a consensus by a panel of experts. No recommendation Unresolved issue. Practices for which insufficient evidence or no concensus regarding efficicacy exist. Sections 1, 2 and 6 of the CDC/HICPAC recommendations advise specifically on handwashing and hand antisepsis indications, hand-hygiene technique and other aspects of hand hygiene. Each guideline is given a classification category relevant to Table 1. These recommendations are as follows: 1. Indications for handwashing and hand antisepsis A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water (IA). B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1C-J (IA). Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items1C-J (IB). C. Decontaminate hands before having direct contact with patients (IB). D. Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter (IB). E. Decontaminate hands before inserting urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure (IB). F. Decontaminate hands after contact with a patients intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient) (IB). G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled (IA). H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care (II. I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient (II). J. Decontaminate hands after removing gloves (IB). K. Before eating and after using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water (IB). L. Antimicrobial-impregnated wipes (i.e., towelettes) may be considered as an alternative to washing hands with non-antimicrobial soap and water. Because they are not as effective as alcohol-based hand rubs or washing hands with an antimicrobial soap and water for reducing bacterial counts on the hands of HCWs, they are not a substitute for using an alcohol-based hand rub or antimicrobial soap (IB). M. Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if exposure to Bacillus anthracis is suspected or proven. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores (II). N. No recommendation can be made regarding the routine use of nonalcohol-based hand rubs for hand hygiene in health-care settings.(Unresolved issue). 2. Hand-hygiene technique A. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry (IB). Follow the manufacturers recommendations regarding the volume of product to use. B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet (IB). Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis (IB). C. Liquid, bar, leaflet or powdered forms of plain soap are acceptable when washing hands with a nonantimicrobial soap and water. When bar soap is used, soap racks that facilitate drainage and small bars of soap should be used (II). D. Multiple-use cloth towels of the hanging or roll type are not recommended for use in health-care settings (II). 6. Other Aspects of Hand Hygiene A. Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g., those in intensive-care units or operating rooms) (IA). B. Keep natural nails tips less than 1/4-inch long (II). C. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and nonintact skin could occur (IC). D. Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not was gloves between uses with different patients (IB). E. Change gloves during patient care if moving from a contaminated body site to a clean body site (II). F. No recommendation can be made regarding wearing rings in health-care settings. Unresolved issue. These guidelines were developed for the use of health care professionals in a clinical setting and were not specifically designed with optometric practice in mind. However, many of these recommendations remain highly relevant when adopted to an optometric environment and are strongly supported by The College of Optometrists. The World Health Organisation have extended the recommendations on hand-hygiene technique and produced a visual publication poster detailing the hand hygiene technique for use with alcohol-based formulations and the handwashing technique for use with soap and water. These are shown in Figures 1 and 2 respectively. Figure 1 showing recommended hand hygiene technique with an alcohol-based formulation (World Health Organisation 2006) ***online access reference 2 Figure 2 showing recommended handwashing technique using soap and water (World Health Organisation 2006) **online access reference 1.4 Hand hygiene practices among health care workers Hand hygiene practice among health care workers is poor with many observational studies reporting low compliance rates in a number of indicative areas. Hence, understanding current trends among health care workers is critical in planning and implementing the necessary modification in behaviour (Allegranzi and Pittet, 2009). Hand hygiene adherence can be investigated over a range of parameters such as duration spent cleansing or disinfecting, frequency of hand washing episodes over a given time and observing the variations in performance with regard to clinical setting, physician status and gender (Boyce and Pittet, 2002). Employing the appropriate hand hygiene technique is essential. Consider the situation in which hand hygiene episodes per hour compliance is high. If insufficient hand hygiene technique is being performed e.g. inadequate coverage of hand surfaces and a short cleansing time, then the overall standard of compliance will decrease. This confirms