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Nursing Research and Practice
Volume 2014, Article ID 170514, 9 pages
Role Clarification Processes for Better Integration of Nurse Practitioners into Primary Healthcare Teams: A Multiple-Case Study
1Faculty of Nursing, University of Montreal, P.O. Box 6128, Centre-Ville Station, Montreal, QC, Canada H3C 3J7
2University of Montreal Public Health Research Institute, P.O. Box 6128, Centre-Ville Station, Montreal, QC, Canada H3C 3J7
3Department of Family Medicine and Emergency Medicine, University of Montreal, CRCHUM, Saint-Antoine Tower, 850 St. Denis Street, Room S03-284, Montreal, QC, Canada H2X 0A9
Received 31 July 2014; Revised 24 October 2014; Accepted 13 November 2014; Published 1 December 2014
Academic Editor: Karyn Holm
Copyright © 2014 Isabelle Brault et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Role clarity is a crucial issue for effective interprofessional collaboration. Poorly defined roles can become a source of conflict in clinical teams and reduce the effectiveness of care and services delivered to the population. Our objective in this paper is to outline processes for clarifying professional roles when a new role is introduced into clinical teams, that of the primary healthcare nurse practitioner (PHCNP). To support our empirical analysis we used the Canadian National Interprofessional Competency Framework, which defines the essential components for role clarification among professionals. A qualitative multiple-case study was conducted on six cases in which the PHCNP role was introduced into primary care teams. Data collection included 34 semistructured interviews with key informants involved in the implementation of the PHCNP role. Our results revealed that the best performing primary care teams were those that used a variety of organizational and individual strategies to carry out role clarification processes. From this study, we conclude that role clarification is both an organizational process to be developed and a competency that each member of the primary care team must mobilize to ensure effective interprofessional collaboration.
1. Introduction
High-performing primary care teams are one of the chief characteristics of healthcare systems that are responsive to population needs [1, 2]. However, the optimal development of such teams is a challenge for primary care systems. Optimizing each professional's scope of practice is one suggested approach to reinforce team functioning and respond to patients' needs [3]. This is difficult, however, because changes in professional roles can lead to power struggles [4]. Whenever the nurse practitioner role has been introduced into clinical teams, one of the greatest difficulties encountered has involved the clarification of professional roles [5]. Lack of clarity about the nurse practitioner's role has created confusion and led to resistance to its integration [5, 6]. Clarifying professional roles among members of a primary care team can be an effective approach to mitigate power struggles, facilitate the integration of new roles in teams, and foster interprofessional collaboration.
In primary care practice, there is a great deal of role overlap, specifically with regard to the roles of physicians, primary healthcare nurse practitioners (PHCNPs), registered nurses, and other professionals on the clinical teams. Clarifying professional roles can serve several purposes: defining each person's responsibilities, ensuring appropriate implementation of each professional's role, optimizing professional scopes of practice, and thereby ensuring efficient patient management.
PHCNPs were introduced in Quebec in 2008 to provide health and wellness promotion and to treat patients requiring follow-up for an acute common illness, chronic disease management, and pregnancy follow-up to 32 weeks of gestation. In Quebec, PHCNPs are Master's prepared registered nurses. PHCNPs can order and interpret diagnostic tests, prescribe medication and medical treatments, and perform specific procedures within their legislated scope of practice [7]. The focus of the PHCNP role is health promotion, disease prevention, preventive care, diagnosis of acute minor illness and injuries, and monitoring and management of stable chronic conditions [8]. PHCNPs in Quebec have some restrictions on their scope of practice, including their ability to establish a primary diagnosis [8].
Several researchers have explored collaboration between physicians and nurses in primary care teams [9], but, to our knowledge, no study has specifically examined the processes by which professionals clarify their respective roles in these teams. In this paper, our objective is to examine the processes of role clarification among professionals in primary care teams when a new role is introduced into the team, that is, the PHCNP. Specifically, we want to understand the organizational and individual components that influence the process of professional role clarification. In the following section we present the key elements of the Canadian National Interprofessional Competency Framework.
2. The Canadian National Interprofessional Competency Framework
The Canadian National Interprofessional Competency Framework was developed by the Canadian Interprofessional Health Collaborative (CIHC) in 2010. The CIHC is made up of academics, researchers, health professionals, students, and health organizations concerned with training for interprofessional collaboration and the associated competencies. This framework defines the competencies required for better collaboration; it positions role clarification as one of the fundamental competencies for optimizing interprofessional collaboration [10]. This framework is relevant for two reasons. First, it presents a shared vision of the competencies associated with interprofessional collaboration. Second, it allows us to link specific activities with the implementation of the role clarification competency, to gain a better understanding of the processes involved. The CIHC framework and the role clarification competency are briefly described below.
According to the CIHC [10], interprofessional collaboration is encompassed by six competency domains: (1) interprofessional communication, which refers to effective, responsible, and open communication within the interprofessional team; (2) patient/client/family/community-centred care, which examines the involvement of patients and their families in care planning; (3) team functioning, which reflects the importance of knowing the mechanisms and principles underpinning effective team functioning; (4) collaborative leadership, whose aim is to facilitate shared decision-making and develop a collaborative work climate by applying the principles of consultation to decision-making; (5) interprofessional conflict resolution, which seeks to engage all team members in identifying constructive solutions to any conflicts arising within the interprofessional team; and (6) role clarification, which is presented in greater detail in the following paragraphs. These competencies are mobilized differently depending on the practice context and the complexity of clinical cases, as well as on the quality improvement processes in place in the clinical settings.
Besides the competencies that underlie interprofessional collaboration, the CIHC framework [10] puts forward three other components to be considered when interprofessional teams work together: the complexity of clinical situations, the practice context, and quality improvement. These components influence the application of the competencies, as they may determine the intensity of interprofessional collaboration in clinical teams. The complexity of clinical situations refers to those situations in which professionals collaborate. They cover a broad spectrum ranging from simple to complex. In most cases, complex situations require the involvement of many professionals. The practice context influences interprofessional collaboration. Indeed, depending on the setting, care teams function differently and adapt differently to the needs of patients and families. Quality improvement is addressed more effectively using interprofessional collaboration. All actors in the healthcare system must work together to transform practices and to improve the quality of care and services. These three components (i.e., complexity of clinical situations, practice context, and quality improvement) refer essentially to elements of the organizational context in which care is provided.
2.1. Role Clarification: An Interprofessional Collaboration Competency
The CIHC framework describes the role clarification competency as follows:
Learners/practitioners understand their own role and the roles of those in other professions, and use this knowledge appropriately to establish and achieve patient/client/family and community goals. [10] (page 12)
This competency is closely linked with the other five competency domains identified in the CIHC framework and is aimed at supporting processes to optimize each professional's field of practice. It is based on a detailed understanding of one's own role and those of other professionals. This competency, which is fundamental to interprofessional collaboration, is defined by seven descriptors that identify the relevant knowledge, attitudes, and values, which are dynamic and constantly evolving [10]. These role clarification competency descriptors include the following:(1)describing own role and that of others;(2)recognizing and respecting the diversity of other healthcare and social care roles, responsibilities, and competencies;(3)performing own roles in a culturally respectful way;(4)communicating roles, knowledge, skills, and attitudes using appropriate language;(5)accessing others' skills and knowledge appropriately through consultation;(6)considering the roles of others in determining own professional and interprofessional roles;(7)integrating competencies/roles seamlessly into models of service delivery.
In order to better understand the role clarification process, it is important to examine the components of the context that influence role clarification (complexity of clinical situations, practice context, and quality improvement) as well as the seven descriptors of role clarification presented above.
3. Methods
3.1. Research Design
This descriptive multiple-case study [11] was approved by the Research Ethics Board of the University of Montreal. Case study design was recommended because it allows for in-depth examination of events while taking into account the larger context in which they occur [12]. The CIHC Framework was used as a reference model to direct data analysis [13]. Multiple-case study design is more robust because using a framework allows the researcher to compare and generalize findings to other cases (i.e., analytic generalization) [11].
3.2. Case Selection and Description
Each case was operationally defined [14] as the primary healthcare setting where the PHCNPs practiced. The cases were bounded by the limits of service as determined by the PHCNP's practice model and reporting structure. We used purposeful sampling [15] to identify cases that offered a broad picture of PHCNPs' roles in the province of Quebec, Canada, where PHCNP role implementation is recent. The cases were selected based on their similarities and differences in terms of geographic location and time elapsed since implementation. We identified six cases in four geographic regions of the province. Half the cases were situated in predominantly rural catchment areas. PHCNPs served patients in all age groups. Also, the cases present a diversity of characteristics in terms of patient management models, size of interprofessional teams, number of professional staff, and number of patients seen by the PHCNP. These intercase variations provide a wealth of data to better understand the phenomena under study [16] which are the deployment of PHCNPs in primary care settings and the associated role clarification processes. The patient populations under PHCNP care included patients without a regular physician, new immigrants, and refugees, among others; conditions managed included chronic illnesses such as diabetes or hypertension, mental health conditions, pregnancy, and routine acute health problems such as otitis. The cases studied are described in Table 1.
3.3. Data Collection and Participants
Data were collected from May 2011 to October 2011. We conducted 34 individual interviews: 11 nurse managers or nursing directors, 15 intraprofessional (i.e., within nursing) team members, seven physician partners, and one interprofessional (outside nursing) team member (Table 2). In each setting, we interviewed the key actors directly involved in the PHCNP integration processes, who were mainly PHCNPs, physician partners, and nurse managers. In only one case was a professional other than a nurse involved in the implementation of the new PHCNP role in the primary care team.
We used semistructured interview guides [17], which we adapted according to the professional's role (e.g., nurse manager, physician, PHCNP, and registered nurse). Initial questions and themes were identified from the literature and included questions about the preparation of the work setting, implementation of the PHCNP role, their vision for the PHCNP role and that of the team, the activities comprised in the PHCNP role, how activities were shared between PHCNPs and other team members, and collaboration within the team [8]. The interviewer's questions were flexible to allow exploration of emerging themes as the interviews unfolded [18]. Interviews were generally audio-recorded with participants' permission and transcribed. For those not audio-recorded, summary notes were prepared. Interviews lasted between 25 and 75 minutes.
3.4. Data Analysis
The overall aim of the analysis was to understand how roles were clarified among team members. The interviews were analyzed within the context of the case, and then the findings from each case were compared. All the interviews were read several times by different members of the research team "to obtain a sense of the whole" (page 108) [19]. Each site was given a unique identifying code number to facilitate retrieval [20]. An overall summary of each case was developed by the research team member responsible for the case to identify key themes.
3.4.1. Phase One: Within-Case Analysis
The qualitative data was analyzed using qualitative content analysis [19], defined by Hsieh and Shannon as the "subjective interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns" (page 1278) [21]. We used the approach described by Miles and Huberman [20] to organize and synthesize the collected data. Matrices were used to display the data and identify patterns [20].
To gain a better understanding of the role clarification process [22, 23], our analysis was supported by the descriptors of the CIHC role clarification competency. We sought to populate the role competencies framework [20, 24]. No additional codes were created. Langley argued that, to understand processes, it is essential to "document as completely as possible the sequence of events" (page 692) [25]. We identified instances where participants described how activities or perceptions had changed over time. Subsequent to this step, we explored similarities and differences in processes within and across the cases [9].
3.4.2. Phase Two: Cross-Case Analysis
In phase two, we proceeded to the overall analysis across the six cases [11]. We used inductive and deductive approaches [26] to understand how roles were clarified. Similarities and differences in role clarification were identified across cases. To identify patterns across the cases, we developed a matrix of the themes and concepts identified in the within-case analysis [20]. We used pattern-matching to understand how the cases fit within the CIHC framework [20].
3.5. Rigour
We used several strategies to ensure the quality of the case studies [11]. We collected data from different sources (PHCNPs, physician partners, and nurse managers) and from rural and urban regions of the province. Patterns in the data were identified by using the concepts of the CIHC framework. We compared the findings across the cases to understand how the process of role clarification occurred [11]. Case study methodology uses analytic generalization to generalize findings to a broader theory [11]. The explicit description of the methodological approach is intended to facilitate reproduction of the study. However, any application of the results must take into consideration the particular features of other contexts [16]. In this study, the identification and selection of multiple cases allowed us to identify similarities and differences across the cases for anticipated reasons, thereby strengthening the conclusions [27]. Through the interviews, we were able to gather information on the different concepts associated with the study, and we conducted interviews until we reached the point of data saturation, when information provided in new interviews was redundant [16]. The results were validated with the participants in the majority of the case settings.
4. Results
The results are presented here in reference to the Canadian National Interprofessional Competency Framework. First, we present the empirical results with respect to the three organizational components that influence interprofessional collaboration: the practice context, the complexity of clinical situations, and quality improvement. This initial step is helpful in understanding how these elements influenced role clarification. We then look specifically at the role clarification competency and present our results in relation to the seven descriptors of this competency in order to better understand how this competency was mobilized in the different settings studied.
4.1. The Practice Context
Our empirical data showed that, with respect to practice context, clarification of the PHCNP's role was based on two elements: an analysis of unmet patients' needs and the legislative framework governing PHCNP practice in Quebec. Accessibility to healthcare and services was the key element that emerged from the analysis of patients' needs. In the high-performing settings, this needs analysis preceded the arrival of the PHCNP and helped clarify the PHCNP's role in the primary care team:
Here in our organization, we met with the director of nursing to determine which would be the most appropriate sectors to receive a PHCNP, and what roles she might take on, while also taking into account the regulations of the regional health agency. (Clinical nurse specialist)
The analysis of patients' needs and the clarification of the PHCNP's role in the team were directly based on knowledge of the legislative framework governing PHCNP practice, in which the scope of the PHCNP role, prescribing activities, and eligible practice settings are defined. Settings that were less knowledgeable about the PHCNP's scope of practice encountered problems in assigning patients to the PHCNP. For example, if the assigned patients had complex needs that could not be entirely addressed within the PHCNP's scope of practice, this inhibited the autonomy of the PHCNP's role. The high-performing settings used the legislative framework to negotiate the PHCNP's role with the different members of the primary care team, such as, among other things, to confirm with pharmacists and radiologists the PHCNP's right to prescribe in that setting.
Thus, the practice context refers to the local context of care and services for each of the settings studied. The legislative context also influenced role clarification, as it helped define the different practitioners' scope of practice (e.g., pharmacist and radiologist).
4.2. The Complexity of Clinical Situations
Clinical complexity refers to the broad spectrum of situations encountered by PHCNPs and primary care teams, ranging from simple to complex. The complexity of clinical situations creates opportunities for interaction among the different members of the primary care team. Most of the settings had instituted formal occasions for interaction through team meetings. Such meetings fostered role clarification among team members and primarily between the PHCNP and the physician partner. However, in some settings, physicians met only among themselves and discussed the PHCNP's practice and how the PHCNP could be more effective and better used:
I think each FMG [family medicine group] will develop, to some extent, its own modus operandi with the nurse practitioner regarding what they want her to do for chronic illness management. (Physician partner)
In another setting, meetings were held to clarify roles in relation to the preferences and interests of the PHCNP:
I sat down with the PHCNP to talk with her about her preferences, her wishes, what she hoped to do in coming to work at our clinic, because the needs are so great that we have to make choices. (Physician partner)
The complexity of clinical situations is an issue to be considered when new PHCNPs are introduced and when the PHCNP's caseload is created. Our analysis showed that when clinical situations were at the high end of the spectrum in terms of complexity, PHCNPs needed to consult physician partners more often. In settings that implemented a system in which nursing assistants collected preliminary patient data to assign patients by level of complexity (two cases in six), the number of consultations between PHCNPs and physician partners was greatly reduced. This initial screening made it possible for PHCNPs to target patients whose full range of healthcare consultation needs they could manage:
… the added value of a PHCNP is that she rarely needs to consult the physician partner; that's when it becomes worthwhile. (PHCNP)
4.3. Quality Improvement in Care and Services
