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AU Intelligent Security System Using Password to Lock & Unlock Devices Research Paper

AU Intelligent Security System Using Password to Lock & Unlock Devices Research Paper.

Requirements:Design and implement an appropriate security system, defining or identifying the architecture and threat mitigation tools that should be applied.Section 1: Statement of the Problem and its Setting (Citations are required)Section 2: Hypotheses and/or Guiding Questions Section 3: Assumptions Section 4: Delimitations and Limitations Section 5: Importance of the Study Section 6: Review of the LiteratureSection 7: Outline of the Proposed Study (Steps to be taken, timeline, etc.) Section 7: ReferencesPower Point Slides:Section 1: Statement of the Problem and its Setting (Citations are required)Section 2: Hypotheses and/or Guiding Questions Section 3: Assumptions Section 4: Delimitations and Limitations Section 5: Importance of the Study Section 6: Review of the LiteratureSection 7: Outline of the Proposed Study (Steps to be taken, timeline, etc.) Section 7: ReferencesAPA FORMAT, MUST BE ORIGINAL & NO PLAGIARISM
AU Intelligent Security System Using Password to Lock & Unlock Devices Research Paper

Morocco Electoral System And Promise Of Democracy Politics Essay. Morocco is one of the few Middle Eastern countries that has a considerable amount of freedom and an outstanding human rights record compared to the rest of the Arab world. From the post colonial period, Morocco was among the few Arab countries that adopted pluralism instead of a one party system or a monarchy without parties. Nevertheless, the amount of freedom and reform was not enough to bring complete democracy that reflects the needs of the Moroccans. The recent parliamentary election in 2007 shows Morocco as one of the few Arab countries that is on the track towards democracy, shown by the transparency of the election and the king’s recruitment of the prime minister from the winning party instead of a technocrat from his own entourage, as in the election of 2003. However, the low voter turnout of 37% [1] underscores the political apathy of the Moroccan citizens as well as their cynicism toward political life, as they view the parliament as an ineffective tool as long as the king interferes with the legislative, executive and judicial branches. As any other country in the Middle East, Morocco is also experiencing the rise of Islamist parties due to their promise of reform, the ineffectiveness of both the conservative and socialist parties in changing the status quo, and the rampant corruption in the administration. The electoral system used in Morocco, proportional representation, which allows for multimember districts and an electoral formula that allows for smaller parties to enter the parliament, is preventing a single party from gaining a majority that might allow it to form a government therefore obliging it to make coalitions with other parties. This situation allows the king to have utmost power in political life and serves also to prevent any Islamist party from forming a government in Morocco. However, the Islamist party, PJD (Justice and Development Party), did not win the majority of seats as was predicted, this fact underscores that Moroccans might be unhappy with the current political system but not to the extent of allowing an Islamist party to govern them. In order for the democratic gains to continue, the king must be willing to give up some of his rights to allow for complete liberation and freedom. Moreover, the United States and the European Union must be ethical and honest instead of just complimenting the country and describing its election as transparent and democratic because of their fear that the Islamists will win in case of complete democracy. [2] After Morocco gained its independence from France in 1956, the political system did not change from that before colonization: a monarchy ruled by the same dynasty Alaouites. However, King Mohamed V made sure after independence to establish a constitutional monarchy and prevented the leading party in the struggle against the French colonization for independence, the Independence Party (PI), from forming a single party system by not allowing it to have full control over the country. The first post independence election was won by a progressive party: USFP (The Socialist Union of Popular Forces), a party that split from the Independence Party, nevertheless, the king dismissed the USFP cabinet and assumed power by relying on rural notables and security apparatus [3] . In 1961, Hassan II became the king of Morocco and brought with him new changes to the monarchy that extended his father’s method, in Hassan’s case by running as the prime minister as well as the king, in addition to naming the cabinet. In the second year of his reign he launched a referendum for a new constitution, which allows him to be a central figure in the system, in addition to forming a bicameral system which has legislative powers that is controlled by the king. The first experience of Moroccans with elections was in 1963 in which the supporters of the king won. However, following series