Implementing Guidelines for Pediatric Tonsillectomies

Implementing Guidelines for Pediatric Tonsillectomies Practice Paper: Implementing Quality Based Procedures  Guidelines for Pediatric Tonsillectomies at Credit Valley Hospital Kathryn DePass Trillium Health Partners, encompassing three sites- Credit Valley Hospital, Mississauga Hospital, and Queensway Health Centre, claims their hospitals are leading with outstanding performance, fiscal responsibility, and quality patient care (Trillium Health Partners, n.d.). With the emergence of the Health System Funding Reform in 2012, drastic changes were made to hospital funding. In particular, to promote innovative and evidenced-based practice, thirty percent of hospitals overall funding was allocated towards Quality Based Procedures (QBP) (Provincial Council for Maternal and Child Heath Ministry of Health and Long Term Care, 2013). QBPs are specific clusters of patient services that offer opportunities for healthcare providers to perform services based on best practice. It is suggested that when organizations adopt clinical evidenced-informed practices, quality patient care will flourish, while also increasing system efficiencies and decreasing costs (Ontario Health Association, 2013). One of the procedures covered under QBPs is Pediatric Tonsillectomy, with or without Adenoidectomy. The Quality-Based Procedures Clinical Handbook for Paediatric Tonsillectomy with and without Adenoidectomy (2013) articulates the specific evidence-based components of care that should be provided for these patients from pre- to post-operation. The Director of Women and Childrens Health indicates that practice variation, lack of standardization, lack of evidenced-based practices, and physician resistance all contribute to the organizations inability to enact QBP standards for this procedure since it was issued in 2014. Specifically, no standardized pre-screening tool exists to assess for complications prior to surgery. In particular, children are neither assessed nor properly diagnosed with obstructive sleep apnea syndrome (OSAS) using a sleep study, the gold standard. This assessment, however, is vital since OSAS patients have a high risk of postoperative respiratory complications (Le ong Davis, 2007). On the day of surgery, it is not standard that patients receive a pre-operative acetaminophen loading dose for prophylactic pain management. Some anesthesiologists vocalize their discomfort with administering acetaminophen rectally, while others are not aware of the significant impact of this administration on post-operative pain management. The American Academy of Otolaryngology Clinical Practice Guideline for Tonsillectomy in Children states that rectal administration is better tolerated than oral administration and is the most effective in reducing pain and opioid requirements following surgery (Baugh et al, 2011). In addition, children with adequate acetaminophen analgesia have less post-operative nausea and vomiting. Both the Director and Educator of Pediatrics argue that physician resistance has been a significant barrier to implement QBP standards (Cathie Boudeau, personal communication, April 27, 2015). Nonetheless, both the surgical and pediatric nurses have disclosed that they look forward to changes that encourage standardization and quality patient care. The Educator has explained that she has already began drafting a post-operative standardized PPO form, which has, surprisingly, gained significant approval by physicians. Therefore, the Educator has requested the writer focus on standardizing the pre-operative experience. Currently, patients and families receive a Pre-Operative Information Sheet. The Educator has noted, however, that this form does not align with QBP advisement. In addition, families have vocalized that the sheet should be more comprehensive and visually appealing. In addition, a standardized pre-assessment form to screen for complications needs to drafted. Changing behaviour in regards to administration of pre-operative acetaminophen will also be considered in this project. The Quality-Based Procedures Clinical Handbook for Paediatric Tonsillectomy with and without Adenoidectomy (2013) will be used as the reference to create a Pre-Operative Information Sheet for families and patients, as well as a pre-assessment checklist to screen for complications. In order to encourage adoption of all new changes and to change behaviour, knowledge of change management is imperative. Therefore, a literature review was conducted to guide the implementation of this project. Inclusion criteria parameters for the literature search included the years 1995 to 2015. Search terms included organizational change, management of change, and change management. Databases used were MEDLINE, PubMed, and CINAHL. Many articles were retrieved (about 300 hits). The search was then narrowed to focus on health care and hospitals. Roughly 145 articles were reviewed. Empirical studies were assessed for clarity of methodology, peer review, and external evaluation. Finally, the number of articles was narrowed down to 45, which met the specific criteria for change management