Integrating a new member into the primary care team can create opportunities to improve the quality of care and services. The introduction of a PHCNP led to a renewed vision of nursing in primary care in which the roles of the different types of nurses could be optimized:
… it's having a vision for nursing practice, saying, what roles should we be giving to each of these different job categories in nursing? So, not to think only about the PHCNP, and where we should put her, but to ask what role she should play in relation to the role of the registered nurse, the role of the staff nurse. But for me, that's always what I'm thinking about, because I also have a mandate, an organizational responsibility, which is to optimize care, or to set care priorities. (Nursing coordinator)
Having clearly defined roles in primary care teams also makes it possible for new professional projects to emerge. Some settings had implemented special projects led by the PHCNPs. These projects helped to promote the PHCNP's role in the team and to underscore the specificity of that role and how it differed from the physician's role. Our data showed that this type of project had positive impacts on the clinic's overall performance:
First, we started by meeting them [PHCNPs]. It's a little simplistic to say. Then to … learn from them what were their abilities, their limitations, and … their wishes to … Not their wishes, but what they wanted to do as work, and what they were able to do as work. (Physician partner)
4.4. Role Clarification Competency Descriptors
As mentioned earlier, the Canadian National Interprofessional Competency Framework presents seven descriptors for the role clarification competency. The analysis of our data provided a better understanding of how the descriptors of this competency were manifested in the primary care teams. In this section we present our empirical results in relation to these descriptors.
(1) Describing Own Role and That of Others. Role clarification in a primary care team requires a detailed understanding of one's own professional role and those of others. In most teams, the arrival of a PHCNP meant integrating a new professional role into the team. PHCNPs have a key responsibility for clarifying their role within primary care teams. The majority of our respondents said PHCNPs were the best persons to explain their own role to other team members. However, PHCNPs could also find themselves in a vulnerable position if their role in the team is a new one and might need the support of resource persons in the setting to support role clarification. Such support from a resource person is crucial to communicate the role optimally and to ensure it is well understood by all the team members. Several respondents estimated that it took about six months for PHCNPs to settle into their role and up to a year for all dimensions of that role to be fully integrated. According to one PHCNP and a physician,
… you have to build up trust, a new role … And no one knows the role better than we do. The guidelines, physicians, they have an idea of the role, but … I had to tell them, "okay, I've come to see you [physician] because I think the patient needs this drug, but I cannot prescribe it." (PHCNP)
Ah! OK. You know he needs it but you cannot prescribe it? OK. (Physician partner)
Nevertheless, once the PHCNPs had settled fully into their role, some respondents were very satisfied with their practice:
… I was pleasantly surprised by their—how could I say it?—their capacity for work and for managing interprofessional care plans. So I quickly accepted this principle and this form of team. (Physician partner)
(2) Recognizing and Respecting the Diversity of Other Healthcare and Social Care Roles, Responsibilities, and Competencies. Role diversity refers to all the dimensions associated with a professional role and its responsibilities and competencies. The diversity of the PHCNP's role is not very widely recognized in primary care teams. Sometimes roles are differentiated uniquely on the time allocated for patient consultations, which varies from one professional to another. As this respondent pointed out,
The PHCNP's consultation will be more comprehensive. Physicians know that, in her role, the PHCNP can take more time for consultations with patients. Also, the nursing dimension of the role makes the difference in terms of teaching. (Clinical nurse specialist)
Another respondent sees the diversity of the role in a positive light and respects the difference:
I don't have any genograms in my patients' charts. The PHCNP does, and for her it's a value, which I respect. But at the same time, for us doctors, we need to respect the fact that the PHCNP won't be doing things exactly the same way we do them. (Physician partner)
(3) Performing Own Roles in a Culturally Respectful Way. This competency indicator can take various forms: first, as respect for the cultures of the different professionals in the teams and then as respect for the culture and values of patients and families followed by the primary care teams. Several PHCNPs in our cases worked with recent immigrants from other countries, refugees, and vulnerable and impoverished groups. The PHCNPs described how they incorporated culturally adapted strategies in their diabetes teaching activities.
As an illustration of this competence, in the less well performing settings, professionals in the same discipline, for example, the PHCNPs and nurses, tended to stick together for mutual support. These alliances occurred more frequently in settings where there was less collaboration with physicians, and they were a source of comfort and support for the PHCNPs.
(4) Communicating Roles, Knowledge, Skills, and Attitudes Using Appropriate Language. Our data showed that members of primary care teams used several different means to communicate their roles, knowledge, abilities, and attitudes in appropriate language. In some of the settings studied, the PHCNP's role was explained to the primary care team in a presentation made by the nursing director and the PHCNP together, in which they were able to respond to various questions from the team members.
In most of the settings, care team members primarily used informal communication to discuss professional roles. Setting size also influenced the type of communication used. Settings with fewer professionals tended to opt for informal communication, whereas settings with larger teams tended to schedule formal sessions for communication. In our study, the better performing settings were those where there was ongoing communication, formal and informal, among the members, in which they were able to discuss grey areas and each person's capacities.
One setting formalized the process of role clarification by developing a matrix of all team members' roles. This matrix was a tool for discussing areas of overlap among the professionals and enabled team members to clarify each person's expertise. As one PHCNP reported,
So, at that moment, the roles were well defined; it helped. I think that, for sure, it doesn't solve all the problems. Having it on paper, you can refer to it, it's useful, but afterward, it's mostly in talking with people. (PHCNP)
The settings that used only documents prepared by the professional nursing and medical associations to clarify roles said these were insufficient and that interactions with other members of the team were essential.
(5) Accessing Others' Skills and Knowledge Appropriately through Consultation. We identified two types of patient management models in the cases: the joint management model and the consultative management model. In the joint management model, a group of patients is followed jointly by both the PHCNP and a physician partner. In the consultative management model, they each manage their own group of patients, and the PHCNP consults the physician as needed for the patients she is following. The consultative model was used in the majority of settings studied. This patient management model fosters consultations between the physician partner and the PHCNP and requires that time be set aside for such exchanges, as pointed out by this PHCNP:
We planned specific times when we could meet: early in the morning, at lunch time, and at the end of the day. These were our times when we talked about cases. (PHCNP)
This type of consultation did occur not only between physicians and PHCNPs, but also between nurses and other team members. However, our data revealed that the informal nature of the consultations sometimes made the PHCNPs uneasy, as they worried about bothering their colleagues, specifically physicians, and disrupting their work.
(6) Considering the Roles of Others in Determining Own Professional and Interprofessional Roles. In primary care, PHCNPs work closely with physician partners to establish their place and their complementary role in the team. This involves identifying what is unique about the PHCNP's role and what elements of the role are shared with other professionals, that is, certain tasks that can also be performed by other professionals or competencies that can be shared by more than one member of the team. According to one physician, the sharing of clienteles raises issues about the physicians' medical role:
We're only going to have the complicated cases, the cases no one wants. Our more stable, easier cases will be given to others. So there's a sort of reassessment happening among the professionals, particularly with respect to the PHCNPs' role. (Physician partner)
For the nurses, the arrival of the PHCNP provoked some apprehension. Some of them had developed expertise in managing patients with diabetes and were worried they would lose that role when the PHCNP arrived. Other nurses saw the PHCNP's arrival as an opportunity to ensure better management of their clienteles and as providing an additional resource to which they could refer patients as needed. According to one PHCNP, recognizing and maintaining the expertise of registered nurses was a key element in defining the PHCNP's own role:
The registered nurses have expertise in adjusting insulin and in the very hands-on management of hypertension. Knowing this from the start made it possible for them to keep their expertise, and for us to take our own place. That was a really, really positive thing. (PHCNP)
The PHCNP's arrival was a catalyst for redefining the roles of every member of the primary care team. According to this nursing director,
They asked me to review roles and to optimize the roles of registered nurses. So we reviewed the roles of the licensed practical nurses, who were doing more than they were supposed to be doing. We reviewed the roles of the registered nurses, who weren't doing enough. (Director of Nursing)
In several settings, the PHCNP's role was developed by building on the complementarity of roles already existing in the team.
(7) Integrating Competencies/Roles Seamlessly into Models of Service Delivery. In several settings, integrating PHCNP competencies into new models of care delivery resulted in the creation of specific clinics for PHCNPs, such as teams for the prevention and treatment of sexually transmitted and blood-borne infections (STBBI). This type of clinic provided an opportunity for PHCNPs to promote their role within the establishment and not just in the primary care team and to showcase the distinctive characteristics of the PHCNP's role in comparison with the role of physicians. These special projects extended outside the boundaries of the primary care clinic; they were projects that involved the entire organization and allowed service delivery to be modulated based on the PHCNP's competencies.
In another setting, the PHCNP was a core resource for training nursing staff, in order to achieve optimal integration of collective prescriptions among nurses (e.g., adjusting antihypertensive medication):
The new director's vision consisted of fostering the autonomy of each professional role. To achieve this, implementing and developing collective prescriptions was essential. (PHCNP)
The arrival of the PHCNP was thus an opportunity to optimize services to the population. The less well performing settings were those that did not incorporate any special projects into the PHCNP's work.
5. Discussion
From the analysis of our empirical data, two major conclusions emerged regarding role clarification in primary care teams: role clarification is both an organizational process and a professional competency. Overall, half of the settings studied (3/6) were defined as "high-performing," in that they had successfully integrated the PHCNP into the primary care team, there was clarity and consensus among team members about their roles, and interprofessional collaboration was well established within these teams.
5.1. Role Clarification: An Organizational Process
In the settings studied, the best performing teams were those that introduced organizational processes to support role clarification. The organizational processes could take several forms: developing a matrix to clarify professional roles, allocating formal time for discussing roles, or implementing special projects for PHCNPs, such as STBBI clinics. According to D'Amour and colleagues [28], these elements correspond to the dimension of formalization of interprofessional collaboration through the use of tools and information exchange. Our data suggest that, for optimal results, role clarification needs to be planned. At the level of nursing administration, in settings where a "champion" was designated to oversee optimal implementation of the PHCNP role and make it known to others before the PHCNP's arrival, the integration was facilitated and colleagues had a better understanding of the role. Several researchers have emphasized the key role of nursing leaders in implementing new nursing roles. Their understanding of these roles affects the implementation of all aspects of the role [6, 8, 29, 30].
5.2. Role Clarification: A Professional Competency
The second conclusion emerging from this study is that role clarification is a competency professionals need to mobilize to ensure their own role is well understood by all team members. As such, professionals have the responsibility for fully understanding their own role and the various dimensions associated with their practice, so they can explain it to the team, make the case for it, and negotiate accordingly. The professionals need to identify all the ways in which the mobilization of this role clarification competency is manifested. The best performing settings were those in which individuals were able to talk about their own roles and understand those of other professionals. This paper provides a first empirical application of the Canadian National Interprofessional Competency Framework and contributes to a better understanding of the development of the interprofessional collaboration competency and more specifically of the role clarification competency. To facilitate the appropriation of the different descriptors associated with role clarification and reduce overlap, these descriptors could be reduced to four. Several interview comments could have been encoded in more than one competency descriptor (e.g., Competency 1: describing own role and that of others and Competency 6: considering the roles of others in determining own professional and interprofessional role). Research is needed to further clarify the distinction between these competencies. Our research has shown that applying the Canadian National Interprofessional Competency Framework empirically is sometimes difficult. Some data fell within more than one descriptor at a time. Nevertheless, using the CIHC framework was helpful in developing a better understanding of the role clarification competency and thereby fostering its full deployment.
6. Practical Implications
This study has provided a deeper understanding of the processes of role clarification when the PHCNP role is integrated into primary care teams. A limitation in case studies concerns the ability to generalize the results to larger contexts, since the cases studied are situated in particular contexts. It is nevertheless possible to draw some practical implications, as presented here.
Effective role clarification processes are those that include both an organizational dimension, in which processes are set up to facilitate role clarification, and an individual dimension, in which professionals are able to communicate clearly all aspects of their roles. All the settings agreed that role clarification processes must take into consideration patients' needs. Role clarity is a key determinant of interprofessional collaboration. Our data showed that no team had planned for a systematic role clarification process in a given time and space. Nevertheless, according to Carmel and Baker-McClearn [31], professional roles are dynamic and become transformed by the practice context and by interactions with other professionals. These authors consider that roles are constructed and negotiated by means of the everyday processes experienced by members of the team. The roles are defined not only by these interactions, but also by legislation and by professional regulatory agencies [31]. For these reasons, roles are not static; they evolve with patients' needs, providers' experience with the role, technological developments, training received, and legislation, and as such, they need to be redefined over time. Therefore, it would be important, as the years go by, to set aside time and space to discuss how roles are changing in primary care teams.
In conclusion, our aim in this paper has been to gain a better understanding of role clarification processes in primary care teams in Quebec. Role clarification is a key determinant of interprofessional collaboration, with both an organizational and a professional component. As such, it is the responsibility of both the organization and the primary care team members. Interprofessional collaboration is a complex competency for clinical teams to acquire, and role clarification is one of the essential competencies they need to master.
Conflict of Interests
The authors declare that there is no conflict of interests regarding the publication of this paper.
This study was supported by a grant from the Canadian Institutes of Health Research (CIHR) and by the Quebec Ministry of Health and Social Services. The authors thank Johanne Charland for her comments on an earlier version of this paper.
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Last year I bought one of those nifty retractable screen doors to replace my old hinged screen door. I thought it would be nice for Winslow to look out the door without having to stand on his hind legs to look out the glass. He seemed to like it and I liked it until one day I saw him push the screen out and crawl under it. My fix for this was a plank of six inch tall balsa wood that I would lay across the threshold to block Winslow in. That worked until last month when I could not find him anywhere in the house and realized the little stinker went over the wood then under the screen door. After a few days of keeping the door shut I went out and bought an inexpensive baby gate to keep him inside.
The plain baby gate was fine, but colorful is better so I bought a can of spray paint, removed all the hardware I could, then covered and taped up the rest of the hardware, and took it outside to paint. The new baby gate has been working well. I have seen Winslow stand up, leaning against it though, I'm assuming to see if he can get over it safely. Here is the sad kitty trying to sniff out an escape plan:
May 31, 2016
Painted Baby Gate
Posted by kelly smith at 7:00 AM
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Stephen Colbert is finally embracing the 'Colbeard'
Stephen Colbert has grown a beard. A big, glorious beard. More
Fashion for the bearded gent.
Stephen Colbert has grown a beard. A big, glorious beard. More
Regardless of what type of beard you fancy, it shouldn't be too hard to find your love a gift this Valentine's Day. More
The fairest beard in all the land goes to the almighty mane of Grimey MacTavish. More
IT has been a sign of the lower class, criminality, the hippy counterculture and even how chic a man can be. More
To me a trend is something that is moving in a certain direction, something that was not here before and will not be here in a while. More
2014 marked a big year for the hirsute gentleman. Here's our pick of the best beards of Instagram. If you haven't lurked them yet, get creeping. More
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Comedy actor James Corden, whose hit series Gavin & Stacey was given its big break by BBC3, has backed its move from television to an iPlayer-only channel.
The BBC has earmarked the station for a move to iPlayer, which would save millions to reinvest in other programming.
But James, speaking to The Guardian at Advertising Week Europe, said the youth audience at which the station is aimed was comfortable with viewing programmes on a computer rather than TV.
"I think it should always be at the forefront of what is fresh and exciting, and therefore it should be the first channel to exist online," he said.
"Providing they still invest and it's still a commitment to make new and interesting shows, then its audience will find them in the same way you and I enjoy House Of Cards (on Netflix)."
Gavin & Stacey began life on BBC3, but as its success grew it graduated to BBC1. James's most recent comedy drama The Wrong Mans screened on BBC2.
Latest Stories
He said today: "The truth is, I don't know if Gavin & Stacey would be commissioned by BBC3 today. The channel has changed. It was 2007 that we made that show. It has a much younger outlook."
The online-only move was proposed last month and is expected to deliver savings of up to £50 million a year.
More than 200,000 people have signed a petition opposing the plan.


