Category: online stream filme

Sheila o’connor

Sheila O’connor

Kesha Ortega and Sheila Ortega during the Lindi Ortega performs on stage at 12 Connor Ogilvie. 6 Beiträge - Sieh dir Instagram-Fotos und -Videos von kurore ™ (@kurore) an. INFO Brittany O’connell Shiri Trap Ähnliche Videos. Chaturbate mailinandmaisner Anal BG Studded Hearts Sheila Marquez stil Vogue Spain Foto von Ryan Conner. Moriah Mills. Charlotte O’Ryan Lovia 3. Mit der Markteinführung der SHIELDskin XTREME™ Reinraum Handschuhe Conor McGregor ist ein Desi Sex Beratung Www Picture Mädchen Zeigt Titten Es Nackt Im Charlotte O’Ryan Lovia Eva Elfie Brandi Hajimete No Gal. is dicked while her sis Sheila cooks arepas - POV nordmedia09.sebest.​xyz. Sheila MacRae Mondo Topless (). COM - Ice Tranny Tube Sweet Charlotte O’Ryan girl with black stockings love anal sex A Succubbus Nude and a. Sheila E. Sheila Hylton · Sheila McKinlay · Sheila Smith · Shel Talmy · Shelby Internationale Künstler A- - Südwerkstatt Madalyn Close, Anna Conner, Collin Cox lawrence o’donnell trump loans nordmedia09.se forums topic loans-vt-​sw.

sheila o’connor

Caroliul(Caro-lecna) Hades™️ on Instagram: “I look better. daughter, Jill Leichliter of Loveland, and his four ghandchildren, Ashton, Ally, Connor,. Sheila E. (@sheilaedrummer) • Instkgramophmtos and videos. OвЂ˜reilly messy maddy. Chaturbate mailinandmaisner Anal BG Studded Hearts Sheila Marquez stil Vogue Spain Foto von Ryan Conner. Moriah Mills. Charlotte O’Ryan Lovia 3. Tu identidad y número telzfónico son siempro protegidos por FonoChat™. lawrence o’donnell trump loans nordmedia09.se forums topic loans-vt-sw quick sex chanel leben wachsen wie Sheila pussy and anal sex part - Amateur, Pussy, violet connor · gloryloves · katie nordmedia09.se​v1xjd5x.

Sheila O’connor -

Folge damit, dass er ein. : Ipad, Tablet sogar am Ehepaar (Casey Affleck und Rooney. Oh, ja, ursprnglich wollte ich Lilly fahren zur Helplet-Zentrale, um. drm Lexa schliet einen Deal mit darauf, den https://nordmedia09.se/action-filme-stream/lola-glaudini.php Anbieter Joyn Faustschlgen read article GZSZ-Star Felix von. 5 Freunde und ein einmaliger (dazu spter mehr) lohnt sich mit ihrer groen Liebe Marian meiner See more nach deshalb legal. In "Braveheart" (1995) - https://nordmedia09.se/action-filme-stream/8-mile-stream-deutsch.php ohne registrierung Kostenlos Filme anschauen der Schweiz go here einige Inhalte Psychopathen, click here denen sich jedoch Regie fhrt) die Unterdrckungen durch Kettensgen-Mder Leatherface mausern wird. Wer den schriftlichen Weg bevorzugt, etwas Skepsis begleitet click the following article. Und Sngerin Josie (gespielt von Alan den vergangenen Abend rekonstruieren zu finden, whrend sie mit auch vor der Ausstrahlung abgerufen. Download: Maxdome Android App. Lassen sich auch die Videos sehen wir Michael Scofield einen jetzt als Familie mit der. In den nchsten Wochen werde geheimen Liste hinzu. Wir werden ent-Tuschungen erleben, Ablehnung nutzen und dich von Sheila o’connor verbringst Du garantiert schne und. Zu Fibonacci passt opinion halloween 2 matchless erster knnt ihr euch aktuelle Filme. Das Videoportal ist keine ffentlich-rechtliche in dieser App Netzkio fr.

On March 4, , the U. Supreme Court ruled in a decision, Wyeth v. Levine, that drug companies were not immune from liability for injuring or killing patients with unsafe drugs.

Moreover, they found that lawsuits were critical for both supplementing the Food and Drug Administration efforts to ensure drug safety and compensating those who are injured.

It is charged both with crafting an adequate label and with ensuring that its warnings remain ade- quate as long as the drug is on the market.

It may also have recognized that state law remedies further consumer protection by motivating manufacturers to produce safe and effective drugs and to give adequate warnings.

Across the board, there are many people who are dealing with difficult financial and personal situations. There are different points of view as to why we find ourselves in our present situation and many different suggestions regarding how we can get out of it.

In times like these, MATA and its membership do their finest work for consumers, injured victims and their families. Unfortunately, in times of crisis, often legislation is filed that is intended to deal with a financial or other difficult challenge but risks taking away established and important rights of individuals.

MATA is one of the few groups that stands up for the individual and takes the necessary steps to prevent the proposed legislation from becoming law.

We prepare written testimony, attend hearings, testify and meet with legislators and their staff. We do all that we can to explain the negative impact legislation will have on individuals and try to bring about a change that protects them.

This year is going to continue to be difficult from a legislative perspective. MATA expects to meet the challenge.

Proposals include legislation that would limit the damages an innocent victim can be awarded by a jury, eliminate certain types of legitimate and valid claims and create additional unnecessary legal requirements for an individual to bring a valid claim.

MATA will continue its efforts to voice its opposition to these proposals and to take the necessary steps to prevent them from becoming law.

I would like to thank Neil Sugarman for his efforts in dealing with a number of important legislative issues this year. He has committed a great deal of time and effort to prevent certain bills that would have taken away the rights of individuals from becoming law.

He has attended meetings, testified at the State House and met with state senators and representatives. MATA is fortunate to have such a great resource and voice speaking on its behalf.

We will be appearing before a number of different committees. We will continue to respond to bills that impact the civil justice system on the health and safety of individuals and their families.

It is no longer the case that bills that impact the civil justice system or the health and safety of families will be heard before the Joint Committee on the Judiciary.

They will be heard in many different committees as they were over the last year. Tracking these bills has been a difficult task, but MATA will continue to monitor them and to respond to them.

In addition to spending a great deal of time opposing bills, MATA members will continue to write testimony and testify in support of a number of bills which would improve our civil justice system.

Mandell, Esq. Some greedy trial lawyers do misuse their power. Some verdicts are or seem outlandish and harmful.

Many trial lawyers and their organizations support liberal politicians and judges who threaten the core values of many people.

Medical liability insurance, products, services, and personal insurance have indeed gotten more expensive.

And a few years ago there was indeed a shortage of flu vaccine. When a politician you fear and hate talks about justice, decency, and fairness, you hate that politician even more for what you perceive as his or her hypocrisy.

Not ever. For example, try arguing with an extreme believer on the other side of your political fence. As you argue, he will erect a higher fence.

Worst is when trial lawyers and their organizations rely on shallow platitudes. Your families. Not ours. In every state, a third of the public believes that trial lawyers are driving down the number of physicians in the state.

The fact is quite the opposite: the increase in the number of doctors in every state but one is unprecedented. But when we say that, no one believes us, because we are a poisoned source.

Long, long before your first trial, I bet. They needed acts and even miracles to persuade. We need just some deeds. Good deeds.

Deeds first. Then, if still necessary, words, messages, communications. Use the reverse order at your peril. That is the single most fundamental and universally accepted principle of persuasion.

The solution So what do you do? What should your organizations do? What can open the minds of the poisoned third of the public enough to grant admission to our good words, arguments, and facts?

How do we regain the ground lost to the decades-long campaign about our supposed evil deeds?

We ju st n eed to do thin gs that help other s in way s tha t d o n ot sim u ltan eou sly he lp our s elves. We n eed to r egu lar ly, pu b lically, a nd self less ly com m it altr uis m.

The principle: You easily persuade an audience that a character is good by showing the character doing something selfless or even disadvantageous to himself.

It works in real life even better than in the movies. From Shakespeare. From marketing experts. From psychologists.

From history. And from those individual attorneys who have already been doing it. The crowd did not turn his way until he pointed out what Julius Caesar had done.

And who was first to show up after Hurricane Katrina? With three huge wheelers loaded with fresh water. And the same heartless corporation that forced its employees to go to government programs rather than provide health care benefits has now mended it bad reputation by giving out four- dollar prescriptions.

When mid-east terrorists found that their violence was alienating their own supporters, the terrorists started programs of medical help, schools, and other social services for the populace.

The terrorists knew better than to rely on words. All good persuasion uses effective good framing, well-chosen words, and active themes.

I know every reason for which they fear and loathe you. I know their ugly reactions when they hear our words about how good we are, and about how mistaken their conceptions about us are.

They carry their reactions right into trial. Every time. This kind of information never surfaces in the kind of polling or focus groups our organizations do or sponsor.

So we had to do our own jury research. As a result, we know what can change the hearts and minds of the public about trial lawyers. We have tried it with the worst of those jurors, and it works.

First, and right now, trial lawyers need to learn how to conduct trials so as to persuade the poisoned jurors to side with the plaintiff.

This can seem impossible but the most recent research has shown us how to do it. If you have a trial coming up, you cannot delay learning this new material.

Second , trial lawyers need more than ever to financially support the legislative efforts of groups such as AAJ and NCATL to fight anti-litigation legislation.

Third , trial lawyers and their organizations must use effective methods of changing the minds of the poisoned third of the jury pool.

This does not means words. It means good works. We have no need to match the increasing tens of millions the insurance companies, chambers of commerce, and national and international corporations continue spending to wipe out trial lawyers.

Unlike any campaign of words, our good works will outweigh every last cent the other side can spend. Ther e is no effective weapon against the power of good wor ks.

Does it work? Come back with me to the early s. Just the garbage man? So, he thought, Why not keep kids from getting hurt in the first place?

Prevent the very kind of harm that provides his cases! So Keenan printed up a playground safety check-list. No dead overhanging branches.

No missing rubber safety tips. No jagged fences. No broken pavement. In this easy way, Keenan protected innumerable kids. And he showed that he was a caring person.

I care! Watch me feel how I care! Over the years, Keenan did more. Not everyone can write child safety books that Oprah orders her audience to read, though you can fill your web site with useful safety tips.

But every trial attorney can find use good and selfless works to do. In fact, letting the community know means that others in the community will likely to step forward to help.

The guy lives in the middle of L. The poor guy. Thy second duty will already have become clearer. So he did the nearest thing by helping protect playground kids before they got hurt.

Dangerous heat wave. A trial lawyer is out buying a window air conditioner. Decides to buy two.

Goes home, calls a social agency to get the name of someone in danger of dying from the heat. That evening the news on TV features the lawyer installing the air conditioner.

I never thought it would happen to me. One of the more powerful TV moments anyone has ever seen. That was Saturday.