in health care. Change management literature draws from a wide range of disciplines, as well as theoretical and organizational perspectives, such as psychology, sociology, business policy, and social policy, creating a complex and robust body of evidence which is challenging to appraise and synthesize. Furthermore, the literature contains numerous and varying frameworks, models, evidence, and illustrations; that may describe, analyze, guide, approach, and test initiatives, programmes, and tools for change. There are no frameworks or models of change unique to healthcare organizations although several models are conducive to change efforts in these areas. Therefore, the literature that was reviewed focused on dominant change management models that are often applied to health care organizations. Furthermore, some models are used primarily for higher levels of leadership. For the purpose of this project, literature focusing on micro-level processes was selected. Case studies, surveys, and pilot studies are the most common methodologies in change management literature. While these methodologies are considered low on the evidence hierarchy, due to the limited ability to control subjects in healthcare, these methodologies do seem the most realistic and accessible means of implementing and evaluating change. Within the literature, one of the most influential perspectives of change management originates from the planned approach created by Lewin in 1951, which argues that change occurs in three progressive stages: unfreezing current behaviour, moving to the new behaviour, and refreezing the new behaviour (Elrod Tippett, 2002). For many years this three-step model has been the dominant approach to organizational change. Critics argue, however, that planned theories are based on the assumption that organizations act under constant conditions that can be controlled and planned for. As a consequence, an alternative approach, namely an emergent approach was developed. This approach considers change to occur so rapidly and unpredictably that it cannot be managed from the top down. Instead, it is argued that change is a process of learning, whereby the organization responds to both internal and external changes (Barnard Stoll, 2010). This approach speaks to the concepts of change readiness and facilitation of change which are viewed as superior to the planned approach with specific pre-planned steps for change initiatives (Todnem, 2005). Nonetheless, emergent approaches do suggest that a sequence of actions should be enacted to increase the likelihood of change being successful (Luecke, 2003). Emergent theories assume that in order to respond to change, managers of change have to have possess a in-depth understanding of the organization, its structures, strategies, people and culture. With this understanding, managers of change are able identify the most appropriate approach to change while recognizing possible facilitators and barriers (Burnes, 1996) The literature argues that while these two approaches are often cited to be polar opposites, it is important to note that they are theoretical approaches. Therefore, the best strategy for organizations to manage change is to utilize both these approaches, in the form of frameworks or models that best meets the particular needs of the organization (Burnes, 2004). When the variety of frameworks, models, and approaches to change management are applied to health care organizations, common trends emerge. These trends include environmental circumstances, organizational harmony, power dynamics, organizational capacity, nature of change, and process of change (Antwi Kale, 2014). Environmental circumstances include the external conditions to the organization that forces change, such as increased competition and technological innovation (Lau, 1999). Organizational harmony illustrates an agreement among individuals and units within the organization. All members should have congruent missions and visions and be working collaboratively towards the same goal. Further, overall organizational plans, processes, and goals should also be compatible (Antwi Kale, 2014). Power dynamics refers to the hierarchy of influence within an organization. Understanding which individuals can influence the change process is important. Change leaders should have buy-in from these individuals before undertaking a change initiative; this will increase likelihood for success (Mitchell, 2013). Organizational capacity indicates that the organization has the necessary human and financial resources to undergo change. Moreover, it is essential that the necessary skill sets and knowledge be present to allow change to occur (Bazzoli, Dynan, Burns, Yap, 2004). Nature of change refers to the rationale behind a change initiative. Change initiatives must consider an organizations external and internal situation. Furthermore, ample evidence must be available to justify that a proposed plan for change has the ability to solve a presented problem (Antwi Kale, 2014). Finally, process for change is the actual step-by-step approach to implement a change. Change leaders must make certain that these steps