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Next apply period: 8.1.–22.1.2020. Further information will be updated.


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Canon Ij Setup PIXMA iP7260
Canon Ij Setup PIXMA iP7260
Canon Ij Setup PIXMA iP7260 – How you feel about the Canon Ij Setup PIXMA iP7260 Wireless Inkjet Photo Printer$79.95 at Amazon will depend to a great extent on how centered you are around yield quality. Contrasted and the Editors' Choice HP Officejet 6100 ePrinterBest Price at Amazon, for instance, it's slower, has a lower paper limit, and offers less highlights. Then again, it conveys outstandingly better yield quality, with preferable content and photographs over most ink planes. In the event that yield quality is your key concern, stop to make it a solid contender for home or light-obligation individual use in any size office. Notwithstanding its amazing yield, the Canon Ij Setup PIXMA iP7260 offers a couple of highlights that go past the essentials, however not by much. As the name recommends, it bolsters Wi-Fi, for instance, and it likewise underpins AirPrint. Be that as it may, there's no Ethernet bolster, so Wi-Fi is your decision for interfacing with a system, and there's no Wi-Fi Direct, so you can't associate specifically to the printer from your cell phone or tablet. Paper dealing with is restricted, yet superior to anything you may expect at this cost. The 125-sheet input limit is supplemented by a photograph plate that can hold 20 sheets of 4 by 6 photograph paper, which implies you can print photographs without swapping out paper in the principle plate. Two other vital additional items are the programmed duplexer (for imprinting on the two sides of a page) and the capacity to print on printable optical plates, in spite of the fact that you may need to check the onscreen manual to make sense of where the circle printing alternatives are covered up in the product that boats with the printer.
Canon Ij Setup PIXMA iP7260 Wireless Inkjet Photo Printer
Setup and Speed
Setting up Canon Ij Setup PIXMA iP7260 was standard toll. For my tests, I associated it by USB link to a framework running Windows Vista. The speed for business applications is best portrayed as somewhat moderate yet inside a middle of the road run for a home or home office printer. On our business applications suite, I planned it (utilizing QualityLogic's equipment and programming for timing) at a successful 2.5 pages for each moment (ppm), making it just around 70 percent as quick as the Officejet 6100 ePrinter, at 3.6 ppm, and considerably slower contrasted and the somewhat more costly Editors' Choice Epson WorkForce 60Best Price at Amazon, at 4.1 ppm.
Making up to some degree for the speed for business applications is the printer's photograph speed, which midpoints a sensibly quick 1 minute 5 seconds for a 4 by 6. That makes it basically tied with the Officejet 6100 for photograph speed, and about twice as quick as the WorkForce 60.
Yield Quality Canon Ij Setup PIXMA iP7260
Likewise compensating for the moderate speed for business applications is that the yield quality is better than expected by and large, with preferable content and photograph quality over most inkjets and standard quality illustrations. The content isn't exactly a counterpart for a run of the mill laser, and I wouldn't utilize it for, say, a resume. In any case, its significantly more intelligible at little text dimensions that most ink planes can oversee, and it's sufficient for any business utilize.
Illustrations quality is dead on par for an inkjet, which makes it effortlessly adequate for any interior business utilize, including PowerPoint freebees. Likewise with numerous printers, the iP7220 tends to lose thin lines against a strong dim foundation, yet relying upon how basic an eye you have, you may think about the quality adequate for yield heading off to a vital customer or client. Photograph quality is in the best level for inkjets that aren't pointed particularly at photograph devotees or experts, which improves them observably than the photographs you'll get from numerous medication stores.
As might be self-evident, the most persuading contention for this printer is its yield quality, with preferred looking content and photographs over most inkjets convey, and sensibly attractive illustrations yield too. On the off chance that you needn't bother with the astounding yield, the HP Officejet 6100 will give you quicker speed and more highlights at the cost, yet in the event that yield quality issues more, the Canon Ij Setup PIXMA iP7260 Wireless Inkjet Photo Printer will probably be your favored decision. That is an easy-to-understand article about Canon Ij Setup PIXMA iP7260 .
canoncom-ij-setup.com provides manual ij setup and driver for your canon printers. Before downloading the software file, you need to be sure the exact model and type of your printer and your computer operating system. The driver software you are going to download is Canon Ij Setup PIXMA iP7260 . We always offer the safe and latest version of the software.
Canon Ij Setup PIXMA iP7260 driver complete Installation procedures:
Here are some steps that you need to follow to download and install the printer driver:
- Click download to download the driver to your computer.
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- When the installation procedure is finished, test your printer by right-clicking the printer icon and click properties.
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Operating system support:
MS Windows Server 2003, MS Windows 7, MS Windows Vista SP1, MS Windows XP SP3, MS Windows Server 2008, MS Windows Vista SP2, MS Windows Server 2008 R2, MS Windows 7 SP1, MS Windows Server 2003 R2, MS Windows Server 2012, Windows 8, Windows RT, Android, iOS, Windows 8.1, MS Windows Server 2012 R2, Apple Mac OS X 10.6.8 – 10.9
Canon Ij Setup PIXMA iP7260 Links
Canon Ij Setup PIXMA iP7260