of failed coup d`etats and violent manifestations in 1965, the king took control of both the executive and legislative powers. Even after the coming back of calm in 1970 immediately after the election, two other failed coups d`etats, which were executed by military generals and politicians who were opposing the monarchy and looking for a republic, occurred which made the king reconsider his decision to democratize the country. [4] During the reign of Hassan II the record of human rights violations in Morocco was unbelievable, especially in the years of lead that lasted for almost 30 years, from 1961 till the end of the cold war in 1989. The violation of human rights varied from torture, forced disappearance, killing, imprisonment without a fair trial, death in detention, and forced exile…Those intimidations from the regime were directed to those who opposed the king or proved to be a menace to the stability of the monarchy, mainly the parties with communist agenda as it is stated by Ottaway and Riley: Hundreds of palace opponents were abducted and “disappeared,” and thousands were imprisoned and sometimes tortured. Victims included anyone perceived as a threat to the regime: The majority was made up of leftists, but Islamists, advocates of Western Saharan independence, and military personnel implicated in several unsuccessful coups all experienced their share of repression. [5] In addition to the mentioned targeted groups, the minorities that asked for independence like the Riffains (Northern Berbers) were also subject to repression from the king as well as the military officers who were responsible for the three failed coup d etat, by impersonating them in secret prisons in remote areas of Morocco like Tazmamart and Agdiz. The prisoners endured very inhumane and atrocious conditions such as mal nutrition, Lack of sanitation in addition to the prevalence of rats and scorpions in their cells… It is also worth mentioning that the abuse did not only cover the leftist opposition and the military officers but also their families. For instance, when Mohamed Oufkir was caught red handed in the coup d’etat of 1972 not only was he tortured, though the regime pointed out that he committed suicide, but his whole family was also detained in the Fortress of Bir-Jdid in the desert and was not released until 1991 owing to US and European pressures on the king. [6] However, during the last decade of king Hassan’s reign he introduced some reforms, such as allowing opposition parties to lead the government, to promote democracy and liberalization especially after the end of Clod War and the pressure from the European Union by using economic aid as a toll to motivate the Moroccan regime to advocate political liberalization as well as making sure to prevent Morocco from becoming another Algeria, as Ottaway and Riley noted: External pressure on the monarchy to conform to the new trend mounted, particularly in 1992 after the European Parliament denied Morocco an aid package because of its poor human rights record. Furthermore, the example of neighboring Algeria, plunged into a bloody war between security forces and Islamists who had turned to violence after being deprived of an election victory, provided a sharp reminder of the new vulnerability of authoritarian political systems. [7] Among the most important reforms was one that brought an alternation in power for the first time in the Arab world, where a government is going to be led by an opposition coalition of parties of USFP, PI, and other progressive parties. Moreover, Hassan II also introduced reforms to improve the human rights record of Morocco by founding “a human rights council, Conseil Consultatif des Droits de l’Homme (CCDH), and later on the Ministry for Human Rights; the release of some political prisoners; the reform of laws on preventive detention and public demonstrations; the ratification of major international human rights conventions; and the formation of a special committee to investigate forced disappearances.” [8] In addition to a considerable increase of the power of parliament and political parties and introducing measures to fight corruption, Induced by the World Bank report that pointed to the impediments that corruption has on foreign investments and economic development of Morocco. [9] After the death of Hassan II in 1999, his son Mohammed VI ruled Morocco, ending the oppressing years of his father which were called “the years of lead,” [10] and bringing about new reforms that liberalized the country. [11] First, the king recognized the importance of reforming the family code and improving the status of women by adding more rights for them, restricting polygamy, and allowing Moroccan mothers to give Moroccan citizenship to their children from non-Moroccan fathers. [12] Second, the king pardoned a number of political opponents to the regime, like the leader of the banned Moroccan Islamist movement (Justice and Charity Party) Abdessalam Yassine and the communist Ibrahim Serfati. The King also formed the Independent Arbitration Commission (Instance d`Arbitrage Independante — IAI) in 1999, which will review cases of abuse and torture during the reign of his father