are agreed upon by all stakeholders and evidenced to create the desired change (Antwi Kale, 2014). The Canadian Health Services Research Foundation (CHSRF)s Evidence Informed Change Management Approach was chosen to be the main model to guide the project as it contains all of the mentioned concepts. In addition, it is structured around specifically targeting the needs of Canadian healthcare organizations and outlines change as it pertains to micro level contexts. The approach presents a practical model for change management and contains four stages: planning, implementing, spreading, and sustaining change (CHSRF, 2012). The planning stage of change involves understanding the context and influential forces of change while determining the organization ability or readiness to change. To understand the context, change managers must determine which steps and people need to be involved to implement change and garner support. Readiness and capacity for change is determined by assessing all individuals at any level of the organization and considering how they will be affected by the chang e. Furthermore, the capacity for the organization, for example, financially, to undergo change, needs to assessed. After the planning stage, change agents can implement change by executing their planned approach. Spreading change entails promoting change beyond its initial context and influencing the culture to introduce new customs, traditions, and ways of practicing. Lastly, sustaining change entails surveying and modifying the change process as practical experience is gained over the course of implementation. The literature also emphasizes that the key to successful change management is strong leadership. Gill (2002) explains that effective change leaders are able to frame the change in terms of results for all involved. Further, change leaders foster and create environments that allow people to experiment with new ways of practicing. This coincides with the Leadership Competency from the Canadian Nurses Associations Advanced Nursing Practice National Framework (2008). Learning about a patients experience and collaborating with other interprofessional disciplines assisted in identifying gaps in care, specifically the lack of adoption of QBP standards for Pediatric Tonsillectomies, resulting in practice that is not evidence-based and negatively impacts patient care delivery. In addition, while changing practice has been attempted in the past, the application of knowledge learned from the competition of a literature review on change management and discovery of an influential model on change , the writer can be successful in enacting a new and effective means of practicing, ultimately improving patient care. Also, the specific nature of this projects focus, to ensure QBP standards are followed, which promotes advocating for system efficiency, quality patient care, and low cost, aligns with the leadership competency of understanding and integrating the principles of resource allocation and cost-effectiveness in all levels of decision-making (CNA, 2008). Literature on change management is diverse and robust, with applicability to health care organizations. In this literature, it is apparent that in order to manage change specifically in healthcare, a model or approach needs to be selected to address an organizations specific needs and current issues. Understanding the organization as a whole and the people within it is an imperative and first step in planning change. Collaborative work among change managers and targets of change will ensure readiness for change, ease of implementation, and sustainability (World Health Organization, 2010). In addition, strong leadership is a significant component of organizational change, laying the foundation to support the change through its continuum. Utilizing these concepts and knowledge will be imperative in guiding the implementation of QBP Standards for Pediatric Tonsillectomies with and without Adenoidectomies at Credit Valley Hospital. References Antwi, M. Kale, M. (2014). Change Management in Healthcare. Queens School of Business.  Retrieved from http://business.queensu.ca Barnard, M. Stoll, N. (2010). Organizational Change Management: A rapid literature review. Centre for Understanding Behavioural Change. Retrieved from http://www.bristol.ac.uk/media-library/sites/cubec/migrated/documents/pr1.pdf Bazzoli, G., Dynan, L., Burns, L. Yap, C. (2004). Two Decades of Organizational Change in Health Care: What Have we Learned? Medical Care Research and Review, 61(3). doi: 10.1177/1077558704266818 Baugh, R., Archer, S., Mitchell, R., Rosenfeld, R., Amin, R., Burns, J., Patel, M. (2011). Clinical practice guideline: Tonsillectomy in children. Otolaryngology Head Neck Surgery, 144(1),p 30. Burnes, B. (2004). Emergency change and planned change- competitors or allies? The case of XYZ construction. International Journal of Operations Production Management, 24(9), p 886-902 Burnes, B. (1996) No such thing as a â€Å"one best way† to manage organizational change. Management Decision, 34(10), p 11-18 Canadian Health Services Research Foundation. (2012). Evidence-Informed Change