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Kington Lodge for 16 - 38 guests
- Midlands and the Peak District
- Lyonshall
- Self Catering
- Sleeps 16 - 38
Bedrooms 8
Beds 14
Dining For 40
Kington Lodge - Herefordshire
Sleeps 16 - 38 guests
The price for this property is based on 16 guests, while extra guests can be accommodated at an additional cost.
Kington Lodge accommodates 16-23 guests and can also be hired with The Forge (sleeping 3), The Garden Cottage (sleeping 6), and The Lodge (sleeping 6) located in the same courtyard together accommodating a total of 38 guests in its 13 bedrooms.
This large Party House in Herefordshire is an ideal place for any kind of event from holidays and birthday celebration, to family and corporate get-togethers. Kington Lodge is a stunning conversion of the estate's Victorian stable-yard. This big house to rent near Wales combines both traditional and modern design for a comfortable and enjoyable retreat for you and your guests. Kington Lodge's private gardens offer a space for any kind of activities, be it a yoga practice, corporate team building exercise, or a place for your kids to play. The standard of this big house is to accommodate 16 guests, however, guests can upgrade their stay to include an additional 7 full-size single beds to sleep 23.
Key Features
- Unique converted Victorian stable-yard
- Outdoor heated pool and hot tub
- Squash court
- Grand piano
Reception Rooms, Kitchen and Dining
Looking for a big and modern kitchen to practice your favourite meals? This large Party House to rent near Lyonshall consists of 5 fully equipped kitchens with 5 fridges including, a large American style fridge and a double range cooker. Everything you would ever need to make that perfect meal, from crockery, cutlery, glasses, cookware, wine glasses, and tumblers will be available for your use. There is also a great dining table seating 16 people while having an option of extending it up to 40 guests.
This big house in Herefordshire comes with 3 uniquely styled reception rooms, allowing you to get some quality time with your loved ones and catch up on recent events. The clock view room with its three comfortable sofas offers a perfect spot for your afternoon cup of tea or coffee. Snuggle into a comfortable armchair and enjoy a book next to an open fireplace in the Tack room.
This large Party House to rent can perfectly accommodate from 16 up to 23 guests in its 8 bedrooms. Be it a family with two children that want to be accommodated close to each other, or a couple seeking privacy, each guest will find their perfect bedroom with an en-suite bathroom at the Kington Lodge. Each room consists of comfortable beds with Egyptian cotton linen, and are supplied with large white bath sheets, a cotton waffle dressing-gown, and hand towels. To see more information about the bedrooms here is the rundown:
- Bedroom 1: a double bed and 2 single beds on mezzanine and a full-size sofa bed, with an ensuite bathroom (sleeps 5)
- Bedroom 2: a double bed, a single bed on mezzanine, with an ensuite bathroom (sleeps 3)
- Bedroom 3: a twin room with an ensuite bathroom (sleeps 2)
- Bedroom 4: a king size bed with sofa and a bath (sleeps 2)
- Bedroom 5: a queen size bed or twin room (bed can be either two single or queen) with an ensuite bathroom (sleeps 2)
- Bedroom 6: a double bed, a single bed with an ensuite bathroom (sleeps 3)
- Bedroom 7: a four poster double bed, a single bed on mezzanine with an ensuite bathroom (sleeps 3)
- Bedroom 8: a double bed and 2 single or a double on mezzanine with an ensuite bathroom (sleeps 4)
As mentioned, if you are planning a big party near Hereford, there is also an option to rent two extra cottages and a lodge located in the same courtyard sleeping an additional 15 guests.
The Forge
1 bedroom with a super-king-size bed, and an additional futon on the mezzanine, and en-suite bathroom (sleep 3)
The Garden Cottage
3 bedrooms with king-size or twin beds (sleeps 6)
The Lodge
2 bedrooms (sleeps 4 - 6)
Start your day with a swim in an outdoor heated swimming pool (available from May until September) and continue your afternoon with a relaxing time at the onsite hot tub and sauna. Have an entertaining evening in the media room with a cinema surrounded by your family playing board games, Wii, and X-box. For all the active guests, there is also a squash court, while the musicians in your family will be able to play their favorite songs on the grand piano.
Local Area
If you're looking to have an active stay, you'll be happy to know that there's an activity park, Oaker Wood Leisure just a 20 minute drive fro the property. Here you and your guests will find numerous fun activities for adults and kids alike such as paintball, team-building challenges, quad-biking, high ropes, zip wire, climbing, rafting and more. Other activity providers you might be interested in are Life Changing Activities run by an ex army trainer, Inspire2Adventure, Really Rural, The Ultimate Activity Company, and others. You can test your skills at Golf or Tennis, have Flying Lessons, go Canoeing, Hiking, Karting, Mountain Biking, Shooting, or Swimming, learn the ropes of Pottery and much more.
If you'd like to explore the local area you can opt-in for a Black and White Village Tour or go exploring by yourself. Visit the beautiful gardens of Bryans Ground, 17th Century Croft Castle, Eastnor Castle, or Hampton Court. Check out the beautiful trees and gardens of Hergest Croft and play tag at the very popular museum of labyrinth gardens of The aMazing Hedge Puzzle.
There's plenty of lovely restaurants and pubs within a 10-mile radius from Kington Lodge including a Michelin star restaurant. Find out more about this in the "Location" section of this venue.
- Lawns
- Swimming Pool
Find below a list of activities and ideas that you can bring either to your Party House or do in the local area, for more detailed information on each visit our Activities and Ideas page.
- Beer Making
- Catering
- Chocolate making
- Cocktail Making
- Cupcake decoration
- Gin & Whisky Tasting
- Golf Course
- Hot Tub
- Laser clay shooting
- Murder Mystery
- Squash
- Swimming Pool
- Walking
- Wine Tasting
- Yoga/Dance Studio
- Archery
- Beer Making
- Chocolate making
- Chocolate Tasting and Truffle Making
- Clay Pigeon Shooting
- Cocktail Making
- Cycling
- Hiking
- Horse Riding
- Murder Mystery
- Pilates
- Spa
- Walking
Kington Lodge for 16 - 38 guestsHerefordshire , Lyonshall, Herefordshire , UK
Closest Train Station :
Hereford Railway Station - 17 miles
Closest Airport :
Birmingham Airport - 55 miles
Nearby Town :
Birmingham - 56 miles
Worcester - 40 miles
Nearby Eatery :
The Stagg, Titley (Michelin starred) 01544 230221 www.thestagg.co.uk
The Lion, Kington 01544 231002 www.lionkington.com
The New Inn, Pembridge 01544 388427
Jules, Weobley 01544 318 206 www.jules-restaurant.co.uk
The Cider Barn, Pembridge 01544 388161 www.the-cider-barn.co.uk
Red Lion, Pembridge 01544 388007
The Ducks Nest, Presteigne 01544 598090 www.theducksnest.com
The Hat Shop, Presteigne 01544 260017 www.thehatshoprestaurant.co.uk
Jules, Weobley 01544 318 206 www.jules-restaurant.co.uk
The Harp Inn, Old Radnor 01544 350655 www.harpinnradnor.co.uk
The Royal Oak Inn, Gladestry (On Offa's Dyke path) 01544 370669
The Angel, Kingsland 01568 709195 www.angelkingsland.co.uk
The Riverside Inn, Aymestry 01568 708440 http://riversideaymestrey.co.uk/
The Tram, Eardisley 01544 327251 http://thetraminn.co.uk/
The Boat Inn, Whitney on Wye 01497 83122
Taj Mahal Indian Takeaway and Restaurant 01544 231999 www.tajmahalkington.co.uk
Hamps Hall & Barn for 40 guests
- Waterhouses
- Midlands And The Peak District
- Sleeps: 40 Bedrooms: 18 Dining: 64
Roaches Hall for 30 guests
- Near Leek
- Midlands And The Peak District
- Sleeps: 30 Bedrooms: 13 Dining: 34
Lyonshall House for 18 - 22 guests
- Lyonshall
- Midlands And The Peak District
- Sleeps: 18 - 22 Bedrooms: 8 Dining: 18