that hand hygiene practic es among health care practitioners involves both multimodal strategies and multidisciplinary approaches to improve adherence (Pittet, 2001; Dierssen-Sotos et al., 2009). Multiple factors are associated with the suboptimal hand hygiene performance among health care practitioners and they vary in relation to resources available and the setting involved. For example, the lack of appropriate infrastructure, equipment and materials will hinder good hand hygiene practice, the cultural background and perhaps even religious beliefs can also affect performance (Ahmed et al., 2006; Allegranzi et al., 2009). The most commonly reported causes of poor hand hygiene compliance are: (i) physician or nursing status, (ii) clinical care setting e.g. ICU, AE, surgery units (iii) understaffing and overcrowding (iv) male (rather than female) gender and (v) inaccessible hand hygiene supplies (Pittet, 2000). (Erasmus et al., 2010) conducted a systematic literature review of studies based on observed or self-reported hand hygiene compliance rates in hospital practice, mainly intensive care units. The median compliance rate was low at 40%. Physician status was found to be a factor affecting adherence, lower among doctors (32%) than nurses (48%). In general, a lower compliance rate was found in physicians reporting a high level of activity in clinical practice. Compliance rates improved in situations whereby physicians or nurses associated the task as being visibly dirty or unhygienic, alcohol-based hand rubs or gels were available, feedback performance was introduced and when materials and facilities were easily accessible. Hand hygiene compliance among optometric practitioners is an area yet to be investigated. Opticians are encouraged to follow the recommended guidelines set by organisational bodies such as the World Health Organisation and The College of Optometrists. 1.5 Hand hygiene behaviour Hand hygiene behaviour can be investigated in relation to factors such as social cognitive determinants. A number of situations trigger a hand cleansing episode to occur and therefore affect compliance e.g. knowledge and perception of the risks associated with cross contamination, social expectations for adequate hygiene, self evaluation of the perceived advantages against the existing hindrances and the initial motivation to perform the hand hygiene action (Pittet, 2004; Whitby et al., 2007). This cognitive behavioural response falls into two categories (Whitby, McLaws and Ross, 2006). Inherent hand hygiene behaviour arises in circumstances when individuals deem hands to be visibly soiled, sticky or gritty. This type of intrinsic hand washing behaviour is initiated when a task is recognised as being unhygienic or has a potential risk factor involved to the individual concerned. The other component of hand hygiene behaviour is denoted as elective hand hygiene behaviour. This type of behaviour is represented in situations such as tactile social contact e.g. shaking hands to greet someone. This will not induce a response for many individuals to wash their hands and instead it becomes an elective response. Similarly, health care workers may partake in non-invasive impersonal contact with patients when taking pulses or touching inanimate objects in their surroundings. This type of social contact is not perceived to be a danger and does not drive a hand cleansing episode to take place. Instead an elective response has to be made. However, hand cleansing or disinfection after such contact in a hospital setting is crucial, because failure to do so may lead to microbial hand contamination, with the increased risk of cross-infection. 1.6 Relation of hand hygiene with the acquisition of nosocomial infections Hand hygiene reduces the transmission of microbial contamination and the spread of health-care associated pathogens from one patient to another via the hands of health care workers (Pessoa-Silva et al., 2007; Pittet et al., 2007; Allegranzi et al., 2010). Hand hygiene is the cornerstone in securing adequate patient safety. Failure to comply with this standard prolongs duration of hospitalisation, causes unnecessary suffering, increases costs as well as mortality rates (World Health Organisation, 2009). Thus, to raise awareness and combat the problem of health care associated infections, (Sax et al., 2007) produced an evidence-based, user-centred design to promote improved hand hygiene adherence termed My Five Moments for Hand Hygiene, shown in Fig.3. This highlights the five most common routes of transmission which HCWs are exposed to in daily clinical practice. The model is based on the World Health Organisations hand hygiene guidelines. It recommends hand washing episodes to occur before touching a patient, before clean/aseptic procedures, after a body fluid exposure risk, after patient contact and after touching patient surroundings. Although designed specifically for HCWs in a clinical setting, this model could be adopted for use in community practice to include an optometric environment. Optometrists should be aware of the risks of cross contamination and demonstrate an understanding of appropriate infection control methods (Lakkis et al., 2007). Figure 3- My 5 moments for hand hygiene model 1.7 Infection control in optometry Modern optometric