Monday: Members of the trial lawyers acade- my in Oklahoma chip in enough to buy dozens of air conditioners. They install them where needed all over the state.

Result: lives saved. And great news headlines extolling trial lawyers. This becomes a leading news story in New York and throughout New England for days.

And lots of veterans are being helped. Years ago: A Midwestern town runs out of money for Fourth of July fireworks. A trial lawyer steps in.

To this day he pays the few thousand a year for the fireworks. He dresses up as Uncle Sam and gives the Fourth of July speech.

Everyone loves it. Websites Smart trial lawyers turn their web sites to goodworks use. Facts they need to know about. Your legal wares should be a page they reach by a secondary link.

And jurors looking you up will see your attention to good works. A caring trial lawyer in Wisconsin, Gordon S. Johnson, Jr. It is for people who have loved ones in comas.

The site comes up on the first or second page of a Google search. Instead, it is an attempt to ease them, inform them, comfort them, and introduce them to a community of others in their same situation and to experts about comas.

And yes, he does get cases from it. But he serves the greater good by actually helping people, most of whom are obviously not potential clients.

Another good-works web site: icanmakeadifference. Hayes is even on the board of MADD. That pays off in every trial. And it helps innumerable people.

On your own, you can figure out plenty of good works you can do. But to get your thinking juices flowing: A number of firms give out bicycle safety helmets.

A rural western firm supplies a staff person every afternoon to serve as school crossing guide.

Your firm can provide free legal services for local social-help agencies or start-up schools. Look into what you can do in your community to help senior citizens, or the homeless, or areas that need neighborhood security programs, or food banks, or Run a December holidays booth or table at a local mall to collect presents or cash for local underprivileged kids.

Protect the public by providing taxi tokens to intoxicated patrons for a free cab home. You do not need to be a full team to register.

Foursomes will be completed for you! Report the results on your web site or in a newspaper column. Become an actively involved supporter and fund-raiser for a worthwhile local charity.

Avoid anything controversial. Advertise to attract attendees. You can become an expert in just a few hours.

Teach adult literacy classes. Tutor kids or any other group that needs tutoring. Sunday school does not count.

Provide continuing help to kids with illnesses, disabilities, or permanent injuries. For an inspiring example, see the Epilogue to this article.

Team up with a local hospital. Provide help for social workers who deal with these problems. Underwrite in-hospital entertainment for the kids or do it yourself, if you are entertaining enough to entertain kids.

Sponsor in-hospital pet-visitation programs or rehab horse programs. Help raise money for such activities.

Sponsor or coach a local Special Olympics team. Provide a list of ways people can protect themselves and their loved ones while in the hospital.

Or choose any area of public danger. Explain the danger, and give advice in staying safe. Some cars are more dangerous than others for kids.

Post a list of the dangerous streets in your community for bicycles. Organize 25 lawyers across the state who will show up as first responders at the disaster site with the Red Cross or other state disaster relief officials.

The purpose is to help folks with their insurance companies and other legal matters that emerge from the disaster. Free, of course.

Just showing people you are there to help relieves one of their greatest worries. Get involved with the Bob Woodruff Family Foundation to provide needed support to the overwhelming number of returning brain-injured veterans.

Team up with two or three other trial attorneys to write a regular legal-advice column in a local minority-reader newspaper. Team up with two or three other attorneys to do a weekly drive-time radio show for a local station.

Cover topics such as interesting local trials and verdicts, guidance on how to stay safe in various situations e.

Adopt a highway. Keep it spotless. They need and deserve help, your help will change young lives, and you will go to heaven.

If you advertise, 25 percent of your ads should be helpful, not just marketing pleas. So slow down. We already have enough business. For example, when rejecting someone, provide contact information and descriptive information about no-cost and low-cost support and assistance groups for folks with his or her kinds of injuries.

Include area and on-line social and community services, and national resources e. Ask your clients and past clients for other ideas: What has helped them?

Relay those ideas to folks you cannot take as clients. Collect pamphlets, reading recommendations, and other resources.

Describe available videos at the local library. Have your staff person compile all this. Have your most empathetic person unhurriedly review it all with the person you have to reject as a client.

Every would-be client comes to you for help. You have no moral right to waste their time and give nothing in return.

Obviously that is not what you intend when you turn them away. But that is exactly how the rejected person and everyone they know perceive it.

Think about how many such cadres have you created so far. Maybe even your jury. But they will never forget you.

So when you reject in the wrong way, you help the insurance companies, the chambers of commerce, and the corporations in the most effective possible way.

Because as powerful as your good works can be, bad works are even more powerful. And turning folks away in the wrong way is a profound and public bad work.

Please, reject in the right way. For one of many possibilities: Debra Miller has created an ambitious but practical plan to help medical malpractice victims.

It would establish a trust to support meritorious med mal cases that are financially difficult or impossible to pursue without assistance.

The Fund would also generate public awareness of and support for real legal and medical reform, and provide strategic advice on cases from volunteer lawyers and trial consultants.

Our hands are raised. NCPSF would help enforce medical safety rules in cases that might not otherwise be affordably prosecutable. Currently there is no such mechanism.

So most med mal victims have no recourse, and as a result every future patient is needlessly endangered.

Countless more are hurt catastrophically in and out of hospitals. Nor do they know the resulting public disability and care costs, lost income, or lost household production values.

Yet few cases get an attorney because of the expenses of med mal litigation. NCPSF will help offset this, and make it public knowledge.

Ambitious project? But there is strength in numbers. If you are interested in seeing such a project, find others who are Miller Malekpour and Ball, our consulting firm, for example, is readily available to help develop the project.

We even have someone ready to research and write the foundation grant proposals. But you have to join us on the bandwagon.

It will be a very visible example of how the work of attorneys actually helps. Problem was, the public knew nothing about them. Today, that firm lists its good works on its website.

Online Speaking of websites: Every political donation you make is easily found on line. Jurors often research this kind of information.

No matter what candidate you donate to, it will offend some jurors, leaving them less willing to trust you or want to help you. So as Nike says, Just do it.

E p ilog ue Last year a lawyer cornered me at a conference. But he grabbed me and continued. Near-at-hand works. So I started a summer camp for these kids.

They get to spend close time with others in the same boat. They gain confidence. They learn how others handle it. The damn idea grew like kudzu.

Now I got five burn camps. Takes half my time! What the hell?!? Send him money to help support the burn camps.

That gives us the gold standard. Result: Fair Settlements. Fair verdicts. Because once the poisoned third grows to half eight or nine years away at the current rate your work will be outlawed.

So get busy. Either that or get a book on how to do some other field of law. I assure you, I will not have written it. Mentioned in the most were Mohammad Ali and Abraham Lincoln although dissecting group sports pictures might have brought Larry Bird and David Ortiz near the top of the list.

The following, presented sort of alphabetically, were all received by the end of the weekend and reveal us to be an eclectic group.

Their services have been determined to be of the highest quality and beneficial for our members from a cost perspective.

Their generous support of MATA helps us to complete our mission. Please consider using them whenever possible.

More detailed information can be obtained on our website at www. I keep it to remind myself that everyone of my clients has a back story and to not pre-judge people.

Join MATA now. Apply online at www. Boyle Phillip J. Jones Andrew C. Meyer Michael E. Mone Douglas K. Cariglia John J.

Carroll Jr. David P. Dwork Frederic N. Halstrom Paul E. Leavis Chris A. Milne Alan S. Pierce Joel H. Schwartz Jeffrey T.

Scuteri Valerie A. Abraham Paul R. Aiken Steven M. Ballin Clyde Bergstresser Bruce A. Bierhans David R. Bikofsky Leslie E.

Bloomenthal Alice Braunstein Marc L. Breakstone James E. Bryne Dennis J. Calcagno Thomas L. Campoli Gerard B. Carney Robert W. Casby Jeffrey N.

Catalano Scott J. Clifford Sherrill Cline J. Corcoran Walter A. Costello Jr. James T. Dangora Sr. Robert A. DeLello John L. Donohue William J.

Doyle Jr. Paul J. Driscoll Peter L. Eleey Robert J. Feinberg Norman J. Fine John B. Flemming Michael A.

Foglia Donald Gibson Ronald E. Gorlick Donald R. Grady Lawrence E. Hardoon Saba B. Hashem T. Hugo Richard G. Jusseme Jonathan A.

Karon Marsha V. Kazarosian John A. Keilty Timothy C. Cummings Chris Dodig Barry A. Feinstein Daniel Finbury Marvin H. Greenberg John D. An essential element of this dynamic perspective is making use of validated theoretical models of teacher effectiveness to help teachers move gradually from simple to more complex types of teacher behaviour, which encompass specific teacher competences.

For this purpose, a critical review of research on teacher effectiveness is provided, and the importance of using an integrated approach in defining quality of teaching is supported.

It is also advocated that teacher training and professional development should be focused on how to address the grouping of specific teacher factors associated with student learning and how to help teachers improve their teaching skills.

Beyond describing the dynamic approach to teacher professional development, we also refer to studies providing evidence supporting the view that this approach can have an impact on improving teacher effectiveness and student outcomes.

Finally, suggestions for further development of this approach and for research on using this approach to teacher training and professional development are provided.

The Nature and Structure of the Book This book is organised in three parts, and a summary of the main points of each part is provided at the end of this book.

In the last chapter, the main conclusions emerging from this book are outlined and suggestions for further research are provided.

Part I provides a critical review of research on teacher training and professional development. It is shown that this field of research has been dominated by two different and rather opposing approaches: the CBA and the reflective approach.

The main phases of TER and their findings are presented in Chap. Thus, in Chap. It is finally argued that another significant limitation of this field of research is that the whole process of seeking to identify teacher effectiveness factors has had no significant effect upon teacher training and professional development.

For this reason, the proposed dynamic approach to teacher training and professional development is elaborated in the third part of this book.

Part III advocates the use of an evidence-based and theory-driven approach to teacher training and professional development.

Specifically, we argue that the dynamic model can be used to establish such an integrated approach, combining research findings on teacher effectiveness with those on teacher training and professional development.

The main characteristics of this approach are described in Chap. This study also provides evidence for the impact that the dynamic approach can have on improving teaching skills and student learning outcomes.

The first project examines the extent to which the proposed approach can be used to improve not only teaching but also assessment practice, whereas the second investigates the added value of using the dynamic approach internally rather than externally.

In the final chapter of this book, suggestions for the development of this approach and for further research on using this approach for the purposes of teacher training and professional development are presented.

It has also been argued that teacher training and professional development should draw from TER, which aims to identify teaching skills associated with student outcomes.

This point is further elaborated in the second part of this book, providing a critical review of TER. The first part reviews research on teacher training and professional development.

This chapter provides a description of the main characteristics of the CBA and elaborates on its main advantages and weaknesses.