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Bad Girls Trail Riding Club
After Easter Ride - Arrowhead State Park, April 26th - 28th
The After Easter Ride was a hit! We could not have asked for more beautiful weather that weekend! What fun it was to be a "kid again" and hunt for Easter eggs! The eggs had candy and raffle tickets in them that were later used to win prizes after dinner. There was also an Easter Bonnet contest and Pat Savage was the Grand Prize winner! The trails had a few boggy spots due to all the rain we've had recently, but overall it was a great ride and a fantastic, fun-filled weekend!
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Office Insights: Positive Momentum Continues
The second quarter of 2018 saw some significant milestones and moves in the Minneapolis – St. Paul commercial real estate market. Capital markets first half volume of 2018 CBD sales surpassed annual volume for nine of the last 10 years. Q2 saw a large-user shake-up in the northwest Twin Cities metro with Cantel Medical taking the former campus of Sleep Number. And downtown Minneapolis' East Town district had more than 730,000 square feet of new owner-occupied office space ready to break ground for new build-to-suit projects.
Investing and Divesting
The second quarter saw a 12 percent increase in CBD sales volume over Q1 with $407 million traded. LaSalle Investments took over ownership from Hines of T3 in the North Loop for $87 million making Hines the largest seller of CBD assets over the last 18 months.
The northwest Twin Cities metro is not typically a prime target for large leases; however, its adjacency to the popular west metro and nearly 20 percent discount to the market average asking rate makes economic sense. In this region, Cantel Medical will fill Sleep Number's former 159,000 SF office campus. This single-tenant space was only vacant since the end of 2017 demonstrating demand for affordable large suburban blocks. In addition, The Mosaic Company announced it will relocate its headquarters to Florida which will open up nearly 75,000 SF of new sublease space.
Building to Suit
Large employers like Prime Therapeutics, Thrivent Financial and the City of Minneapolis are all constructing their own headquarters. Thrivent Financial broke ground on their new site in July. This coincided with the City of Minneapolis' new consolidated office building just one block away where demolition of a parking ramp began in May. Combined, these projects will bring about 730,000 square feet of new owner-occupied office space to East Town in 2020. Other owner-occupied projects underway around the market include Prime Therapeutics in Eagan, and Thor Construction's headquarters in Minneapolis.
Renovate, Renovate, Renovate
Tenant activity in renovated buildings was hot in the second quarter of 2018. Fifth Street Towers, The Baker Block, West End Center, 801 Marquette all saw sizeable absorption or new leases signed. More moderate growth in asking rents is expected due to the remaining unrenovated space more heavily influencing weighted average asking rates.
Read our complete 2018 Q2 Office Insight Report for more details on the Minneapolis – St. Paul market.