practitioners are offering an expanding area of services and care with regards to the treatment and management of eye diseases and eye injuries. Therefore, more specialised procedures and techniques are being carried out in the primary care setting which have the potential to spread infection and disease via blood borne and air borne transmission. Hence, practitioners have an obligation to carry out adequate infection control measures to ensure a high standard of patient safety and protection (Tyhurst and Hettler, 2009). The majority of optometric procedures are considered low risk for the spread of disease and infection. However, in a few occasions the risk increases e.g. when instruments come in direct contact with an infected patient and when blood, cuts or abrasions are exposed (AOA Primary Care and Ocular Disease Committee, (1993). Other procedures which have the potential for infection include the collection of eye culture samples, foreign body removal, contac t lens fitting, lacrimal lavage and the treatment of patients exhibiting ocular trauma. 1.7.1 Hand hygiene and protective barriers to infection A basic measure of infection control begins with effective hand hygiene. Many eye diseases and infections are spread manually, and it is the responsibility of the optometrist to minimise this transmission to patients by adhering to appropriate hand washing techniques before and after examinations and procedures. Appropriate hand hygiene technique refers to the standard described in section 1.2. In addition, the use of protective barriers such as disposable medical gloves, gowns, masks and protective eyewear has been suggested in specialised circumstances as a precautionary control to minimise the transmission of microorganisms (Lakkis et al., 2007). 1.7.2 HIV, Hepatitis B and Hepatitis C Diseases can be spread by direct contact between individuals, via blood or other bodily fluids and as a result of airborne transmission. Considerable awareness has been directed towards the transmission of the human immunodeficiency virus (HIV) and the Hepatitis B and C viruses, (HBV) and (HBC). HIV has been isolated from tears, contact lenses and ocular tissues, but there is no evidence to support transmission of the disease through these medians (Cantrill et al., 1988; Tillman, Klotz and Maino, 1992). Studies have reported the detection of the hepatitis B surface antigen in tears and aqueous humour, suggesting that optometrists must take all necessary precautions in clinical practice (Temel, Seber and Gunay, 1990; Tsai et al., 2009). Although these are areas of concern, the risk of transmission in an optometric setting is remote. 1.7.3 Influenza A (H1N1) virus In 2009, the emergence of the influenza A (H1N1) virus in humans has led to the first global pandemic in 41 years. It is more commonly referred to as swine flu and is made up of porcine, avian and human genes. Although a potentially fatal disease, the mortality rate is expected to be less than previously known influenza pandemics and is more likely to cause harm to young people and individuals with compromised health (CDC 2009). In order to contain the spread of this infection, health care personnel were advised to heighten infection control measures. (Kiely et al., 2009) discussed specific infection control guidelines applicable in an optometric environment. A basic measure of infection control begins with frequent handwashing. Due to the close proximity to patients throughout the eye examination, in a more extreme guideline, it was recommended that optometrists should wear personal protective equipment such as surgical masks, goggles, gowns and gloves when treating a suspected infe ctious individual. It was indicated that influenza A (H1N1) should be treated like any other form of influenza. 1.7.4 Creutzfeldt Jacob Disease The theoretical transmission of prions, implicated in Creutzfeldt Jacob Disease (CJD) and variant Creutzfeldt Jacob Disease (vCJD) is an area of concern in optometric practice (Lakkis et al., 2007). These diseases are degenerative neurological conditions that are incurable and invariably fatal. Reusing ophthalmic devices such as RGP trial lenses and contact tonometer heads has been identified as a possible risk factor in spreading this disease from one patient to another but has been described as highly improbable (Armstrong, 2006). 1.7.5 Summary of infection control in optometric practice Due to the potential risk factors in an optometric environment, practitioners must abide by the recommended guidelines in order to control the spread of infection and disease. Lack of motivation and insufficient knowledge of expected protocol will lead to non-compliance among optometrists. Hence eye care personnel are advised to develop and implement a suitable infection control policy within practice (Seewoodhary and Stevens, 1999; Stevens, 2008). 2.0 Aim The purpose of this survey was to examine the typical hand hygiene practice among optometrists in a primary care setting. It investigates the level of compliance among practitioners to include the type of hand products used, hand hygiene technique and the hand hygiene facilities available in various optometric environments. 3. 