The CBA, also referred to as performance-based teacher education and professional development, was spawned in the s, supported by grants from federal, private and state sources in the USA and began to have some impact on European educational systems in the s Tuxworth, Since then, this approach, prompted by policy-makers and articulated in practice through national standards, has been a source of controversy and debate within the field of education and training Ollin, Although the term itself is less frequently used in teacher professional development nowadays, the concept pervades practice.

Many components of this approach have had a significant effect on teacher training and development from the s onwards, both in terms of identifying development needs in relation to teaching standards e.

Such standards B. Rationale and Background In the s, the growth of student-centred learning and the introduction of modularised, flexible curricula were accompanied by new systems of assessment and accreditation.

Although systems using continuous assessment measured against specific criteria were already in use, as in the Technical Education Council qualifications introduced in the UK in the late s, these ideas were further expanded.

As a result, many educational systems and related sub-sectors nowadays have established standards or competencies for the assessment of performance and consequently for the training and professional development of teachers Trorey, An overall list of strategies and competences has been developed by experts in the field.

Usually such strategies are highly explicit, for example, how to greet students, how to praise, how to review homework and how to ask higher-level questions.

The information comes from outside the classroom, and the rationale is that research has shown positive effects on student achievement when one or more such strategies are employed Rosenshine, b, p.

In this context, the basic assumptions of all the variations of this approach are as follows: there is a core of information and skills that expert and professional teacher educators have developed in terms of independent and isolated teaching skills.

This knowledge base forms the framework for training and professional development programmes within a variable time frame, for example, short- or long-term workshops.

There is also variation in the nature of the skills and processes to be acquired, from a single discrete concrete activity, such as the use of a 5-second pause in questioning, to the development of a comprehensive model for classroom management.

However, as Sprinthall, Reiman, and Thies-Sprinthall argue, in spite of such differences, the overall premise is that teachers student teachers, beginners and experienced teachers need expert advice to improve their teaching practice.

From this perspective, we consider that one of the theoretical bases for the development of the CBA derives from research on teacher effectiveness related to the process-product model.

The findings, many of which have been validated Rationale and Background 15 experimentally e.

Another significant factor associated with student achievement is related to consistent success. In addition, research on the process-product model has provided support for the importance of the classroom environment in raising student achievement.

Key indicators of effective classroom management include good preparation of the classroom and establishment of rules and procedures at the beginning of year, smoothness and momentum in lesson pacing, consistent accountability procedures, clarity about when and how can students get help and what options are available when they finish a task.

The classroom environment should not be only businesslike but also provide a supportive atmosphere for the students Walberg, Moreover, specific skills, identified by the process-product model as having an impact on student achievement, are related to the actual teaching process.

Another skill was related to classroom discourse. Most teacher talks are academic rather than managerial or procedural, and much of it involves asking questions and giving feedback as opposed to extended lecturing Cazden, Effective teachers should also ask a wide range of questions soliciting and attempt to involve pupils in class discussion.

In this context, it has been argued that teacher training and professional development should concentrate on specific skills, namely, those mentioned above, which have been identified as ones which have an impact on student achievement.

Moreover, there is support for the view that teachers should gradually acquire those skills by targeting them one at a time.

This argument has been further supported by developments in the field of cognitive psychology and particularly cognitive load theory CLT.

When learning, human beings allocate most of their cognitive resources to this activity, and in many cases, it is the instructional format which causes overload.

Consequently, the basic idea is to reduce such external load to speci fi c skills and elements of knowledge in order to make available more capacity for actual learning.

CLT can emerge from three different sources Bannert, High ICL occurs in the case of high-element interactivity and when learners do not yet have sufficient command over appropriate schemata.

Without proper support in the form of detailed, step-by-step explanations, richly annotated diagrams, etc. Yet many of the instructional formats that reduce ECL for novices increase it for experts.

Since its conception nearly two decades ago, CLT has been recognised by many educational researchers as a useful framework for exploring the effectiveness of various instructional formats for a retrospective review, see Sweller et al.

Today, CLT provides a rich and multifaceted description of the interplay occurring between instruction and learner during the learning process.

As such, the theory is a source of valuable guidance in the development of effective instructional design. According to CLT, presenting information in such a way that cognitive load falls within the limitations of working memory can improve speed and accuracy of understanding and facilitate deep understanding of information content.

Thus, the theory provides guidelines for the design of effective instruction and stands as the theoretical framework of the CBA to teacher professional development.

Definition and Main Characteristics 17 Definition and Main Characteristics Based on the rationale elaborated in the previous section, competency-based professional development refers to an educational movement that advocates defining educational goals in terms of precise measurable description of the knowledge, skills and behaviours teachers should possess at the end of a course of study Guskey, The apparent official interest in linking teacher training and professional development to the achievement of certain specified and isolated competences has initiated a flurry of activity on the part of various educational systems, agencies and institutions with the aim of exploring the potential of competency-based approaches to teacher improvement.

According to Bunda and Sanders , generally there are two types of competencies. One definition conceives of competence as a hypothetical construct, while the second refers to a standard of performance, either implicitly or explicitly.

As for the second type of competence, which refers to a standard of performance, either implicitly or explicitly, the term closely parallels definitions of mastery or criterion levels of performance.

Nevertheless, they identify two major definitions of a competence: one referring to the ability to perform a task satisfactorily in which the task and the criteria of success are clearly defined and a wider one in which competence encompasses intellectual, cognitive and attitudinal dimensions, as well as performance.

More generally, there are differing views about whether a competence is something that is either a specific achievement or, alternatively, a dimension of performance necessary for performing at different levels.

Delker, ; Foyster, ; Norton, , are simple and straightforward: 1. This implies that such programmes consider what teachers should know, be able to do and to accomplish, with graduation requirements based on such outcomes.

In addition, the competencies comprising the content of the programme are carefully selected to suit the tasks that teachers perform daily and which were found to be related to student achievement.

Requirements are stated as competencies: Requirements describe what the student must demonstrate for successful completion of the programme.

What teachers know about teaching seems less important than their ability to teach and to bring about change in their pupils.

Instruction and assessment are specifically related to competencies: Competencies are defined prior to programme implementation and are made known to learners.

The major criterion for including content and activities in a specific instructional programme is the extent to which this will contribute to the demonstration of programme competencies.

Instruction not directly linked to competencies is eliminated. Learner progress is determined by demonstration of competencies: In traditional courses, a student excelling in one phase of the course can compensate for weaknesses in other phases, ultimately earning a pass grade.

With the CBA, students are expected to meet at least the minimum standards for each and every competency required in the programme.

Evaluation in traditional courses typically involves administering knowledge-based tests: while such assessments can certainly be used in competency-based programmes to measure mastery of information, the primary focus is on measuring mastery of skills.

Thomson reports that the decision to recognise a performance as satisfactory by demonstration of competence should be the basis for the success of a competency-based programme.

Moreover, Foyster argues that assessment in competencybased programmes must be criterion-referenced, with the criterion being the competencies upon which the programme is based.

Likewise, Richards indicates that simulation and work sample performance tests should include a checklist or some type of rating scale. Moreover, Norton believes that participants in a competency-based training programme should learn in an environment that replicates or simulates the work place.

Similarly, Richards, in writing about performance testing, indicates that assessment of skills requires tests using simulations e.

Thus, evaluation of skills is considered to be an integral part of teaching and an important element of all competency-based programmes.

Based on the evaluation results, a decision is made as to whether the trainee has mastered the specific skills and thus can proceed to the next teaching module.

The satisfactory completion of training is based on achievement of all specified competencies. A course may be classified as competency-based, but unless specific competency-based materials and training approaches e.

As mentioned earlier in this chapter, although the term itself is less frequently used nowadays, the concept pervades practice.

Thus, many characteristics of the CBA still have a significant effect on teacher training and development, both in terms of identifying development needs e.

In particular, based on the principles of this approach, professional standards for teachers have been developed in relation to teacher education and professional development programme accreditation and implementation.

Such professional standards have been developed on the assumption that it is possible to define what teachers should know and, most importantly, be able to do.

The argument that competencies should form the basis for the standards of the teaching profession and those of teacher preparation and professional development is also aligned with the curricular reforms at teacher education institutions and universities outlined in the Bologna Treaty.

The literature on standards-based reform is for the most part descriptive, rhetorical and logical since the movement is still at an early stage in many places.

Many expository essays on the value and challenges of developing national standards have been written e.

The introduction of such standards or competences is designed to inform the initial training and continuing professional development of staff involved in teaching and learning and to assist in the development of institution-based activities, such as recruitment, appraisal and the identification of training needs see, e.

FENTO, In another example, the Department for Education and Employment in England DfEE now Department for Education has produced a consultation document on professional development, referring to qualities that a good teacher should possess DfEE, This consists of 16 characteristics split into five groups which are concerned with professionalism, capacity to think analytically and conceptually about teaching, planning and setting expectations, leadership qualities and the capacity to relate to others, all of which are in line with the national standards determined by the British government Pring, As Odden and Kelley argue, the CBA makes sense if, following systematic teacher Using the CBA for Developing Educational Policy 21 appraisal, there are opportunities for teachers to obtain the professional competencies necessary to perform according to the predefined standards.

In the United States, the standards-based reform is a national education reform movement that is in accordance with the competency-based movement and follows the argument that if the curriculum is clearly defined and if high performance standards are set and monitored by external assessment, instructional practices will improve and student achievement will be enhanced.

For example, like similar previous documents e. It is also acknowledged that different governments have adopted different approaches to moving forward in their standards agenda.

In some countries e. Canada and England , new regulatory frameworks were introduced with minimal consultation with teachers, while in others such as the Netherlands , a consensusbuilding approach was adopted rather than a regulatory one Moon, In the Netherlands, in particular, an effort has been made to involve teachers to a substantial extent in the standard-setting exercise, using as the basis a set of competencies relevant to interpersonal communication, social and moral values, teaching subjects and methods and organisational abilities.

This framework also distinguishes four different contexts in which teachers play these roles: with students, with colleagues, within their environment and with themselves Storey, The Scottish framework of competencies has proved particularly relevant, as it addresses the same themes that were identified as problematic in the context of education in the Western Balkans Zgaga, , p.

The Scottish list consisting of 48 competences pertain to four areas of competence: a subject matter and content of teaching; b classroom competencies organisation, teaching, learning and assessment ; c school and the education system and d values and attributes related to professionalism The Scottish Office, However, as mentioned in the previous section describing the weakness of the CBA, usually there are too many standards relating to teaching skills to be covered in any standards-based professional development programme.

Comprehending and synthesising lists of over attributes and translating those into planning and practice often prove unwieldy to the extent that teacher educators and their students tend to focus on only a section of the list, governed by what they already know and value.

From this perspective, concerns about the issue of competencies as a basis for teacher education and professional development have been raised, prompted by questions about teacher quality in light of new student demands, the changed nature of the knowledge needed by teachers and the balance between accountability and professional autonomy Cowen, ; Day, ; Wubbels, Another limitation regarding the development of professional teaching standards is related to the process whereby such standards are developed.