Management in Canadian Healthcare Organizations. Retrieved from http://www.cfhi fcass.ca/Libraries/Commissioned_Research_Reports/Dickson-EN.sflb.ashx Canadian Nurses Association. (2008). Advanced Nursing Practice: A National Framework. Ottawa, Canada : Canadian Nurses Association Elrod, P. Tippett, D. (2002). The death valley of change. Journal of Organizational Change  Management, 3. p 273-291 Gill, R. (2002) Change management- or change leadership? Journal of change management,  3(4), p 307- 318. Lau, A. (1999). Making sense of contemporary strategic implementation: towards a conceptual  model. Public Administration Management, 4(4), p 494-507 Leong, A., Davis, J. (2007). Morbidity after adenotonsillectomy for paediatric obstructive  sleep apnea syndrome: waking up to a pragmatic approach. The Journal of Laryngology and Otology, 121, 809-817 Luecke, R. (2003). Managing Change and Transition . Boston, MA: Harvard Business School Press  Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing  Management, 20(1). Ontario Hospital Association. (2004). Toolkit to Support the Implementation of Quality-Based  Procedures. Retrieved from https://www.oha.com/KnowledgeCentre/Library/Toolkits/Documents/OHA_QBProcedur es_toolkit_FNL.pdf Provincial Council for Maternal and Child Heath Ministry of Health and Long Term Care. (2013). Quality-Based Procedures Clinical Handbook for Paediatric Tonsillectomy with and without Adenoidectomy. Retrieved from www.health.gov.on.ca/en/pro/programs/ecfa/docs/qbp_tonsil.pdf Todnem, R. (2005). Organizational Change Management: A Critical Review. Journal of Change Management,5(4), p 369-380. Trillium Health Partners. (n.d.). Who We Are. Retrieved from  http://trilliumhealthpartners.ca/aboutus/Pages/Overview.aspx World Health Organization (2010). Framework for action on interprofessional education and  collaborative practice. Geneva, Switzerland: World Health Organization.  http://whqlibdoc.who.int/hq/2010/WHO_HRH_HPN_10.3_eng.pdf

Excersise speech Essay

Informative / PowerPoint Speech Formal Outline TITLE: Exercise GENERAL PURPOSE: To inform my audience about exercise. SPECIFIC PURPOSE: To inform my audience about types of exercise, Benefits And long lasting effects. THESIS/MAIN IDEA: Exercise has many heath benefit and can affect your life in the most positive of ways. INTRODUCTION I. Types of exercise II. Benefits of exercise III. Long lasting effects of exercise Do you get 30 minutes of exercise daily? Less than 5% of adults do. Being informed about the types of exercise, benefits of exercise and long lasting effects of exercise could improve the statistic drastically. BODY I. Types of exercise A. Cardio 1. Work out that raises the heartbeat. 2. Ex: jumping jacks, running, dancing, and pretty much anything that gets you heart beat going. 3. Some of the cardio I like to do is running, and basketball. B. Weight lifting 1. Work out to tone and build muscles. 2. Ex: Bench pressing, dumbbell exercises, dead lifts, squats with weights. 3. There is a great Importance of lifting correctly. You should always have a large amount of knowledge about the lift you are going to do, to avoid injuries. For example when doing a squats with weights you should have you feet shoulder with apart and when you squat down you should keep a straight back and bend your knees to a 90 degree angle lifting back up with your legs. 4. My favorite part of weight lifting is being toned, some like to lift to gain big muscles, and some do it to keep their muscles toned and  healthy. C. Aerobics 1. Vigorous exercises, swimming, and walking. 2. Aerobics are typically for people that have issues with high impact exercise. 4. Aerobics are a good beginning exercise to develop the body to be able to do more strenuous exercises. 5. When you are doing daily things such as walking, sweeping, or going up stairs it is a great opportunity for exercise. You can walk swiftly, sweep while moving you abs from left to right, and going up stairs at a faster pace. There are many ways to include exercise in your daily activities. II. Benefits of exercise A. Benefits of exercise 1. Exercise combats health conditions and diseases 2. Exercise improves mood 3. Exercise boosts energy 4. Exercise controls weight B. Improving mood 1. Exercise improves your mood because it stimulates various brain chemicals or endorphins that may leave you feeling happier and more relaxed 2. You may also feel better about yourself because with exercise you will look healthier and that may boost you self-esteem. D. Controls weight 1. Getting the recommended 30 minutes of exercise daily or even 2-3 times a week can help keep you body healthy inside and out. 2. For people looking to lose a large amounts of weight it is a good idea to consult a doctor about an exercise plan that would work for them. III. Long lasting effects of exercise A. Exercise has great benefits for your heart for later in your life. 1. It  helps heart health because when you exercise it strengthens your heart by ejecting more blood per beat, even at rest, and that causes less stress on your heart. 