0 Method 3.1 Survey design In order to determine the role of hand hygiene in optometric practice, a questionnaire was designed to gain an insight into hand hygiene product use, hand hygiene technique, facilities and general compliance among practitioners. The questionnaire was split up into three sections, All About You, Facilities and Hand Hygiene Technique. It consisted of 28 questions, the majority being mandatory to answer. The format of questions was either on a yes-no basis, multiple choice, tick box and rating of answers using a scale based response. Questions were designed on the basis of international guidelines regarding hand hygiene. A detailed literature review was conducted to ascertain appropriate hand hygiene technique, hand hygiene facilities and reported barriers to hand washing. The questions from the survey are shown in the Appendix. 3.2 Survey circulation The questionnaire was launched using Bristol Online Surveys. This is a site used by over 200 UK organisations in order to develop, distribute and analyse web-based surveys. It was sent to volunteers via e-mail using a webpage link. 3.3 Volunteers A total of 124 individuals responded to the survey which included optometrists working in university, hospital, multiple, franchise and independent optometric practice around the UK. If an individual worked in a combination of practices, they were instructed to answer questions based on the place they worked most of the time. All participants were asked to answer honestly as the survey would remain anonymous. 3.3 Survey analysis Results were recorded online within the Bristol Online Surveys (BOS) site. Key features of the BOS results section included the option of statistical investigation, cross tabulation of answers, looking at individual responses and the export of data to a spreadsheet document on Microsoft Excel. The data was analysed and arranged into a variety of tables, graphs and pie charts for easier interpretation of results. 4.0 Results 4.1 All about you A total of 124 optometric practitioners took part in the study. An almost even distribution of gender was found totalling 61 males and 63 females, with an average age  ± SD of 41.4  ± 15.5. The majority of individuals who responded to the questionnaire were Cardiff University graduates totalling 26%, followed by City University, Aston University , The University of Bradford , The University of Manchester and Glasgow Caledonian. The remaining sector of individuals were grouped in the category other and included graduates from Auckland University, Bradford College, Dublin Institute of Technology, Northampton Polytechnic, Rand Afrikaans University, Southern College of Optometry, University of Durban and the University of Ulster. This is shown in Figure 4. Figure 4. University attended by each participant The number of years qualified as an optometrist was investigated and is shown in Fig. 5. Most respondents have been qualified for 21-30 years, followed by participants who have been practicing for less than 5 years. A small minority of individuals have been qualified for more than 40 years. Figure 5. Years qualified as an optometrist Over half of respondents work in independent practice, with a smaller proportion working in a variety of practices such as multiples, hospital based settings, a combination of practices and franchises. The minority fall into the category named other e.g. domiciliary practitioners, retired optometrists and University based optometrists who no longer practice. This is shown in Fig. 6. Figure 6. Type of practice participants work in Figure 7. Gender related response regarding hand washing or disinfection between each patient episode Fig. 7 illustrates that more females than males wash or disinfect hands between each patient episode. 71.1% of the male and female optometrists who wash or disinfect hands between each patient episode, do so in front of the client. Table 2. Reasons for not washing or disinfecting hands between each patient episode Reasons Male response as a % Female response as a % Busy clinic 24 57 Forget 20 43 Unnecessary 48 76 Lack of facilities 4 5 Sore skin 8 19 Other 12 14 Practitioners who do not wash or disinfect hands between each patient episode (25 males and 21 females) were asked their reasons for not doing so. More than one answer could be selected and is shown in table 2. The majority of these individuals deemed hand washing or disinfection an unnecessary practise. Twice as many females compared to males report that the busy clinic prevents such behaviour occurring, they forget or blame sore skin as reasons for not washing hand between each patient episode. Refer to Table 3 for Other responses. Table 3. Other reasons for not washing or disinfecting between each patient episode Other responses from optometric practitioners: Never been part of routine Was never stressed during University or Pre-reg Only recently became an issue Wash hands for each contact lens patient, but not all refraction patients Hand wash during the appointment and not between Figure 8. Practitioner response as a percentage regarding patient greeting with a handshake Fig. 8 illustrates that just under half of respondents do not greet patients with a handshake. The remaining individuals answered yes or sometimes to this form of patient contact. 