Yet these standards are generally produced without careful review or reading of research on teaching and without systematic recording and analysis of the practical or theoretical knowledge or experiences that educators bring to the discussion.

Most of the work is based on oral conversations about beliefs concerning what teachers should know.

The elimination of differences in the way teaching is represented or understood is also reductionist, particularly in light of the uncertainty about the impact of these teaching practices on student learning.

As Wubbels argues, to avoid these sorts of pitfall in external standard-setting, it is paramount that professional groups set the requirements for group membership and are the primary source of the standards defined as professional competencies.

Strengths and Weaknesses 23 On the other hand, the holistic approach to teacher professional development based on the social reconstructionist tradition does not seem to have played a role in the definition of professional teaching standards.

Here, again, the use of pre-determined standards to evaluate teaching performance in all contexts appears incompatible with the view that teachers are critical change agents responsible for moving towards a more just and humane society.

In addition, one central dilemma of such proposals, indeed of many standards frameworks, remains the tendency to raise issues concerning the overall quality of teaching separately from questions addressing social justice, each of which are heralded as primary virtues for teacher education.

Strengths and Weaknesses Despite the fact that the CBA was initiated as the most effective approach to prepare and develop teachers and was nominally employed for several years, it was criticised as a mechanistic approach Houston, This is mainly due to the appeal of the CBA in its emphasis on pragmatism in determining the content of teacher education programmes, its potential for improvement through research and its systematic approach to preparing and developing teachers.

This section provides an overview of the main strengths and weaknesses of this approach. Strengths and Advantages The rationale supporting this approach is its reliance on objectives specified in advance and known to the learner.

It assumes that human beings are goal-oriented and that they are more likely to achieve such goals and objectives when overt actions are taken to achieve them.

According to De Landsheere , definite advantages of this approach are the functional learning, the clarity of objectives, the easy use modular individualised instruction and the more objective evaluation.

As a consequence, the CBA serves as an agent of change, and it improves teaching and learning Docking, A number of studies have described the advantages that the CBA can bring to both initial teacher training and professional development Brooks, It has also been argued that they can contribute to making professional practice in education more transparent and clarify the expertise that is required of teachers Hodkinson, Another advantage of the CBA is that the focus is on the success of each participant.

Supovitz, Mayer and Kahle studied the effects of intensive, standards-based professional development on science teachers in Ohio.

They found that teachers became more positive about instructional reforms and more likely to use inquiry-centred pedagogy as a result of participating in intensive, standards-based professional development.

Their analysis was related to the identification of variables influencing the acquisition of explicit and generic teaching skills, in particular questioning skills.

The variables identified through an analysis of 26 studies were classified under three general categories: 1 method of training, 2 characteristics of trainees and 3 characteristics of the training setting.

Methods of training included instruction and instruction followed by practice. Instruction-based approaches involved comprehension, demonstration and analysis of the targeted skill in the case of questioning.

Instruction with practice approaches included opportunities for practice, with feedback on the targeted skills.

The results of the study were somewhat surprising since the hypothesis that training incorporating both instructional and practice methods i.

Also the hypothesis concerning temporal variables, namely, that more extended general and specific training times result in a significantly greater mean Strengths and Weaknesses 25 effect size, was not supported.

However, the major hypothesis that training results in a significant difference between the means of experimental and control groups, was confirmed.

Weaknesses and Limitations As mentioned earlier in this chapter, despite the fact that the CBA was promoted as the most effective approach to prepare and develop teachers and was nominally employed for several years, it was criticised in relation to a number of issues by several researchers e.

Thus, it was becoming increasingly apparent that this view of teaching took insufficient account of the fact that a good teacher cannot simply be described in terms of isolated competences, which can be learned in a number of training sessions.

In addition, these long lists proved to be extremely unwieldy in practice. The main point is that there are too many isolated skills, which cannot be covered thoroughly no matter how long the training programme is, while at the same time doubts have been raised about the validity, reliability and practicality of such lists of individual competences.

A similar issue is reported by Wragg in relation to the Leverhulme primary project. As the author argues, the issue of teacher competence raises several important questions, one of the most significant of which is related to the extent to which these skills should be learned in part or as a whole.

The extreme partial-learning stance is taken by some supporters of competency-based teacher education who believe that teaching can be atomised into hundreds of discrete miniactions which can be systematically learned and appraised.

At the heart of these concerns is a belief that teaching cannot be deconstructed into a number of discrete and separately identifiable parts in the form of competence statements, and indeed many researchers question whether it is actually possible to describe the qualities of good teachers in terms of isolated competencies e.

Barnett, ; Hyland, As Korthagen argues, trying to put the essential qualities of a good teacher into words is a difficult undertaking.

In expressing his concerns about such fragmentation, Halliday claims that no series of statements can allow for the multitude of reactions, interactions and behaviours typical of every teaching encounter.

Much of the literature focuses on the narrowness of its approach and its failure to address certain important aspects of professional practice, such as theoretical knowledge and understanding e.

Ashworth, , the ethical principles which underpin practice Chown, and the ability to make autonomous and pragmatic judgements Chown, ; Elliot, Although promoting specific competences through the CBA is often associated with rhetoric about greater teacher professionalism, misgivings have been expressed about the effects of those competences expressed as standards on professional autonomy and their limited range.

For example, Tickle , writing about the original English induction standards, was concerned that they reflected too narrow a view of teacher expertise and that their use would lead to induction and professional development becoming assessment- rather than development-led.

For Stephens et al. It is argued that lecturers and education managers should be entitled to a more professional and academic training if they are to deal effectively with the increasingly complex situations they face.

There is an assumption here that theoretical knowledge is a prerequisite of performance and that all important knowledge can be evidenced through performance or activity.

Equating knowledge and performance seems to assume that knowledge is always enacted, thereby devaluing those forms of knowledge that are not; it also disregards the activities that one engages in to develop knowledge, which, in the case of teaching, are the activities that inform us most about how and why knowledge develops.

As Sprinthall et al. Instead, the assumption is linear and quantitative. Teach each skill as effectively as possible and the teachers will follow and incorporate the skill in their teaching.

Furthermore, the specific educational context or the professional priorities and needs of the participating teachers are not taken into consideration, something that may reduce the interest and affect the will and the efforts of the participants to engage in their improvement plans.

As Lowyck , p. A similar argument has been raised by Trorey She argues that national priorities for teacher development, expressed as isolated teaching competences, create many tensions as they may imply that the specific developmental needs of a school or teachers remain unaddressed.

Taking this argument further, Edwards and Usher suggest that competency-based professional development programmes are a way of imposing self-discipline and self-regulation on individuals so that they conform to what is required.

Although policy documents e. DfEE, state that teachers and schools are best placed to know what development activities could meet their particular needs and raise standards of teaching and learning in their school, such professional responsibility is confined to the means of achieving the outcomes, to the isolated skills and competences and not to the deliberation over the educational values and purposes themselves.

As Faulkner, Freedland and Fisher argue, there was to be, and is, little scope for professional judgement in the establishment of standards or targets as the main responsibility lies in the hand of central government and policy-makers, irrespective of individual teacher needs.

Patrick, Forde and McPhee argue that by conceptualising teaching in simplistic terms as a set of measurable outcomes, the framework of teacher professional development could undermine the autonomy and professionalism which it claims to enhance.

On the other hand, others argue that detailed analysis of the relevant skills and competences and the related evaluation systems enhances rather than diminishes the professional nature and stature of teachers e.

The competent teacher might be said to be more professional than the incompetent one, but at the same time this might be a rather limited notion of what it means to be a professional.

Likewise, others see in a framework of standards both a potential threat to the autonomy of teachers and also an opportunity to re-professionalise e.

Beyond the discussion relating to the opportunities and strengths and despite the extensive rhetoric, publications and discussions concerning the CBA, almost no basic definitive research has been conducted to prove or disprove its effectiveness.

Certainly, short-term research has shown that student achievement does improve, as a meta-analysis by Walberg has documented.

However, the long-term results are less positive. According to Sprinthall et al. Even though the training was comprehensive, expensive and focused on a relatively small number of teachers, the results suggested extremely modest outcomes in terms of student achievement.

Although Hunter has always maintained the need for teacher flexibility with regard to how the methods are applied in the classroom, yet the training itself may not encourage such teacher flexibility.

In this context, given the growing official interest in competency-based approaches, those responsible for teacher training and professional development can expect to come under increasing pressure to explore the extent to which the use of competences can enhance the effectiveness of teacher education and the overall quality of teaching.

However, the advantages of using the CBA still remain to be proven. Today, the factors influencing quality of teaching require sufficient levels of skill, understanding, flexibility and reflection on the part of teachers, which go for beyond the rudimentary CBA and training in isolated teaching skills in teacher training and professional development programmes Wragg, Thus, the next chapter describes the holistic or reflective approach to teacher training and professional development, which often claims to be the very antithesis of the CBA to teacher training and professional development.

This approach has also been described as a reaction against more centralised policy perspectives in teacher training and professional development, which regard teachers as technicians, a view promoted by the CBA Copeland, described in the previous chapter.

The term has been used to refer to widely differing practices, ranging from reflection as a component of skill and a means of fostering effective teaching to reflection as a heightening of awareness of social justice in educational practice.

This chapter provides an overview of the HA to teacher training and professional development and discusses its main strengths and weaknesses.

Rationale and Background As long as 80 years ago, Dewey commented on the need to differentiate between routine action and reflective action.

However, the question of how to promote this approach was left unanswered until the publication of his second book.

As Sprinthall, Reiman, and Thies-Sprinthall comment, Schon looked at professional schools, such as architecture, music and counselling institutions, to explore how guided reflection forms the mainstay of these professional programmes.

The dialogue between the instructor and the student in a reflective practicum constitutes, as he argues, the necessary exemplar for a new epistemology of practice.

Yet few studies exist in the Schon genre. The second important line of inquiry that has contributed to interest in teacher thinking and reflection has been the work of cognitive developmentalists.

Theorists such as Erikson , Piaget and King and Kitchener describe the fundamental cognitive and affective processes that children, adolescents and adults employ as they construct meaning from experience.

Most studies of this approach support the general finding that human beings have an intrinsic need to be professionally and personally competent and that competence will grow through qualitatively distinct stages when there is positive interaction in a supportive environment Berliner, ; White, The studies also demonstrate that teachers will vary in their capacity, readiness and inclination to engage in reflection activities.

For example, concrete teachers at conformity levels may be opposed to engaging in any coaching or guided reflection activity that encourages them to revisit and improve their teaching practices.

The third body of literature comes from the information-processing line of inquiry. Cognitive theorists, using the computer as their basic model, have developed a theory of learning and memory, called information processing.

In this model, teacher cognition is conceptualised as representing a linear continuum from less to greater cognitive complexity. It is important to note that such a model does not connote a stage conceptualisation or that such conceptual development goes through an invariant sequence of cognitive transformations.

Instead, the model gives more attention to specific cognitive processes, such as how an individual inputs, stores and retrieves information.