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King's Hall Ilkley
06 November 2018
Following the success of the first two tours of Bikeology, journalist, television presenter and best-selling author Ned Boulting is back in 2018 with the all-new show, Tour de Ned.
Boxes for four people still available - just £96. Call the Box Office on 01274 432000 to book!


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2017 National Adult in Scouting Workshop of The Scout Association of Nigeria
All National Scout Committee Members
Dear Sirs/Ma'am
In line with the World Organization of Scout Movement Vision 2023 and her Strategic Priorities deployed at the 40th World Scout Conference & 16th All Africa Scout Conference respectively, l am inviting you to the Drilling-Down Workshop of the National Scout Committee Members to the Planning & Execution of the General Administrative and Operational Processes of the NSO in-line with the Strategic expectations.
While counting on the foregoing, the date of the workshop has been fixed for 23rd to 26th of March 2017 at our Technical Operational Center, Oba Akenzua International Scout Camp, Ogba, Benin City Nigeria.
Please Note:
Limited Accommodation are available at the Campsite, but have a dedicated Clean Hotel for N3,500 (Scouts negotiated Price) around the Campsite for use by any of our members.
Feeding is on Personal arrangement of Pay-as-you-eat. The Association shall negotiate a N200 per plate meal with the Food Sellers within the Camp. I will look forward to seeing all of us at the Workshop.
There shall be 9th Session meeting of the National Scout Committee within the Leadership Programs. Members are expected to mark their Calendar for this period.
Workshop Objective:
To learn and understanding the Guiding Principles of Scouting Governance Processes.
To appreciate the Roles & Responsibilities of Sectional Business Units in the Organizational Management of Scouting.
To review our Administration & Operations in preparations for the 2023 100 Million Target in which Nigeria is going to play a major Role
Resources Persons:
Prince James Adeolu Oyelami, Assistant Chief Commissioner, & Head of Department Educational Method in Scouting
Apostle Adetola Adenekan, Assistant Chief Commissioner, & Head of Department Diversity, Inclusions & Social Impacts
Alhaji Gambo Ado, Assistant Chief Commissioner, & Head of Department Youth Engagement
Bar. Mrs. Mary Emengo, Assistant Chief Commissioner, & Head of Department Communication & Ext. Relations.
Very truly yours in Scouting,
Officially Signed by:
Olusoga Sofolahan (Olori Omo-Oba) LT, FSM, FCE,
The Chief Commissioner Scout of Nigeria,
Leadership & Governance Department.


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It has sadly come to my attention that there are a few people out there compromising doing the right thing to save their own ass, don't they get that doing the right thing is what saves your ass?
I am only going to say this once...
-I will not be involved with any show, article, campaign, commercial or book that mentions the name of the program I got sober in. Thank you for respecting this.
-Also I am asking that only the faded picture of my children in People magazine be shown on TV. I understand that People magazine gives shows permission to show the article and that is fine with me (I <3 People Magazine) It is just my personal request.
With that being said I want to thank a few people. Thank you to Alicia Dennis the best reporter in the world. Thank you to Laura Frank for your kindness and understanding. Thank you to People magazine for both doing an article on such an important topic and publishing www.emilyism.com. I will do a story for you anytime! It is helping a ton of women and doing it was worth every bit of fear I had to walk through. You guys ROCK!!