39.5% of male optometrists and 44% of female optometrists who greet patients with a handshake, wash or disinfect their hands after this contact. Figure 9. Satisfaction of hand hygiene practises The vast majority of individuals have a high level of satisfaction with the hand hygiene practices currently employed at the practice where they work. Collectively, 8.9% of individuals are fairly unsatisfied or unsatisfied with current hand hygiene practises. Results are illustrated in Fig. 9. 4.2 Practice facilities and structure The questionnaire investigated the number of staff members in each individual practice to include optometrists, locum optometrists, dispensing opticians, optical assistants and receptionists. These results were calculated as a median function to include the range and are shown in Table 4. The frequency of patient appointments in an average working day were investigated and appointment duration. Practice facilities were reported upon such as number of consulting rooms and number of bathrooms. Results were averaged or calculated as a median function to include the range and are illustrated in Table 5. Table 4. Number of staff members in practice Position held (Median, range) Optometrist (1, 1-20) Locum Optometrist (0, 0-5) Dispensing Optician (1, 0-6) Optical assistant (1, 0-35) Receptionist (2, 0-8) Table 5. General practice statistics and available facilities Average ±SD (Median, range) Number of patients seen per day per optometrist 13.8 ±3.74 (14, 10-25) Appointment length (in minutes) 30.7 ±6.21 (25, 15-60) Number of consulting rooms (2, 1-12) Number of bathrooms (1,1-5) In regard to practice facilities, greater than half of all participants are assigned to their own personal consulting room and report that the hand washing facility is separate from the toilet Three quarters of individuals said that there is at least one wash basin in each consulting room. Fig. 10 illustrates these findings. A large proportion of individuals reported that the practice they worked in did not display a poster detailing official recommendations on the hand washing and hand rubbing technique. Just under half of participants were aware of the poster being displayed in practice. The minority were unsure and this is shown in Fig. 11. Figure 10. Practice facilities Figure 11. Guidance poster detailing the advised handwashing and hand rubbing technique 3.3 Hand hygiene products Figure 12: The gender related practitioner response as a function of hand hygiene product use. A variety of hand hygiene products were listed. Participants rated how often they used each product in relation to the scale provided (always, most of the time, occasionally, very rarely or never). Results were plotted as a function of gender. Fig. 12(a) illustrates that the majority of male

Symbols in Cat and Mouse Essay -- Mouse

Symbols in Cat and Mouse Symbols are very important in the story "Cat and Mouse" by Lisa Metzgar. Lisa tells the story of a woman dealing with issues from a small mouse in her house, to not wanting to be married. Animals are used throughout the story to symbolize underlying issues. The reason for the story being called what it is instead of just plain 'mouse' is because both the cat and the mouse represent Marcy at one point. The mouse is a symbol of her in that it is trying to escape the traps that are out for it. This is the same way that she is trying to avoid being tied down by the people in her life. The cat can also represent Marcy after it has taken the poison, symbolizing what will happen to her if she allows others to determine her happiness. When the story opens, Marcy seems to have only one problem, and that is the fact that she has a mouse in her house. However, it isn't until she starts thinking about the mouse that she, "cannot help thinking about all the other things that are wrong with her life" (Metzgar, 67). The first problem for her is that her parents are in the beginning of a divorce and they both seem to want to pull her in their corner. Her father wants her to get to know (and eventually like) his new girlfriend Helen, while her mother wants Marcy to hate her. The other (and definitely the biggest) problem is her relationship with her boyfriend Tom. She didn't really want a serious relationship when the two first started dating but didn't want to hurt him either. Now she fears that he is smothering her and worries that he will propose. The mouse represents Marcy in that like her, it is being hunted. The difference between the two is that she is the one trying to de... ... main character. The mouse, which is scurrying around Marcy's house, can represent her free self that does not want to be tied down. The traps that the mouse repeatedly escapes are representations of the traps that Marcy herself escapes when dealing with people throughout the story. The lazy cat that has nerve damage from eating the rat pellets can represent Marcy if she allows herself to be controlled by the people around her. Although, the reader can see the link between the main character and the animals, it isn't until the end of the story that Marcy realizes that the mouse is really warning her of what will happen if she gives in to the 'traps'. By physically seeing the mouse being caught by the nose in the trap and seeing the misery on its face, she realized that this is the same way that she will be if she allows her spirit to be controlled by others.