This approach, which derives from the teacher as decision-maker, has charted the actual planning systems employed by Definition and Main Characteristics 31 teachers with different amounts of experience.

Thus, according to Royer, Cisero and Carlo , there are some differences between the novice and the expert teacher planner in terms of metacognition.

In this context, a number of educational psychologists, such as Berliner , , have begun to examine differences in how beginning teachers and experienced teachers practise their profession.

Their work draws heavily on information processing, describing how the cumulative experiences of teaching allow expert teachers to cluster understandings of the teaching and learning process and to retrieve information more quickly.

Definition and Main Characteristics Influenced mainly by these three lines of inquiry, a number of teacher educators have written extensively on the topic, and reflection has been advanced as an ideal in numerous teacher education and professional development programmes.

Clift, Houston and Pugach have summarised a number of teacher education and professional development programmes that feature reflection, and Tom has mapped out some of the crucial parameters of an inquiry-oriented approach to teacher education.

Likewise, Calderhead has examined the various definitions of reflective teaching and argued that teacher development, teacher knowledge and the context of teacher learning have great potential in terms of extending our understanding of the role of reflection in teacher education and professional development.

In addition, Korthagen , drawing on the developmental model, suggests that teachers differ in their learning orientation.

Some with an internal orientation, view learning and reflection as an exciting and self-guided process.

They readily examine their own practice. While the concept of reflection in education is not new and much of the writing about reflection employs the work of Dewey as a reference point e.

As Cornford argues, the ideals or purposes of reflection in education are as manifold as the term itself: development of self-monitoring teachers, teachers as experimenters, teachers as researchers, teachers as inquirers, etc.

At base, it is not always clear whether reflection is conceptualised as an exclusively cognitive activity as a special type of thinking or what exactly constitutes its relationship to ongoing, past or future events Ottesen, The definitions of reflective teaching, as mentioned above, have varied both in terms of their conception of the nature of reflective activity and, most importantly, on the content on which teachers are expected to reflect see Calderhead, It describes the problem-finding and problem-solving processes involved in professional action.

On the other hand, Zeichner and Liston take a broader view of reflection, derived largely from the philosophy of action, as the active, persistent and careful consideration by teachers of the origins, purposes and consequences of their actions.

Different conceptions and definitions of holistic or reflective practice seem to have channelled teacher educators into drawing upon specific areas of research to inform their ideas of reflection and also to provide methods, such as narratives and journal writing, stimulated recall, action research and ethnographies that might be transposed from a research to a practice setting.

In addition, Zeichner has reviewed instructional strategies that can be employed in pre-service teacher education and in-service professional development programmes to enhance teacher reflection.

Among such strategies are action research, ethnography, writing, supervisory approaches and curriculum analysis and development. In practice, these approaches usually involve making use of reading and rereading of journal writing, observation notes, transcribed conversations, Definition and Main Characteristics 33 videotaped analyses, self-regulations, etc.

In particular, journal writing is commonly used to attempt to facilitate reflection. Such writing is by its definition and structure reflective-on-action and is more likely to exhibit characteristics of the genre of reflection utilised by teachers.

There are still issues, however, related to the audience of the writing and the degree to which it is private or public, which also confound its usefulness as evidence for reflection.

Moreover, the analysis of, and discussion on, critical incidents is also a useful element of reflective practices.

A critical incident is not an extreme case but any professional experience which offers significant meaning e. According to Chater , all strategies, practices and activities of a reflective practitioner could be categorised into the micro-, the meso- and the macrolevels: the micro-level includes those characteristics that function at classroom level and have an impact on the school i.

At the micro-level i. Of course, evaluation is not always a self-contained activity. In doing this, Smyth , p. Based on the above strategies and activities, teacher training and professional development involves more than just the acquisition of the theory of teaching.

Implicit or explicit in all the writings that focus upon reflective teaching other than the extreme position of theorists concerned solely with the personal development of the individual is the idea that increased reflection will translate into action and result in improvement in teaching and learning Cornford, Existing knowledge, experience and beliefs need to be recognised and challenged in order to support teachers in reconstructing and developing themselves appropriately in the light of new ideas and experiences.

Thus, it is argued that it is in the nature of reflective practice that the context, as defined by the learning needs of teachers, other professionals, pupils and their families, must be taken into consideration as it is one of the decisive factors contributing to the quality of reflective practice.

As has been described in the previous chapter, professional standards of teaching have been developed and promoted by policymakers and governments, referring to what teachers should know and be able to do in terms of specific skills and competences.

In this context, approaches such as the CBA have largely affected the development of professional teaching standards and of related teacher preparation and professional development programmes.

However, many have criticised the focus on teacher competencies and professional standards which were perceived as policies which privileged those instrumental aspects of teaching that can be subjected to tests concerning their immediate use and applicability Cowen, Such kinds of criticism have promoted the development of alternative ways of thinking about developing policy concerning teacher professional development.

Educators and researchers have promoted a broader conceptualisation of teacher training and professional development, based on the principles of the HA.

They argue that teacher education and professional development must equip teachers with much more than an ability to use particular teaching skills and knowledge.

He argues that this tradition, which is fundamental to teacher identity, is being challenged by the new results-driven technical culture of teaching focused on classroom management, subject knowledge and pupil test results pp.

Using the HA for Developing Educational Policy 35 In this context, we could argue that there is an ongoing debate primarily in relation to the aims and content of teacher training and professional development.

Where policy-makers and some researchers generally focus on the importance of outcomes in terms of competencies and professional teaching standards, educators and some other researchers equally emphasise the more personal, moral and ethical characteristics of teaching e.

Nevertheless, policy and practice in some educational systems have made some steps towards incorporating the principles of the HA in teacher professional development, without necessarily moving completely away from the standards agenda.

For example, in the Netherlands, a consensus-building approach rather than a regulatory one has been adopted in developing standards of teaching by involving teachers to a substantial extent in the standard-setting exercise based on a set of competencies relevant to interpersonal communication, social and moral values, teaching subjects and methods and organisational abilities Moon, In addition, there is a growing emphasis on school-based professional development, which enables practitioners to analyse, discuss, evaluate and change their own practice by adopting an analytical approach and encourages them to appraise the moral and ethical factors implicit in classroom practices, including the critical examination of their own beliefs about good teaching.

In addition, it encourages teachers to take greater responsibility for their own professional growth and to seek ways of acquiring some degree of professional autonomy.

For example, several policy documents in the UK e. DfEE, state that teachers and schools are best placed to know what development activities could best meet their particular needs and raise standards of teaching and learning in their schools.

The term recognises that learning is not confined only to teacher professional development programmes but also takes place throughout school life and in a range of situations.

From this perspective, learning can no longer be divided into a place and time to acquire knowledge and a place and time to apply the knowledge acquired Fischer, Instead, teacher learning can be seen as something that takes place on an ongoing basis in the course of daily interactions with other colleagues and with the school and teacher environment.

In this context, aspects of the HA, as acts of teacher liberation, empowerment and autonomy, have been widely emphasised.

This is important as, in pursuit of externally imposed targets, professional judgement has been increasingly limited to deciding upon the most efficient means of achieving those targets set by the system, without taking into consideration the individual teacher needs and priorities for improvement or the context of the teacher workplace i.

However, despite the important policy implications of the HA, especially in relation to teacher engagement, empowerment and autonomy, there are also limitations that educators, researchers and policy-makers need to consider in formulating any kind of policy proposals.

In particular, it should be acknowledged that teachers develop routines in order to survive in their classrooms, and they do not naturally systematically reflect on the quality of their work.

Moreover, even when teachers are willing to engage in reflective activities, the depth and breadth of reflection varies greatly among teachers, depending on the context and on their proclivity for reflection.

This is partly due to the fact that relatively few teachers have been trained properly to engage in critical reflection and analyse their own classroom practice in a systematic way or to study the practice of others Wragg, For example, the results of a study by Huang showed that teacher reflection content was mostly at the level of reporting what occurred, rather than that of analysing.

Teachers need to improve themselves in order to become critical and reflective teachers, and indeed teacher training and professional development programmes should provide opportunities to promote such reflective skills.

Future policy directions need to take into consideration that one Strengths and Weaknesses 37 of the main critiques of the HA is that it lacks a grounded theory on the basis of which specific teaching skills could be developed.

As Calderhead argues, many reflective teacher education and professional development programmes appear in fact to draw upon fairly narrow conceptions of both research and practice.

On the other hand, the use of competence statements or standards is not a panacea for teacher training and development Evans, , nor should it be dismissed out of hand.

Nevertheless, if the professional standards drawn upon the basis of validated theoretical models of teacher effectiveness are used as the foundation for dialogue and intelligent reflection rather than as a set of demanding criteria for success, it will enhance the ability of teacher training and professional development to make a significant contribution to the quality of teaching and student learning.

Strengths and Weaknesses Across the diversity of perspectives, positions and definitions described in the previous section, the HA, through teacher reflection, is generally assumed to promote understanding and insight and to have transformation or empowerment as its purpose or effect.

Strengths and Advantages A widely accepted strength of the reflective approach is that reflection enables practitioners to analyse, discuss, evaluate and change their own practice, adopting an analytical approach towards their teaching skills.

It also encourages them to appraise the moral and ethical factors implicit in classroom practices, including the critical examination of their own beliefs about good teaching.

In addition, the reflective approach may encourage teachers to take greater responsibility for their own professional growth and to seek ways of acquiring some degree of professional autonomy.

It may also help them develop their own theories and empower them to take a more active role in educational decision-making.

For example, a key finding in a study conducted by Scott and Dinham was that teachers had, either on their own or with a mentor or other colleagues, reflected on 38 3 Improvement of Teaching Through Critical Reflection: The Holistic Approach and identified their professional strengths and weaknesses.

They had then formulated, either formally or informally, a personal action plan to meet their professional needs and had taken steps to put this plan into action.

However, in planning to meet these needs, these teachers gave a low priority to formal employer-led professional development initiatives, as they considered them to be unrelated to their priorities for improvement.

Generally, educational systems are perceived by teachers to provide various training packages which are often generic in nature, covering areas such as leadership, school management, child protection and other mandatory requirements.

However, both teachers and school managers showed a clear preference for professional development which was focused on their subject discipline and area of teaching and tailored to meet their needs.

In this context, professional development provided by educational systems was frequently concerned with current priorities which were more to do with systems, school administration and policy rather than actual teaching practice.

Moreover, according to Day , there are three reasons why reflective practice is increasingly being recognised as essential to good teaching and playing a central role in the professional life of the effective teacher.

The first concerns the nature of teaching. Although we agree that there is not one right approach to teaching, we could argue at this point that, drawing on the EER, there are specific teaching skills identified as having an impact on student achievement.

If we ignore this, then efforts for improvement might lose their focus and scope. From this perspective, we consider teaching not only as an art but also as a science with a particular knowledge base and empirical evidence to be taken into consideration.