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Introduction to mapping and spatial analysis with R 25-29 November 2019, ICES HQ, Copenhagen, Denmark
Principles and methods of broadband technologies: application to fisheries acoustics10-17 December 2019, Onboard G.O. Sars, Bergen, Norway
Data-limited stock assessment methods and reference point estimation6-10 January 2020, Nanaimo, British Columbia, Canada
Something missing from the list above? Members of the ICES community are invited to submit proposals for new training courses. Looking forward to hearing from you!


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- strategy
The full article can be read here. Two things stand out.
First, on long term view. Jeff is famous for his long term view even in 1997 when Amazon just went public. Economist also has a profile about his 10,000-year-clock and Blue Origin project. He famously said:
"If everything you do needs to work on a three-year time horizon, then you're competing against a lot of people," Mr. Bezos told reporter Steve Levy last month in an interview in Wired. "But if you're willing to invest on a seven-year time horizon, you're now competing against a fraction of those people, because very few companies are willing to do that. Just by lengthening the time horizon, you can engage in endeavors that you could never otherwise pursue. At Amazon we like things to work in five to seven years. We're willing to plant seeds, let them grow—and we're very stubborn."
[caption id="" align="alignnone" width="380"] Jeff Bezos at AllThingsD[/caption]
Talking about the Kindle Product series. Here is another excellent example on taking really long term view.
In a previous interview, you said it takes five to seven years for a new business to either break even or become profitable. And you are now in year five of the Kindle.
Bezos: True story. Typically, of course, they vary a bit. We are in year five, but actually you could say we are in year eight because we worked on the device — the Kindle one — three years before we launched it.
Another thing that goes against common wisdom is about focus. It's really dazzling that Amazon is competing with NetFlix on video streaming, Walmart on retail, Google/Apple on mobile and leading the AWS service.
Anyone ever tell you that you have a focus problem?
Bezos: Hahahaha! That's so funny because my Montessori teacher used to have to pick me up and move me from one task to the next.
So, no?
Bezos: So, no, I have never been asked that question. But I know where that's coming from. I would say we do have a different philosophy from other companies — another common phrase is "stick to your knitting." Our approach is, if we have a good idea, and if it's something we think customers would care about, like AWS or Kindle Fire, then we don't ask why do this, we ask why not do this? We have a high bar for doing those things. We don't want to do me-too things. The people we've attracted over time to Amazon want to be pioneers. They want to be inventors. They want to do new things.
Take away? Do what makes sense to one's own company and ignore what others have to say. Do the same thing everyone is doing is not going to make or break a company.


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Summer is almost here, but you don't have to worry about not feeling "beach-ready" if you have a swimsuit that flatters your figure. Shapewear swimsuits are all the rage and with good reason. Their special design keeps all the bits you want tucked in and hidden away.
Like normal shapewear, swimwear and tummy control swimsuits add extra support to smooth your body's curves and give an extra boost of confidence. They are not only super comfortable, but fashionable, too. Whether you're looking for a simple and chic one-piece or love a splash of color with your tankini, we've found an array of shaping swimwear to suit your body type and taste. Like the best shapewear for plus-size women or bathing suits for women over 50, these will add some extra support while still looking stylish.
Scroll down to see our 13 picks for the best shapewear swimsuits!


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Tom Ault
Jefferson City
Dear Editor:
We live in a world of ever-changing landscape. A factory is built, small homes left in ruin in its wake; once cabins by the water where fishermen dreamt, now multi-family apartments on the waterfront where the enjoyment has changed from fishing to extreme water sports. This is America, the ever-changing, but not always better changing country we live in.
I have no idea who Steven Lightner of Marketing Specialists Inc. is nor do I know where he lives. What I do know is that his attempt to place four rental units at the Shermans Hollow entrance to the West Point development of lovely residential duplexes will not enhance the integrity of that community.
The West Point Homeowners Association has insisted that every duplex owner maintains their property in accordance with certain specifications. Since its inception it has been a place to live and enjoy the benefits of home ownership for many retired, semi-retired and soon to be retired folks. This is, for many, their last investment in a home and it was made knowing that maintenance would be a guideline and consequently the home values would remain steady with the economy. To date it has done just that!
Once rental units are introduced to the area, the pride of ownership will diminish.
Most of us rented in our early adult lives until we could afford to buy. Some of us maintained the places we rented as though we owned them, but several did not. Those that did not assumed it was someone else's responsibility to maintain and all they had to do was pay the rent.
I handled several rental units for owners a few years back. I also handled the maintenance for those rental units. Even though careful screening was done, there were problems with lawns not being mowed, trash not picked up on the lots, screens and door looks damaged and sometimes eliminated, and a multitude of other problems which could barely be kept up with.
I think rental units are great, but not by sacrificing a community of caring homeowners just because a developer sees an empty lot!


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"Lookin' Bro"
Submitted on 11/14/2012
This is a funny song… point them out! Point them out!
This is a funny song… point them out! Point them out!
We all at one time in our lives looked like an idiot in a class photo. However, I feel confident that this guy was an idiot on more then just picture day! Nice Shirt
Is this a man law violation? What say you?
This is part 2 about being successful.
Listen… if you take a picture with your shirt off looking into the sky… you must have douche infused with your DNA. We are dropping you from the team…
Is it really worth it, and why on earth would you take a picture?
I am sorry, but if you rock affliction anymore or pretty much ever… your a man law violator! Please know every normal guy wants to kick you in the nutts!
Will someone on this site please point out that these 3 ass clowns are ruining Xfactor! This has to be a man law violation! Their entire presence is douche to the core!
This is just crazy! If you have this car… how do you not know how to drive it! That is a man law violation!
This is for those guys that have every excuse for why they are not successful!


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Today I am just thankful. Thankful for life. Thankful for grace and mercy. Thankful I know Jesus.
Do you ever wonder how anyone makes it through every day life without Jesus? Think about the worst storm in your life – the most horrid of circumstances you can imagine. What got you through it? For me – only Jesus. So often I wonder how people just simply make it day to day without knowing HIS love for them. And it makes sense why the world is so crazy and bleak sometimes – because people are lost…..and desire acceptance and unconditional love….and they don't know that the ONLY place they will find it will be with Jesus. Not the concept of Jesus. Not the idea of a savior….but Jesus. The savior.
We had a guest speaker in church Sunday – Danny Egipciaco – he is from Miami and works together with our missions ministry on global outreach. I am so incredibly blessed to go to a church that is dead on with the gospel and the message of grace and moreover one that puts so much emphasis on mission work – both locally and globally. So Sunday Danny is speaking about his calling to share the gospel in Miami and preached about our responsibility to share the gospel. To share the love of Christ. He brought it with his sermon and I loved it. What struck me most was how real he was in saying "I don't know how we are going to do this. We don't have enough people. We don't have the right skill sets. We don't have a strategy and it's a big God sized vision. But I'm here and I'm willing." That's it folks – plain and simple. Are we willing? The rest is up to God. We talk and talk and talk about how we trust God and know He has got it under control, but how willing are we? How willing are we to share with those people who are lost – the ones we wonder about making it through any given day without knowing His love for them? It's our responsibility. I was refreshed Sunday with a willingness to just DO – to stop talking and just DO. I'm so thankful for Danny's willingness to share and to make a BOLD calling to all of us to go where the Lord leads us. To pay attention to stirring in our hearts and to act. I, for one, want to be used. Here I am. Send me.
So what does that mean? I'm going to be so much more intentional. I talk about Jesus every day. It's my favorite thing to do! Seriously. At work. With my friends. With my family. In these blogs. On facebook. It's what I do. But here is what I'm going to do – be more intentional with sharing love with the lost. Every day while I am out, I commit to asking at least one complete stranger if they know Jesus. We should be doing that with EVERYONE and guess what? I don't. I know, I know, you'll say "well the time isn't always right. The circumstances have to be right." For me, hogwash. The time is now. Pray for me for awareness and intent to start locally sharing with the lost – and I will only know who the lost is if I ask! OR, join me in a challenge to ask one stranger a day if they know Jesus.
Let's be a light in a dark world. Love them like Jesus.