2. Less chance of heart disease 3. Less chance of heart attack B. when you exercise your body uses more energy making your metabolism work faster and more efficiently. 1. And Higher metabolism leads to Healthier weight C. Exercise can help people have longer lives. 1. Exercise leads to a longer life because when your heart is healthy, your metabolism is working efficiently and you have a healthy weight your body will be under less stress. 2. People who worked out 3 times a week in a Mayo Clinic study had fewer wrinkles, healthy heart, less stress, and had a healthier weight than those who did not workout. CONCLUSION I. 2013 statistics show that only 5% of adults get 30 or more minutes of daily exercise; And, as have already stated, there are many easy ways to exercise. There are many benefits from exercising and long lasting effects from exercise. If people are properly informed about exercise then there should be an increase in the percentage of adults that exercise in today’s society. REFERENCES www.Mayoclinic.org www.Vigurousexercize.com www.karmajello.com

Synopsis of a Phrase: You Don’t Know What You Have Until It’s Gone

â€Å"You don’t know what you have until it’s gone† Like an old saying â€Å"You don’t know what you have until it’s gone†. For some people these are just words, but for others it’s really more a life changing phrase. To me this phrase are more than just words. I question myself every time I see or hear about mother’s abandoning their children’s. I really can’t understand what come across their minds to make a life changing decision. Every woman who has the blessing of having children’s should be grateful, because not every woman has the glory of giving birth.I can’t comprehend leaving behind a part of you like if it didn’t exist, that is just outrages. But then again life in some way or somehow it comes back and haunts you, it’s all about karma. This is where the old saying of â€Å"You don’t know what you have until it’s gone†, kicks in then it’s too late to try to regain what you had back then. As I grew up as a teenager I always had in mind that I wanted to have a boy first and then a girl as my own children. Well, God heard my wishes and made them true, but not knowing that later on in my life I was going to wish that I hadn’t made that petition.I had my son at age 17 and my daughter at age 19, years passed by and simply no more pregnancies came along. I was divested as well as my husband we wanted to have more family. Apparently it just wasn’t going to happen I was diagnosed with PCOS (Polycystic Ovarian Syndrome). The possibilities of getting pregnant were between 2% to 5% which let’s be honest, â€Å"Not enough†. Pretty much I become infertile, but I had set my mind if these are Gods wish let them be. I was already so grateful in having my two kids. I’m not going lie I still had that wish of becoming mother again back in mind.I have a sister who had a beautiful daughter two years ago. I was hopi ng for my sister to change for good, since she was more into going out with friends, boyfriends, and anything relate to being irresponsible. The first year seemed to be okay even though she still went out. In the beginning of the second year she started to complain about having her daughter. She would say, â€Å"I wish I have never had you†. How can she possibly say this, she is only an â€Å"innocent little girl† who didn’t ask to be brought to this world. I spoke to my mother about this situation.I simply couldn’t let this go on. My mother said, â€Å"I will not let this happen again†. My mother did actually speak to my sister, she obviously didn’t like that so she called me up and said, â€Å"I’m leaving the house and I’m giving the baby away to someone†. I said â€Å"No you are not†! Give her to me, I said. My sister answers back by saying, â€Å"Well, come for her now or I will give her away†. So I eag erly left to my mother’s house. I had to tell my sister, that I hope you never ever regret what you are doing. This is when I brought up the old saying, â€Å"You don’t know what you have until it’s gone†.Some day you will be begging for the forgiveness of your daughter and this is when you will realize that what you did was wrong and it will be to late. At the end I tried to understand why she took this decision. What was going thru her mind? I just can come with an answer. I’ve tried every possible method of getting pregnant and here she comes and leaves her daughter like nothing as if she never carried her in her stomach for 9 months. By the way I was present in the baby’s birth. It was wonderful reliving the moment when I gave birth to my children.Now I’m going thru the moment of seeing my niece being abandoned by her insensitive mother. This really breaks my heart by seeing my little niece looking for her mother and not finding h er. To me this kind of people should not have the blessing of being a mother, if in some way you can call them mothers. While other women try and wish they could be mothers. We should have more conscious in what we do and the consequence that later in life will bring us. We should treasure what we currently have and not wait until it’s too late to realize what slip away from our hands. Life is to short to make wrong decisions.