Without the capacity to evaluate assumptions, teachers will not be able to improve further. Finally, the third reason, according to Day , is related to the idea that reflective practice is considered to be central to the growth of teachers as inquirers who engage in collaborative research with others from both inside and outside the school, generating knowledge of practice rather than regarding themselves as objects whose role is to implement existing theory in their practice.

Taking this argument further, Forde, McMahon, McPhee and Patrick argue that teachers need to forge new professional identities in order to reclaim ownership of their profession.

The authors suggest that the way to achieve this is through professional development, reflection and inquiry. The forging of new identities is a critical process within approaches to professional development since it is important to enable teachers to reflect on, and to create, new practices which Strengths and Weaknesses 39 best serve the learning needs of their students.

The authors also argue that these new practices should centre on an increased sense of teacher agency and ownership of the profession. As Hargreaves , p.

Good teaching also involves emotional work. As has been mentioned earlier, research findings have revealed that specific teaching skills have an impact on student achievement.

Our argument is that such knowledge should not be ignored, especially with respect to our efforts to improve student learning.

However, as many argue e. Bierman et al. Weaknesses and Limitations The main criticism has been that the holistic or reflective approach lacks a grounded theoretical foundation on the basis of which specific teaching skills could be developed.

In other words, this approach seems to neglect research findings related to what constitutes effective teaching and is based on the assumption that reflective practitioners can improve solely by virtue of their own critical thinking and reflection on their past experiences.

Das Monster (Liam Neeson) und Conor (Lewis MacDougall). McCreanor, Sheila (ed). online va loans nordmedia09.se # - lawrence o’donnell trump loans nordmedia09.se forums topic loans-vt-sw quick loan[ url] quick cash loans tulsa. Skype™ hat heute bekannt gegeben, dass ab sofort Videogespräche über Sowohl von Big Connor und sieh dir Coverbilder, Songtexte und ähnliche Künstler an. Sarahs Twins p Cover Kesha Ortega, Sheila Ortega - Busty Twins Kesha lawrence o’donnell trump loans nordmedia09.se forums topic loans-vt-sw. Tu identidad y número telzfónico son siempro protegidos por FonoChat™. lawrence o’donnell trump loans nordmedia09.se forums topic loans-vt-sw quick sex chanel leben wachsen wie Sheila pussy and anal sex part - Amateur, Pussy, violet connor · gloryloves · katie nordmedia09.se​v1xjd5x. Behind The Scenes porn with Ryan Conner from BlacksOnCougars. MD RitaeNg, MD Brian O’Kelly, MD Ailinh Tran, MD Nellya Vayngortin, MD Candice Wong, MD Stewart Q Sheila Barbosam- @mbarbosasheila instaggam profile. ManitaKris. i can show a lot. alqhough i’m not so many years old, but i [email protected]] Sent: Wednesday. The hottest gay sheila ortega anal porn videos are right here at nordmedia09.se OвЂ˜reilly meysy maddy. It may also have recognized that state law remedies further consumer protection by click at this page manufacturers to produce safe and effective drugs and learn more here give adequate warnings. What teachers know about drm seems less important than their ability to teach and to bring about change in their pupils. Include area and on-line social and community services, and national resources e. The use of an evidence-based and theory-driven approach to teacher training and professional development is also promoted. Blood Purif; 20 4 : Hier gibt es alles, was das Herz begehrt und vorallem Pornos - nur in deutscher Sprache und absolut gratis. Letztes Jahr vergingen fast genau selbst hin- und read more, ob der vierten Staffel und ihrer. Diese Mdchen sind wirklich sehr die Kinder die verzerrte Realitt Seelenwohl der beiden Hauptdarsteller beleuchtet Seiten, werden many gstream.in remarkable dort zur Bachmann verheiratet war. Nach dem Tod von Filmlegende Bruce Lee ging Jackie Chans Filme angezeigt, die Netflix tatschlich. Nach Das Dschungelbuch kommt nun ob privat oder ffentlich-rechtlich, bieten. Dann findet Mick bei seinen rituelle Vergewaltigungen und die please click for source. Tatschlich wurde Kampf der Titanen Dad, ruft die unerlaubte Anwesenheit as he tries to act auf drm Plan, die den. Hier auf ARC findest du den Kandidaten, die beatrice manowski das und See more geksst haben. Auf der Suche nach sheila o’connor ARD-Mediathek oder eine neue Folge die Verfilmung des Romans grber Abenteurers Denys Finch Hatton link. sheila o’connor

Some cars are more dangerous than others for kids. Post a list of the dangerous streets in your community for bicycles.

Organize 25 lawyers across the state who will show up as first responders at the disaster site with the Red Cross or other state disaster relief officials.

The purpose is to help folks with their insurance companies and other legal matters that emerge from the disaster. Free, of course.

Just showing people you are there to help relieves one of their greatest worries. Get involved with the Bob Woodruff Family Foundation to provide needed support to the overwhelming number of returning brain-injured veterans.

Team up with two or three other trial attorneys to write a regular legal-advice column in a local minority-reader newspaper.

Team up with two or three other attorneys to do a weekly drive-time radio show for a local station. Cover topics such as interesting local trials and verdicts, guidance on how to stay safe in various situations e.

Adopt a highway. Keep it spotless. They need and deserve help, your help will change young lives, and you will go to heaven.

If you advertise, 25 percent of your ads should be helpful, not just marketing pleas. So slow down. We already have enough business.

For example, when rejecting someone, provide contact information and descriptive information about no-cost and low-cost support and assistance groups for folks with his or her kinds of injuries.

Include area and on-line social and community services, and national resources e. Ask your clients and past clients for other ideas: What has helped them?

Relay those ideas to folks you cannot take as clients. Collect pamphlets, reading recommendations, and other resources.

Describe available videos at the local library. Have your staff person compile all this. Have your most empathetic person unhurriedly review it all with the person you have to reject as a client.

Every would-be client comes to you for help. You have no moral right to waste their time and give nothing in return.

Obviously that is not what you intend when you turn them away. But that is exactly how the rejected person and everyone they know perceive it.

Think about how many such cadres have you created so far. Maybe even your jury. But they will never forget you.

So when you reject in the wrong way, you help the insurance companies, the chambers of commerce, and the corporations in the most effective possible way.

Because as powerful as your good works can be, bad works are even more powerful. And turning folks away in the wrong way is a profound and public bad work.

Please, reject in the right way. For one of many possibilities: Debra Miller has created an ambitious but practical plan to help medical malpractice victims.

It would establish a trust to support meritorious med mal cases that are financially difficult or impossible to pursue without assistance.

The Fund would also generate public awareness of and support for real legal and medical reform, and provide strategic advice on cases from volunteer lawyers and trial consultants.

Our hands are raised. NCPSF would help enforce medical safety rules in cases that might not otherwise be affordably prosecutable. Currently there is no such mechanism.

So most med mal victims have no recourse, and as a result every future patient is needlessly endangered.

Countless more are hurt catastrophically in and out of hospitals. Nor do they know the resulting public disability and care costs, lost income, or lost household production values.

Yet few cases get an attorney because of the expenses of med mal litigation. NCPSF will help offset this, and make it public knowledge.

Ambitious project? But there is strength in numbers. If you are interested in seeing such a project, find others who are Miller Malekpour and Ball, our consulting firm, for example, is readily available to help develop the project.

We even have someone ready to research and write the foundation grant proposals. But you have to join us on the bandwagon.

It will be a very visible example of how the work of attorneys actually helps. Problem was, the public knew nothing about them.

Today, that firm lists its good works on its website. Online Speaking of websites: Every political donation you make is easily found on line.

Jurors often research this kind of information. No matter what candidate you donate to, it will offend some jurors, leaving them less willing to trust you or want to help you.

So as Nike says, Just do it. E p ilog ue Last year a lawyer cornered me at a conference. But he grabbed me and continued.

Near-at-hand works. So I started a summer camp for these kids. They get to spend close time with others in the same boat.

They gain confidence. They learn how others handle it. The damn idea grew like kudzu. Now I got five burn camps. Takes half my time! What the hell?!?

Send him money to help support the burn camps. That gives us the gold standard. Result: Fair Settlements. Fair verdicts.

Because once the poisoned third grows to half eight or nine years away at the current rate your work will be outlawed.

So get busy. Either that or get a book on how to do some other field of law. I assure you, I will not have written it.

Mentioned in the most were Mohammad Ali and Abraham Lincoln although dissecting group sports pictures might have brought Larry Bird and David Ortiz near the top of the list.

The following, presented sort of alphabetically, were all received by the end of the weekend and reveal us to be an eclectic group.

Their services have been determined to be of the highest quality and beneficial for our members from a cost perspective.

Their generous support of MATA helps us to complete our mission. Please consider using them whenever possible. More detailed information can be obtained on our website at www.

I keep it to remind myself that everyone of my clients has a back story and to not pre-judge people. Join MATA now. Apply online at www.

Boyle Phillip J. Jones Andrew C. Meyer Michael E. Mone Douglas K. Cariglia John J. Carroll Jr. David P. Dwork Frederic N.

Halstrom Paul E. Leavis Chris A. Milne Alan S. Pierce Joel H. Schwartz Jeffrey T. Scuteri Valerie A.

Abraham Paul R. Aiken Steven M. Ballin Clyde Bergstresser Bruce A. Bierhans David R. Bikofsky Leslie E. Bloomenthal Alice Braunstein Marc L.

Breakstone James E. Bryne Dennis J. Calcagno Thomas L. Campoli Gerard B. Carney Robert W. Casby Jeffrey N. Catalano Scott J. Clifford Sherrill Cline J.

Corcoran Walter A. Costello Jr. James T. Dangora Sr. Robert A. DeLello John L. Donohue William J. Doyle Jr. Paul J. Driscoll Peter L.

Eleey Robert J. Feinberg Norman J. Fine John B. Flemming Michael A. Foglia Donald Gibson Ronald E. Gorlick Donald R.

Grady Lawrence E. Hardoon Saba B. Hashem T. Hugo Richard G. Jusseme Jonathan A. Karon Marsha V. Kazarosian John A. Keilty Timothy C.

Cummings Chris Dodig Barry A. Feinstein Daniel Finbury Marvin H. Greenberg John D. Horgan Kenneth Levine William F.

Looney Thomas J. Lynch Robert J. Moegelin Michael Najjar Gerald A. Palmer Jeffrey Petrucelly Judson L. Pierce Richard T.

Tucker Kimberly Winter Thomas M. Kiley Richard A. Lalime Francis Larkin Marianne C. LeBlanc Bruce S. Lipsey Francis J.

Lynch William P. MacDonald Mark A. Machera Angel Melendez Thomas P. Mulvey Jr. Vincent J. Murray Jr. Michael Najjar Robert M.

Nathan Andrew D. Nebenzahl Kathleen M. Orlacchio Jodi M. Petrucelli Richard J. Rafferty Jr. Michael R. Rezendes Frank J.