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Today we will discuss about another best android app "Swift key".
An app that we use all day on our mobile is keyboard app. These days keyboard apps are getting smarter and they provide tons of features and shortcuts. Which help you to type faster with accuracy. We will tell you 10 reasons why you should use Swiftkey keyboard app.
Swiftkey keyboard is a best keyboard app for every android users.
- Swiping
Swiping is much faster compare to typing. Most of us don't use this feature but once you get used to this it can come very handy. This is a quick way to type fast. When you type a word if you want that word again swipe that word will come automatically.
- Best Autocorrection
Swift key artificial intelligence is by far the best. When you are adding your word to dictionary . When you type any word, then the word is ready, tap on it, your keyboard will learn this word automatically for you. Swiftkey will autocorrect and suggest your custom words as well.
- Full sentence suggestion
Swift key's artificial intelligence reads your typing style and it will recommend you the entire sentence that you have used before.
- All languages support
Swiftkey has a support for almost all native languages. Auto correction and suggestion's work for all the languages as well.
- Themes
If you like customization. There are more than hundred themes that you can try and best thing is all them are free
- Takes small storage
We already know memory can be critical for low end devices. It takes less storage compared to Google keyboard
- Backup & sync
If you sign in to this keyboard with your Google account. All your custom words and typing style will be synchronized in a Google cloud storage. If you buy a new phone you just need to install this app and sign in again. Then all the words that you have added before will be available for you
- Emoji's suggestion
Swiftkey not only suggest words but it can suggest emoji's as well. It can be any emotion and a think of this. Let suppose you want to insert a flag of a certain nation and you don't know how the flag looks like. Then all you need to do this 'type the nations name and the keyboard will suggest you the flag. You don't have to search for any emoji's you just need to type it and get it but sometimes this feature dosen't work in google keyboard.
- Punctuation's
Swiftkey can predict punctuation's as well. If you add two consecutive spaces then keyboard will insert a fullstop to end the previous line and if you are adding a extra space between your word and a symbol then the keyboard will rectify that and add the symbol write next to your word. But Google keyboard cannot do this
- Free
This app doesn't have any ads or in app purchases. It is completely free to download on playstore and also available on iOS as well
So that's all for now guys and thanks for reading this review. What do you think about this app, tell us in comment section.


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What you will need is:
- suitable protective clothing - goggles, dust proof mask, gloves. You may wish to button your shirt collar up to prevent insulation fibres from going down your neck
- a couple of sticks for poking the insulation into the eaves etc
- a Stanley knife and/or stout scissors for cutting the insulation
- a portable light if no lighting yet installed
- hammer and 4" nails for providing temporary hooks to hang the light (if support is needed)
- short planks for placing across the trusses to kneel on - they should span at least 3 joists
- knee pads
- refuse bags for the rubbish
It is now good practice to install manufactured fire proof electrical fittings in all areas required. The manufacturers instructions are to be followed at all times - your electrician should be installing such fittings as routine. In this case, make sure that there is clearance around any downlighters (also called recessed luminaires) fitted into the plasterboard - cut the insulation away to within 6 inches of the downlighter body. Your electrician may fit intumescent covers (also called fire hoods). If possible, move electrical cables above the insulation to stop any overheating. ,
Getting the insulation into the space above a gable extension is a nightmare!!! Best done by someone who can contort themselves and make good use of sticks for positioning the insulation.
It is best to insulate the loft before the plasterers skim the upstairs ceilings to minimise the risk of 'popping' the nails or screws (screws are preferred) used to fix the plasterboard.
Your electrician won't thank you if you've insulated before he's done his stuff in the attic, so contact him first.
Make sure you leave a gap of 50mm at the eaves to provide adequate ventilation of the roof space.
Boarding it OutUnless you are using a very shallow pitch, there may be quite a bit of space in the attic that you could use for storage - in which case you will need to board it out. A typical 10" depth of glass fibre insulation will not allow floorboarding to go in unless you squash it down, which will ruin its insulation properties - and will get picked up by Building Control. Instead, you will need to use a cavity insulation between the joists. Ask your architect what thickness insulation you will require. You will need to increase the depth available by nailing wood (something like 2" x 2") onto the joists to give the required depth. Then saw the cavity board into strips, put in between the joists and screw the boards down.
It is preferable to screw the boards down in case they need to come up to get to the wiring underneath (not a likely eventuality), and avoiding hammering is less likely to pop the screws holding the plasterboard up.
You may need to cut out some small pieces of the board around the downlighters and screw these down, so you can get to the downlghters easily.


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March 26, 2013
Ukraine Christian Adoption Trend Spreads
The concept of adoption holds a special place in scripture and in God's heart in particular. Perhaps that is why the Church in Ukraine is coming together in a focused effort towards adopting the nation's orphans.
This movement is sweeping across Ukraine and other former Soviet countries as well and it can't be traced to any one church or denomination. Perhaps that's one of the most beautiful aspects of this dramatic adoption movement.
A pastor recently described how his family adopted 31 children. Another family adopted seven children infected with HIV. Drug addiction and family problems have been key causes for the rise in orphan statistics, but the tide has been turning and other former Soviet countries are also seeing a rise in this unique trend of family rebuilding. Russia began banning US adoptions of Russian children effective January 1, 2013, but Ukraine is still open to US and international adoptions.
The CBN documentary news video outlines how Svetlana and Isaev Evgeny decided to adopt the seven HIV infected children. It also documents how Ukraine has honored this family as national heroes in a moving award ceremony. Wes Stafford describes how God is committed to blessing orphans and those who bless orphans. But even deeper than this understanding is the biblical precept that life is sacred and precious and highly valued by God. There are many verses in the Bible that touch on the theme of adoption and one of the central themes is that of spiritual redemption as a form of spiritual adoption. As a matter of fact, the phrase 'spirit of adoption' is quoted from a verse identifying one of the signs of true salvation known as the witness of the Holy Spirit.
Josh Wiley has complied a list of 10 Bible verses related to adoption:
#1. John 1:12 - #1 Adoption Verse- All who believer are adopted as children of God But to all who believed him and accepted him, he gave the right to become children of God. Romans 8:14-16 -
#2 Bible Verse About Adoption-The Holy Spirit For all who are led by the Spirit of God are children of God. So you have not received a spirit that makes you fearful slaves. Instead, you received God's Spirit when he adopted you as his own children. Now we call him, "Abba, Father."For his Spirit joins with our spirit to affirm that we are God's children. Galatians 4:4-6 -
# 3 Scripture On Adoption- Freedom from the Law But when the right time came, God sent his Son, born of a woman, subject to the law. God sent him to buy freedom for us who were slaves to the law, so that he could adopt us as his very own children. And because we are his children, God has sent the Spirit of his Son into our hearts, prompting us to call out, "Abba, Father." James 1:27 -
#4 Bible Verse on Adoption- Caring for the Orphans Pure and genuine religion in the sight of God the Father means caring for orphans and widows in their distress and refusing to let the world corrupt you. Additional Scriptures About Children Psalm 68:5-6 -
#5 Adoption Scripture Verse- God the Father Father to the fatherless, defender of widows- this is God, whose dwelling is holy. God places the lonely in families; he sets the prisoners free and gives them joy. But he makes the rebellious live in a sun-scorched land. Matthew 18:5 -
#6 Bible Verse About Adoption- Welcoming a Child "And anyone who welcomes a little child like this on my behalf is welcoming me. John 11:52 -
#7 Bible Passage on Adoption- All are Welcome And not only for that nation, but to bring together and unite all the children of God scattered around the world 1 John 3:1-2 -
#8 Bible Scripture on Adoption- God's Children See how very much our Father loves us, for he calls us his children, and that is what we are! But the people who belong to this world don't recognize that we are God's children because they don't know him. Dear friends, we are already God's children, but he has not yet shown us what we will be like when Christ appears. But we do know that we will be like him, for we will see him as he really is. Scriptures About God's Love Exodus 2:10 -
#9 Adoption Bible Verse- Adoption of Moses Later, when the boy was older, his mother brought him back to Pharaoh's daughter, who adopted him as her own son. The princess named him Moses, for she explained, "I lifted him out of the water." Esther 2:7 -
#10 Bible Verse on Adoption- Adoption of Esther This man had a very beautiful and lovely young cousin, Hadassah, who was also called Esther. When her father and mother died, Mordecai adopted her into his family and raised her as his own daughter.
Tags: Ukraine adoption movement, Bible verses on adoption, redeeming heart of God, spirit of adoption and witness of the Holy Spirit, Russian adoptions 2013, Ukraine adoptions 2013
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text: The third graders created these Andy Warhol inspired Pop Art flowers using gelli plate and fake flowers to create a positive and negative print on colorful paper. They really enjoyed using the gelli plate to create these prints. They also learned about Andy Warhol and Pop Art when viewing this presentation.