Fake Friends or True Friends - 821 Words

FRIENDS: friend or foe? Friends are extremely important and friendship is a major part of our lives. If there’s one thing we can all agree on, it’s that friends are awesome. Having friends is similar to having family. During the good times and the bad, through thick and thin, your best friends are there for you. They are the people that you can count on in your greatest time of need. They can help you in times of trouble, and be there to enjoy and share the great parts of your life too. Our friends are the people we can rely on to give us the much needed support and comfort that we all seek in life. Knowing that you have friends is a wonderful feeling but something that we learn a lot about us as we get older is our two types of†¦show more content†¦In fact, they may refuse or feel burdened if they do anything for you Real: Will offer to help before you even ask and if you do ask, they help out, willingly and without resentment Fake: Talks about you behind your back Real: If they have a problem with you, they discuss it, face to face, and in a respectful and mature manner. Fake: One-dimensional. They see only their needs and is oblivious to needs of others. They often use you as a sounding board and you rarely get a word in. Real: They are in-tune enough to sense your pain, your needs and are supportive. They are the type who listens attentively and with concern and interest. Each of you will have your time to vent and be heard. It won t be one-sided as it is with a fake friend. 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The Birth Date Of Football - 1200 Words

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Canada s Health Care System - 973 Words

Canada’s health care system is one that formed in the 1950s and 60s, also known as Medicare. It is a system that Canada as a nation often takes pride in, as it is predominantly public with basic health care is available to all citizens, and has some aspects of the private system incorporated as well. Health care often occurs in terms that compare public versus private health care systems. After a thorough analysis of private health care associated with neo-conservatism, and public health care associated with welfare state liberalism, I assert that the more beneficial option for Canada would be public health care. Public health care is very accessible, and universal, therefore allowing the individual to have access to health care nation-wide. As well, it is significantly more affordable than private health care when concerning the average Canadian citizen. Although, it can be argued that private healthcare is a better option for Canada because it would improve the quality of he alth care, offering quicker access it, and it reduces the amount of stress put on the upper class in paying for public health care. However, privatization acts as a barrier to providing universal and quality health care on an equitable basis. To understand why public health care is a more fitting choice for Canada, one must understand the relationship between the welfare state and public health care, and why liberals advocate for public health care. In Canada, public health care is a system of whichShow MoreRelatedCanada s Health Care System931 Words   |  4 PagesMaintaining the health of the nation is one of the priorities of societies throughout the world. Canada s health care system is an essential value for Canadians because it provides them equal rights when getting access to government-funded medical care. 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Charles Dickens Bleak House Essay Example For Students

Charles Dickens Bleak House Essay Chancery, The Parasite That Plagues the Victorian SocietyIn Charles Dickens Bleak House, Chancery is portrayed as a disease that plagues the Victorian society. Dickens uses the suits and the lawyers of Chancery to display its effects on the whole society. The suits are â€Å"slow, expensive, British, constitutional kind of things† (25) that stifle and bemuse those that come in contact with them. In Ms. Flite’s case, the suit has deteriorated her life. She attends Chancery regularly expecting a judgement that is never to come and yet, she lives a â€Å"pinched† (73) lifestyle, unable to help herself or others. In addition, she cages birds she intends to set free on her judgement day, however, she states, â€Å"I positively doubt sometimes whether while matters are still unsettled I may not one day be found lying stark and senseless here, as I have found so many birds!