Ipod Decision Making Process

Describe and explain the characteristics that affect consumer behaviour and outline the consumer decision-making process as it relates to Apple iPod Introduction ‘Consumer purchases are influenced strongly by cultural, social, personal and psychological characteristics’ (Kotler, Armstrong, Wong & Saunders). This report will investigate the characteristics that affect consumer behaviour and the consumer decision-process as it relates to the purchase of an Apple iPod.This report will be describing and explaining how consumers go through five different stages to reach a buying decision and outlining the consumer decision-making process when a consumer buys a product. The Apple iPod is a brand of portable media players and was launched on October 2001. There are four different types of players, which can play both music and videos, including the ‘iPod Classic’, ‘iPod Touch’, ‘iPod Nano’ and the ‘iPod Shuflfe’. The Apple â⠂¬Ëœitunes’ software can be used to transfer music to the iPods from computers.Both the Sony Walkman and Samsung YP-P2 are the iPods biggest competitors and have the same touch screen control panel. They both can hold similar amount of music to that of an iPod. ‘Mintel forecasts that the UK audio equipment market will grow by an estimated 8% to reach a value of ?2. 2 billion at current prices over the period 2007-12. In real terms, with massive price deflation for electronics taken into consideration, this equates to 100% rate of growth until 2012. (mintel, accessed at 19th November 2009) ‘Market growth since 2006 for the Apple iPod has been in decline due to the high pricing scheme of the devices although price cuts like those applied to the iPod shuffle on Tuesday and cheaper Internet –capable models down the line should help the company reverse course and maintain a steady rate of growth through 2009, says one Wall Street analyst’, (http://www. ap pleinsider. com/articles/08/02/20/growth_potential_seen_in_steadily_maturing_ipod_market. html 20th February 2008). The Apple iPod is aimed at young adults aged between 12-25, both males and females.The Apple iPod is aimed at people in the middle/high class and for those who have a particular interest or passion in music. The report will also provide a discussion of the type buying behaviour related with Apple iPods and compare the process with a less complex product, such as a bottle of water in this report. Marketing recommendations will then be given for the purchase of an Apple iPod. The Characteristics that Affect Consumer Behaviour It can be seen that cultural, social, personal and psychological are the four characteristics that influence consumer behaviour.This section will describe how some of the characteristics associate with consumer behaviour when purchasing an Apple iPod. For the social characteristic influence, this can be that the person who is buying an iPod can be i nfluenced by friends, family or any other groups the person is part of, a friend of the person may recommend an iPod to be the best portible audio player to purchase, which would then give the consumer more confidence to buy an iPod. Inspirational groups, such as celebrities who could be seen using an iPod, might have also influenced consumer behaviour. This may influence a consumer, due to the status of a celebrity.Personal characteristics such as the age of a person can affect consumer behaviour. In this case a consumer may be in an age group where it is cool and common to have an iPod, so this would be more of a want for the buyer to have the product. An Outline of the Consumer Decision-Making Process Type of Buying decision behaviour This section of the report will discuss the type of buying decision behaviour associated with the Apple iPod. The decision behaviour for the buyer of an iPod would be complex buying behaviour due to the high cost of the product and is mainly purchas e infrequently.It could be said that the consumer has much to learn about the product and may have little knowledge about the product before making a decision to purchase it. For example, an iPod buyer may not know what functions of the product to consider. ‘Many product features carry no real meaning to the great majority of potential purchasers’ (Kotler 2008 page 263, p1). This can relate to the iPod when looking at the memory size and price of the product, a customer may not know the difference between a ‘10GB iPod and a ‘160GB’ iPod. So the buyer will pass though a learning process, first developing attitudes, and then making a thoughtful purchase choice’ (Kotler 2008, page 263, p1). So for marketers of an iPod, they must understand the way a consumer gathers information and the evaluation behaviour of a high involvement product. The advertising and size of the iPod may be used to help make it easier for a consumer to understand what the me mory size is of an iPod. Dissonance-reducing buying behaviour can be associated with the buying of an iPod, due to how expensive the product is and how infrequent it is purchased.For example, consumers buying an iPod could face a high involvement decision because of the high price of an iPod compared to a low involvement product such as a toothbrush and how the product can express the consumer, such as the which style and colour of iPod suit the consumer best. The Consumer may evaluate and do some research into the types iPods, prior to the buying decision to make give them more knowledge of the product. An explanation of each stage of the decision-making model This section of the report will explain each stage of the decision-making model for a buyer of an iPod.Below is the five-stage decision making process, buyers go through when they purchase