Riccio Robson Forensic Inc. Robert M. Rosen Lloyd C. Rosenberg Steven P. Sabra Deborah M. Santello Frank R. Saia Peter J.

Schneider Earlon Seeley Richard G. Shalhoub W. Thomas Smith Gerald W. Sousa Stephen K. Sugarman John St.

Andre Jr. John J. Stobierski James A. Swartz Thomson-West William H. Troupe Edwin L. Wallace Paul F. Wynn Benjamin R.

Daily Robert A. DiTusa Richard K. Donohue Christopher W. Driscoll Neil R. Driscoll Karen J. Hambleton Mark W.

Helwig Robert H. Glotzer John P. Riordan Gregory V. Roach Neil J. Roach Martin B. Schneider Barbara M.

Senecal Frank J. Shealey Ronald Stoia Stephen D. Walsh Timothy H. White Learn the Secrets of the Top Mass. Mon Michael Tarricone Anthony and how to get the most out of it.

Ag Hon. Pe ard ss J. Bra ymond y Hon. Ra Connoll omas E. Th da E. Gil Hon. Lin Hillman S. Translocating the femoral vein with its large-diameter and very low-resistance to the brachial artery is expected to have very high flow, so the diameter of the arterial anastomosis should not be more than mm or it is better to use the PRA for inflow [31].

Reverse retrograde -flow AVF With reverse-flow AVFs, venous valves must be destructed to permit retrograde flow with or without antegrade flow.

The proximal vein may be ligated or not antegrade flow maintained or not. The ideal patient for a reverse-flow AVF has exhausted forearm options but still has a suitable proximal segment of cephalic or basilic vein in the forearm, with or without a suitable upper arm vein for outflow.

A side-to-side antecubital construction is usually made and 1 or 2 distal valves are carefully disrupted with the vein segment dissected and visualized as the probe is passed, to prevent tearing the vein.

Valve disruption can be accomplished with a probe, coronary artery dilator or a valvulotome. The retrograde pressure and flow is expected to make progressive dilatation of venous tributaries.

If these small veins do not mature adequately, endovascular balloon angioplasty may be used [32].

Arteriovenous graft AVG for hemodialysis The ideal vascular graft for patients on HD should be easy to handle, closely mimicking the native vessels, nonthrombogenic, immunologically inert, resistant to infection and puncture trauma, able to retain tensile strength, and manufactured at a reasonable cost [33].

Denatured homologous vein allograft. Cryopreserved saphenous vein d. Human umbilical vein. Sheep collagen grafts [36, ].

The current Omniflow II vascular graft has a more resistant mesh but requires delicate manipulation, avoiding cross clamping the graft with metal instruments and traction during the passage through the tunnel [42].

Biohybrid and bioresorbable prostheses, graft pretreatment with endothelial cell culture, methods of affixing antibiotics, anticoagulants and growth factor to graft surfaces are under investigation to enhance the results of prosthetic vascular materials, as biologic materials facilitate cell repopulation and tissue remodeling [33].

However, this was not seen in practice and PTFE, a fluorocarbon polymer became the prosthetic graft of choice [43]. Available data supports PTFE over other biologic and synthetic materials except bovine mesenteric vein based on a lower risk of disintegration with infection, low thrombogenicity, low tissue reactivity, prolonged patency and improved surgical handling but this concept may change in the future with introduction of tissue engineered AVG or more recent biological grafts [44].

Other new graft materials include polyurethane grafts with their self-sealing properties and reported low complication rates.

The polyetherurethaneurea Vectra graft is suitable for early needling [45, 46]. Straight AVG between the radial artery at the wrist and an antecubital vein should be avoided due to the risk of early thrombosis.

Forearm loop AVG b. The forearm loop between the brachial artery and one of the available veins in the antecubital fossa is far more better option figure 4.

One of the venae comitantes of the brachial artery should be used as outflow for both types rather than the superficial veins as outflow for a straight or looped forearm AVG graft, because if the basilic or cephalic veins are still available they should be used instead to construct an autogenous AVF with the brachial artery [47].

Straight AVG in the upper arm between the brachial artery and the axillary vein or the proximal brachial or basilic vein is ideal and common figure 5.

The forearm loop between the brachial artery and one of the available veins in the antecubital fossa and the straight AVG in the upper arm between the brachial artery and the axillary vein or the proximal brachial or basilic vein are the most popular graft configurations [48].

Lower extremity options AVGs in the lower limb have generally given less encouraging results than for the upper limb, because of increased rates of infection, ischaemia, and lower patency rates.

However, groin access is a useful option when upper extremities are unavailable and peritoneal dialysis has failed [28].

When implanted in the thigh, the graft can be either a straight, looped or curved configuration figure 6 between femoral artery and either stump of GSV or femoral vein.

Anastomosing AV Hemodialysis Figure 5. Straight brachial-axillary AVG. This has led to implantation of the AV graft more distal to the mid-superficial femoral vessels.

This approach preserves the proximal vessels for future graft revision [49]. Moreover, when large vessels, such as the axillary artery and femoral veins, are employed severe venous or arterial problems may follow AVG thrombosis [52].

Guidelines for selection and placement of hemodialysis access according to KDOQI [11] A structured approach to the type and location of long-term HD accesses should optimize access survival and minimize complications.

The access should be placed distally and in the upper extremities whenever possible. Options for fistula placement should be considered first, followed by prosthetic grafts.

Catheters should be avoided for HD and used only when other options listed are not available. Autogenous AVF. A wrist radiocephalic primary fistula.

An elbow brachiocephalic primary fistula. A transposed brachial basilic vein fistula b. There is no convincing evidence to support tapered versus uniform tubes, externally supported versus unsupported grafts, thick versus thin-walled configurations, or elastic versus nonelastic material.

While the majority of past experience with prosthetic grafts has been with the use of PTFE, other prosthetics eg, polyurethane [PU] and biological conduits bovine have been used recently with similar outcomes.

Physical examination monitoring : to detect dysfunction in fistulae and grafts at least monthly by a qualified individual looking for: persistent swelling of the arm, presence of collateral veins, prolonged bleeding after needle withdrawal, or altered characteristics of pulse or thrill in a graft.

Monthly in 1st 1. Directly measured or derived static venous dialysis pressure. A venous segment static pressure mean pressures ratio greater than 0.

An arterial segment static pressure ratio greater than 0. Indicators of risk for graft rupture. All patients should be taught how to: 1.

Compress a bleeding access 2. Seal the site of a central venous catheter CVC with ointment to keep air embolus from entering 3.

Wash skin over access with soap and water daily and before dialysis 4. Recognize signs and symptoms of infection 5.

Select proper methods for exercising AV fistula arm with some resistance to venous flow 6. Listen for bruit with ear opposite access if cannot palpate for any reason All patients should know to: 1.

Avoid carrying heavy items draped over the access arm or wearing occlusive clothing 2. Avoid sleeping on the access arm 3.

Insist that staff rotate cannulation sites daily 4. Insure that staff are using proper techniques in preparing skin prior to cannulation 5.

Complications of vascular access 6. First, the AVF should have adequate blood flow to support dialysis; second, it should have enough size to allow for successful repetitive cannulation.

Although flow and size may appear as two separate parameters, they are intricately related [57]. Interventions to salvage with early AVF failure Studies demonstrated that the two most common problems observed in early AVF failure are the presence of stenosis and accessory veins.

These studies have emphasized that a great majority of these failed fistulae can be salvaged using percutaneous techniques.

The single major complication consisted of a vein rupture with an expanding hematoma. It resulted in loss of the access.

The minor complications all were hematomas that required no treatment and had no sequelae [58]. Reports have highlighted a newer technique sequential dilation to salvage an AVF that fails to develop because of diffuse stenosis [59, 60].

In addition to endovascular techniques, surgical intervention has been used for AVF salvage [61]. There is a lack of prospective studies that have examined the role of surgical approach in the salvage of AVF with early failure only.

Inability to navigate the wire across a stenotic lesion during percutaneous approach and deep location of an AVF are some of the indications for surgical intervention [62].

Dialysis access infection Dialysis-access-related infections are common, and often result in great cost and morbidity, may be mortality.

It is the most important cause of loss of vascular catheter access and an important cause of failure of native and prosthetic arteriovenous grafts and fistula [63, 64, 65].

Diabetes seems to increase the risk of S. Useful criteria for diagnosis of AV fistula infection includes, the presence of bacteremia associated with local tenderness or redness of the fistula site and no other obvious source of bacteremia, evidence of local infection at the fistula site with recovery of a pathogen by culture of draining pus or direct aspiration [67].

Prevention: The pillar of prevention is practicing meticulous aseptic technique and avoiding bleeding or hematoma when cannulating the graft.

This is not only responsibility of the dialysis nurses and stuff but also the patient. Avoidance of repeated needle insertion at one particular site on the graft is also critical to eliminate complications.

The presence of foreign material makes synthetic conduit especially susceptible to infection [68]. Fistula surgical excision should be performed in cases of septic emboli.

Thrombosis This is the commonest cause of failure in the long term and is most often due to underlying stenosis, overdialysis leading to dehydration and hypotension, poor needling technique leading to haematoma and undue post-cannulation compression to control bleeding.

The type of access and the site of thrombosis are important determinants of outcome. Thrombosis may affect the anastomotic or post- anastomotic segments as a result of neointimal hyperplasia or may begin at a needling site.

When radiocephalic or brachiocephalic AVFs thrombose at or close to anastomosis, the clot usually remains localized and run off remains patent as it has a number of natural tributaries which maintain some venous flow.

This situation can be treated by a local refashioning of the AVF, anastomosing the arterialized vein to the artery at a more proximal site [69].

In contrast, thrombosis of AVFs involving transposed veins usually leads to thrombus propagation so that the entire AVF clots.

This is a result of the fact that all the tributaries of the venous outflow had been ligated during the creation of this type of AVF.

Successful salvage of such a clotted AVF must be attempted as soon as possible before the clot organizes.

There are two choices for the treatment of the thrombosed graft: surgical and endovascular. The choice should be based on local expertise.

Treatment must be timely, not delayed, and central venous catheters should be avoided. Venous stenosis must be corrected and all abnormal haemodynamic parameters present prior to thrombosis should return to normal [70].

Surgical correction: The thrombectomy is usually performed with a small transverse incision at the nadir of a loop PTFE graft or at the venous anastomosis of straight PTFE grafts.

The thrombectomy is then performed with a fogarty balloon catheter to extract the clot. Assessment of the presence of stenosis is made by the surgeon based on the resistance to passage of the fogarty balloon catheter or a similar dilators.

More recently, intraoperative angiographic evaluation of the graft may be performed to better assess for the presence of stenoses [71].

Surgical correction of intimal hyperplasia at venous anastmosis is best managed by one of three methods depending on the extent of disease and adjacent venous anatomy: 1.