† (74). Like Miss Flite, the suit has stagnated Robert’s life. Robert, â€Å"So young and handsome, and in all respects so perfectly the opposite of Miss Fliteis so dreadfully like her† in his clouded, eager, and seeking mannerism (592). Under the misconception that the suit â€Å"can’t last forever† (599), Robert dec lares, â€Å"I am young and earnest; and energy and determination have done wonders many a time†¦I devote myself to the suit. I make it the object of my life† (599). As a result, this suit not only causes Robert to loose himself, but his misplaced suspicions cause him to loose his sound relationship with Mr. Jarndyce. â€Å"The one great principle of the English law is, to make business for itself†¦viewed by this light it becomes a coherent scheme† (621) of which lawyers are the key players. Mr. Vholes, Robert’s lawyer, â€Å"always looking at the client, as if he were making a lingering meal of him with his eyes as well as with his professional appetite,† (624) dupes Robert into believing that he needs him for his suit. This â€Å"respectable† lawyer tells Robert that because he is represented he will have a voice in the legal system, however, it means nothing for Robert’s suit. Thus, these false hopes told to Robert by his lawyer eventually results in his melancholy death. â€Å"Make man-eating unlawful, and you starve the Vholeses,† (623) however, Mr. Vholes is only one type of lawyer. Mr. Tulkinghorn, â€Å"reputed to have made good thrift out of aristocratic marriage settlements and aristocratic wills,† (23) leads to Lady Dedlock’s demise. Mr. Tulkinghorn wished to display his power over Lady Dedlock (a representative of the aristocratic class) thus, he blackmailed her. In Lady Dedlock’s own words, â€Å"I am to remain upon this gaudy platform, on which my miserable deception has been so long acted, and it is to fall beneath me when you give the signal† (659). Mr. Tulkinghorn’s desire to know the secrets of the aristocratic leads him to deceive, bribe, threaten, blackmail and eventually kill others. One unfortunate soul used by Mr. Tulkinghorn is Joe. He bribes Joe to confess about Lady Dedlock’s visit to him disguised as her maid. Later, he hires Inspector Bucket who says, â€Å"Don’t you be afraid of hurting the boy†¦it’s all right as far as the boy’s concerned†¦he’ll be paid for his trouble, and sent away again†¦it’s the best and wisest way to keep little matters like this quiet†(356). This inspector kidnaps Joe, bribes him, threatens him to stay away from London and leaves him to fend for himself. However, Joe falls ill and returns to London where he eventually dies. Thus, Dickens successfully portrays how Chancery diminishes people’s way of life, whether they are of a lower class like Joe and Ms. Flyte, or are of an upper class like Robert and Lady Dedlock. I personally believe that the message is that the cause and the need for change are present and people need to work together despite their differences or social classes to bring on the necessary change. .u2ff2d108cbd1526359bdc27da41a49cb , .u2ff2d108cbd1526359bdc27da41a49cb .postImageUrl , .u2ff2d108cbd1526359bdc27da41a49cb .centered-text-area { min-height: 80px; position: relative; } .u2ff2d108cbd1526359bdc27da41a49cb , .u2ff2d108cbd1526359bdc27da41a49cb:hover , .u2ff2d108cbd1526359bdc27da41a49cb:visited , .u2ff2d108cbd1526359bdc27da41a49cb:active { border:0!important; } .u2ff2d108cbd1526359bdc27da41a49cb .clearfix:after { content: ""; display: table; clear: both; } .u2ff2d108cbd1526359bdc27da41a49cb { display: block; transition: background-color 250ms; webkit-transition: background-color 250ms; width: 100%; opacity: 1; transition: opacity 250ms; webkit-transition: opacity 250ms; background-color: #95A5A6; } .u2ff2d108cbd1526359bdc27da41a49cb:active , .u2ff2d108cbd1526359bdc27da41a49cb:hover { opacity: 1; transition: opacity 250ms; webkit-transition: opacity 250ms; background-color: #2C3E50; } .u2ff2d108cbd1526359bdc27da41a49cb .centered-text-area { width: 100%; position: relative ; } .u2ff2d108cbd1526359bdc27da41a49cb .ctaText { border-bottom: 0 solid #fff; color: #2980B9; font-size: 16px; font-weight: bold; margin: 0; padding: 0; text-decoration: underline; } .u2ff2d108cbd1526359bdc27da41a49cb .postTitle { color: #FFFFFF; font-size: 16px; font-weight: 600; margin: 0; padding: 0; width: 100%; } .u2ff2d108cbd1526359bdc27da41a49cb .ctaButton { background-color: #7F8C8D!important; color: #2980B9; border: none; border-radius: 3px; box-shadow: none; font-size: 14px; font-weight: bold; line-height: 26px; moz-border-radius: 3px; text-align: center; text-decoration: none; text-shadow: none; width: 80px; min-height: 80px; background: url(https://artscolumbia.org/wp-content/plugins/intelly-related-posts/assets/images/simple-arrow.png)no-repeat; position: absolute; right: 0; top: 0; } .u2ff2d108cbd1526359bdc27da41a49cb:hover .ctaButton { background-color: #34495E!important; } .u2ff2d108cbd1526359bdc27da41a49cb .centered-text { display: table; height: 80px; padding-left : 18px; top: 0; } .u2ff2d108cbd1526359bdc27da41a49cb .u2ff2d108cbd1526359bdc27da41a49cb-content { display: table-cell; margin: 0; padding: 0; padding-right: 108px; position: relative; vertical-align: middle; width: 100%; } .u2ff2d108cbd1526359bdc27da41a49cb:after { content: ""; display: block; clear: both; } READ: Spaniard Quietist Miguel De Molinos EssayBibliographyBleak House, Charles DickensEnglish Essays