a product. ‘The buying process starts with need recognition – the buyer recognising a problem or need’ (Kotler 2008, p age 265, p4). The first stage of the decision making model is where the consumer has recognised a problem or a need. Need recognition In relation to the iPod, is where the consumer has recognised that the product is available to buy and may have dissatisfaction with their current portable audio player.The iPod is not necessary a need, such as food or water. It is more of an individual want and the consumer may have more income spare to purchase an iPod. The purchase of an iPod could be mainly because of its appeal. ‘A need can also be triggered by external stimuli. Anna passes a bakery and the smell of reshly baked bread stimulates her hunger; she admires a neighbour’s new car; or she watches a television commercial for a Caribbean holiday’. (Kotler et al 2008, page 266 p1). This statement states that external stimuli can trigger a need.In relation to the iPod, the external stimuli could be an advert on television or someone in the public using an iPod, who seems to be having a fun with the product. The second stage of the decision-making model is the information search stage. This is the stage where a consumer is aroused to search for more information about the product they have been attracted too in the need recognition stage. ‘The consumer may simply have heightened attention or may go into active information search’ (Kotler et al 2008, page 266 p2). Heightened attention simply means the consumer becomes more receptive to information about a product.The consumer may pay more attention to adverts and products used by friends. Active information search is where the consumer gathers information, such as searching reading material or phoning friends to gather information, this usually depends of drive of the consumer to search for information about a product. ‘The amount of searching she does will depend upon the strength of her drive, the amount of information she starts with, the ease of obtaining more information, the v alue she places on additional information and the satisfaction she gets from searching’ (Kotler et al 2008, page 266 p2).This statement explains that the more a consumer wants a product, the more searching for information about the product will occur. In relation to the Apple iPod, a consumer may have been aroused by external stimuli such as an advert on television and then may go through active information search, where the consumer can obtain information from any of the following sources: * Personal sources: Family, friends, neighbours Commercial sources: Advertising, salespeople, the Internet, packaging, displays * Public sources: Mass media, consumer-rating organisations * Experiential sources: Handling, examining, using the product Personal sources can be the most effective for some products, as friends and families recommendations can be more reliable than an advert on television. As more information has been gathered from the above sources, the consumer’s knowle dge of the iPod increases. The consumer may know the different types of iPods available and their features that best suit the consumer.The third stage of the decision-making purchase is the information evaluation or evaluation of alternatives. This is the stage of the decision-making process, where the consumer uses information from the previous stage to evaluate other brands, products and services. The consumer also evaluates the benefits and features of the product they are going to buy. For high-involvement products such as the Apple iPod, the consumer is more likely to carry out a more extensive evaluation. Such as evaluating the advantages and benefits of the product they are interested in purchasing.

The Iliad An Epic Poem Essay - 1918 Words

The Iliad is known to be one of the most influential books of all time alongside with the Bible. Influential when it comes to art, architecture, TV, movies, music, religion, etc. There have been many things out there that have been influenced and continue to be influence by the Iliad. The Iliad is an epic poem written by Greek Poet Homer that revises the final weeks of the Trojan war and the Greek siege of the city of Troy. This epic poem introduces us to some of the mightiest Greek gods known to be in a Greek mythology. Just like the Iliad, the Bible would also be recognized as an influential book in all parts of the world. With its short stories that include war, romance, miracles, and other characteristics that a classical hero may have. Both these books are filled with extravagant and mythical stories that will keep your attention. In the Iliad we have Zeus who is the king of the gods and the ruler of Mount Olympus. He s known as the god of the sky, lighting, thunder, law, order, and justice. In the Bible we have Jesus Christ, he is known to be the Messiah. He s the king of all kings, God, our Shepard, and many more. The Iliad can have possibly influenced modern Christianity in ways similar to having higher powers/rulers. The birth of Jesus could be known to be one the unusual births of all time. Jesus was born from Mary who happened to be his mother and Joseph his father. The odd side to this was that Mary was still a virgin when she was told by an angle that sheShow MoreRelatedThe Epic Poem, The Iliad By Homer975 Words   |  4 Pages The epic poem, The Iliad by Homer tells a story of tragedy and love. Every book in the epic contains pieces of evidence that wrap the story together. The themes that occur in both Books are competition, pride, and hate. Deception, war, and assistance from the gods are important factors in both Books. 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