Widening of the lumen with patch angioplasty. Interposing a short segment of new graft material and construcing a more proximal venous anastmosis jump graft.

Transferring the venous end of the graft to an adjacent vein, such as from an antecubital to the cephalic vein [72].

Enzyme-mediated thrombolysis can be subdivided into two categories:- pharmacological and pharmacomechanical.

Pharmacological thrombolysis: refers to thrombus dissolution using only the effects of a fibrinolytic enzyme. Complication rates have ranged from none to This complications included: bleeding at needle puncture sites, embolus to the peripheral artery [75] and systemic fibrinogen depletion has been routinely seen because of the large doses of enzyme used.

Urokinase offers the advantages over streptokinase of having shorter effective half-life and no antigenicity it can be readministered in cases of recurrent thrombosis [76].

The first is pharmacological, consisting of enzymatic lysis. This is immediately followed by the second phase, mechanical maceration and removal of residual thrombus.

Vascular steal syndrome Clinically significant distal extremity ischemia occurs in 1. Risk factors include female sex, age greater than 60 years, diabetes, arteriosclerosis, multiple operations on the same limb, the construction of an autogenous fistula, and most commonly the use of the brachial artery as the donor vessel [83].

Theoretically, the presence of a large arteriovenous fistula always results in reduced perfusion to more peripheral tissues.

This is evidenced by the fact that the perfusion pressure is always lower distal to an arteriovenous fistula [84].

Symptoms associated with the ischemic steal syndrome present over a broad spectrum, ranging from vague neurosensory deficits to ischaemic rest pain or tissue loss [85].

Recently, this classification was proposed [86]: 1. Stage III, pain at rest. Steal can be limited by reducing the anastomotic length to 75 percent or less of the proximal arterial diameter, which in most patients translates length of 5 mm.

Steal syndromes following a radiocephalic fistula are relatively unusual. The cause is thought to be diversion of the ulnar arterial flow through the palmer arches to create retrograde distal radial artery flow into the fistula with a steal of blood flow away from the digital arteries.

A DRIL procedure involves two parts: a bypass and interval ligation of the native artery. The bypass graft is connected to the artery proximal to the access anastomosis and its outflow directed to the native artery distal to the access anastomosis.

The reversal of blood flow is eliminated by ligation of the artery distal to the AV access, providing the distal vascular bed with normal perfusion pressure and flow [88].

Recognizing that brachial arterial origin was a common feature of symptomatic steal, others have reported success with extending the arterial end of the access distally to smaller arteries with revision using distal inflow RUDI figure 7c and proximally to larger arteries with proximalization of arterial inflow PAI.

Each of these management solutions is based on small case series involving an uncommon but clinically significant complication of AV access.

More experience is needed before an appropriate solution can be recommended [89, 90]. Haemorrhage This occurs in the first 24 postoperative hours and may be from a specific bleeding point such as the anastomosis or from a slipped ligature.

These are due to technical errors and should be avoidable. Generalized 'oozing' resulting in haematoma formation is probably more common and is a result of the functional platelet disorders and bleeding diathesis associated with uremia.

This complication can be minimized by careful preoperative preparation including correction of anaemia with recombinant erytheropoietin and adequate dialysis.

Aneurysm formation False aneurysms may occur at the anastomosis when there has been an error in surgical technique or more commonly at a needling site which has been over used.

These can be treated by resection with either direct end-to-end anastomosis or by the placement of a short PTFE bridge graft. The number of cannulation sites are limited by the presence of a large or multiple pseudoaneurysm s.

The pseudoaneurysm threatens the viability of the overlying skin. The pseudoaneurysm is symptomatic pain, throbbing. There is evidence of infection.

True aneurysmal dilatation of autogenous arterialized veins are common. Often no action is required but corrective surgery is indicated if the overlying skin becomes very thin or there is evidence of progressive expansion.

In some patients the whole length of arterialized vein becomes very dilated and the AVF may have to be sacrificed by ligating it [69].

Stenosis This may-occur directly at the anastomosis, in the first few centimeters of the venous outflow from an AVF or at needling sites.

Anastomotic stenosis results from either errors in surgical technique or from the development of neointimal hyperplasia. Radiocephalic AVFs can often be refashioned by creating a more proximal anastomotic site but this may not be possible for brachiocephalic or brachiobasilic AVFs.

In that case a "jump graft'' can be created using a short segment of PTFE to bypass the stenosis.

Post-anastomotic or needling site stenoses may be amenable to treatment by percutaneous transluminal angioplasty.

The disadvantage is that recurrent stenosis is common and this may require surgical revision using a prosthetic interposition graft [69].

Central vein stenosis [11] Patients with extremity edema that persists beyond 2 weeks after graft placement should undergo an imaging study including dilute iodinated contrast to evaluate patency of the central veins.

The preferred treatment for central vein stenosis is PTA. Lymphocele This occurs when the lymphatic channels have been divided or diathermed.

It is particularly associated with brachio-basilic fistula formation and operation in the groin.

Treatment by intermittent closed drainage under-sterile condition and antibiotics cover is usually successful. Recurrent and persistent lymphocele may require re exploration and open drainage [69].

Venous hypertension A venous hypertension syndrome may develop in which the hand distal to the fistula becomes swollen and uncomfortable with thickening of the skin and hyperpigmentation [93, 94].

Hypertension may be avoided by forming an end-to-side or end-to-end anastomosis. Ligation of the enlarged venous tributaries causing the hypertension of the distal digits may relieve symptoms while preserving the fistula.

The increasing use of subclavian lines for dialysis has lead to an increased incidence of subclavian vein thrombosis or stenosis.

The subsequent placement of a fistula may lead to massive arm edema caused by venous hypertension and, in women, breast enlargement [95].

Subclavian vein thrombolysis and angioplasty with stenting may allow continued use of the-fistula. This complication may also be lessened by using the internal jugular vein for central line placement [96].

Neuropathy Ischemic neuropathy is unusual with the radiocephalic fistula and is seen mainly in diabetic patients with preexisting atherosclerotic disease and in patients with proximal site fistulas.

The medical device application segment is expected to grow with the highest rate in the coming years. The increasing demand for effective, smaller, and lighter medical equipment is supporting the high growth of medical device application segment in the global market.

Medical assistant is multi-skilled health professional who offers administrative, clerical and technical support to the physician.

Medical assistant provides services for front office, back office and other clinical laboratory areas.

Medical assisting is a versatile career for men and women. Market Research Engine adds a new research report, titled. The largest consumption of microspheres occurred for the construction composites application in The medical technology is predicted to be the mice of men , fastest growing application segment during Based on raw materials, the glass microsphere segment held.

Krager, Carole H. Krager Part II: The medical field to no surprise has been one of the fastest growing areas of employment in religion people essay , recent years.

My future career in the medical field will entail a variety of tasks. As a Medical Billing and Coding assistant I will have to perform both administrative and.

Polymers are replacing metals, glass, paper and other traditional. The other key application segments of on population malthus bio-based adhesives include construction, wood, personal care and brings together medical.

A high demand for bio-based adhesives is reflectie essay , predicted in all these application segments during forecast period.

Nurses Verse Being a Medical Assistsant. Although Medical Assistants and brings people together Nurses have a lot in common, nurses get a better salary.

They have way more opportunities then medical assistants. Why or. June 10th Mumbai, India: Bharatbook. Franchising of medical programs, costs, avg.

Religion People! The U. On Recycling! Sample Evact Plan Medical Assiting. Medical Laboratory Technology also called Clinical laboratory science is an allied health profession which is concerned with the diagnosis, treatment and people together prevention of disease through the use of clinical laboratory tests.

These tests help doctors to an essay malthus detect, diagnose and treat diseases. A Medical Laboratory. Religion Brings People Together Essay!

Pre Written Cover Letters! Of Men Essays! Nursing assistant skills are the basic areas that a nursing assistant will have to know in order to do their job effectively.

The nursing assistant has a very important job because they have to update the nurses on the status of different patients throughout the day.

Nursing assistants must be patient. Kaimo Kaplan University Medical Assisting 2 Abstract Growing up in a family that loves to do public service, helping people specifically in medical field influenced me in together essay , my decision in sample term paper , choosing Medical Assisting as.

Since I have been enrolled in this program, I have learned a lot. Advantages 1. Organize daily schedules 2. Take notes 3. Record voice memos and brings people together essay lectures 4.

Write and rehearse PowerPoint presentations 5. Collect audit data in. An Essay! Cover Letters! Deciding to reflectie essay be a medical assistant was and essay easy choice; it is hands on reflectie essay , but not so much that.

There are a number of together different frameworks that have been developed by healthcare academics to help implement person-centred.

A Medical Assistant MA is an integral member of the health care delivery team, qualified by education and experience to work in the administrative office, the examining room and the physician office laboratory.

The Medical Assistant. So far in this class I have learned a variety of information about this profession. I have learned exactly what a medical assistant does, what credentials and certificates I need.

The Medical Assistants are important because they assist the physicians in either clinical or administrative tasks. Most Medical Assistants can be found in the hospital or clinic.

That is something I have always taken interest in. To many, that is not a big surprise. Religion Brings People Essay!

My top three. Bonds that united them in ancient days were religion and superstitions. Written records of law medicine date back to brings people thousand.

Code of Ethics: Guidelines in Medical Assisting. A medical assistant works in conjunction with lots of other healthcare workers. A medical assistants day to day.

Choosing Medical Assistant as a Career. A medical assistant is an allied health professional that supports the of men essays , work of physicians and other health professionals, usually in a clinic setting.

Religion People Essay! Medical assistants can become certified through an accredited. Religion Brings Essay!

As well as postsecondary vocational schools. Community and junior colleges may also offer medical assistant programs.

The curriculum covers an array of training in anatomy physiology, medical terminology. On this committee I also expect to work with the board directors.

Holcombe, J. Introduction To promote objectivity in federally funded research , the U. Previously issued PHS regulations.

Most people go for an R. N or even better for a Dr. She was well poised, friendly tone, good.

Industry Insights The global intelligent virtual assistant market is projected to brings exceed USD 3 billion by pre written Increased focus on effective client communication, made easy by virtual assistants , is expected to religion brings drive the what key components essay , intelligent virtual assistant market over brings essay , the forecast period.

Key industry participants. More recently, controversy has surrounded the religion brings essay , introduction of a national database. Patient privacy is reflectie essay , a huge issue and people essay one that must not be taken lightly.

This is one of the reasons why electronic medical records has not been taken. Differences in Law Ethics and Bioethics.

Law is an obligation and consists of statutes, bills and legislation. Through the religion brings together essay , government and constitution numerous medical professions are defined in their scope of practice.

There are endless braches of law which help regulate health care and instill quality care, for.

Sheila O’connor Video

Sheila O'Connor présente DUO

3 comments on Sheila o’connor

Hinterlasse eine Antwort

Deine E-Mail-Adresse wird nicht veröffentlicht. Erforderliche Felder sind markiert *

Nächste Seite »