and compensate victims. [13] However, the reforms did not transform Morocco in a full democratic country, as most of the rights gained were later taken back after the terrorist attacks of May 16th 2003 which paved the way for the parliament to pass the Anti-Terrorism Law which allows the state to limit freedom of citizens, for instance, regarding press criticisms of the palace as a terrorist act. [14] This resembles the Patriotic Act passed in the United States after September 11th under the pretext of fighting terrorism. The electoral system in Morocco is List Proportional Presentation using the highest remainder formula. The elections are held on the parliamentary level which has two chambers: the Chamber of Counselors with 270 seats and the Chamber of Representatives with 325 seats. In the first chamber the 270 members are elected by local councils, professional organizations and labor syndicates to serve nine-year terms with one third of the members renewed every three years. In the second chamber, the 325 members are elected through party list to serve five years in addition to 30 seats guaranteed for women. The threshold for a party to be represented in the parliament is 6%. Morocco has 95 multi-member electoral districts in which representatives compete for a maximum number of 5 seats and a minimum of one depending on the size of the district in a closed party list. As the electoral formula is highest remainder, it is difficult for a strong party to win more than one seat in each district and easy for smaller parties to win some seats, as noted by Michael McFaul and Tamara Cofman Wittes, “the remainder rule makes it very difficult for any party to win more than one seat per district.” [15] Due to the complicated electoral system used in which The seat allocations are made through a complicated “remainder system” run by local magistrates who determine the “threshold number” needed to win a seat in a particular district. After the top vote-getting parties have been allocated one seat each, the threshold number is subtracted from their vote totals, and the rest of the seats are allocated to parties according to their remaining vote totals, in descending order. [16] Basically what this means is that it is hard for any party to get more than one seat in each district as noted in the Economist article: The new rules by which this parliament is being elected …divide the country into 95 districts, allotting an average of three deputies to each. By a party-list system with proportional representation that works at district level, the best-scoring party wins a seat for the first candidate on its list. But to take a second seat, it must have won at least twice as many votes as any other party. [17] So winning more than one seat in a given district is difficult if not impossible under this electoral formula. This law goes on the side of the king, as it is “a roadblock against Islamists” [18] and also a “means of ensuring that the monarch can `pull the strings` of political life for as long as he wishes.” [19] Since the reign of Mohamed VI, Moroccans have experienced two parliamentary elections that have been described as highly transparent and uncorrupted compared to the elections in the years of Hassan 2nd. The first election was in 2003, in which none of the major parties won a majority, with the USFP winning only 50 seats out of 325, the PI 48 and the PJD 42. The election results led the king to choose his prime minister from his entourage, Driss Jetto, a technocrat with no political affiliation [20] . This choice has angered a lot of parties, especially the PI as it has been supposed to lead the government according to the principle of alternation that was brought by Hassan II in the election of 1997 but not enough to show it. The election also put the Islamist party, the PJD, to the forefront, as it came in third place for seats number in the parliament. The election outcome induced parties to make coalitions and gave smaller parties a kind of power to exert over the biggest parties, by influencing the biggest party they are allying with to support some of their policies. The recent election of 2007 added new elements to the political life in Morocco. According to the media and foreign observers, this has been one of the most transparent elections in Morocco. However, the results were not very promising as none of the parties won a majority due to the high number of parties that participated in the election, 33, which made it impossible for any party to win 50% of the seats. Therefore, the elections resulted in establishing the PI as the winning party but with only 48 seats, while the PJD came in second with 46 seats. The most surprising result was the results for the USFP, the biggest leftist party in Morocco, which decreased from the second position in the 2003 elections to fifth place in the 2007 elections. Concerning the Islamist party, there was a huge debate for whether the PJD would get a lot of seats, just as like Hamas in Palestine. However, the party ended up winning only 46 seats and came in second, raising its number of seats from the 2003 elections. Concerning the turnout for the 2007 election, only 37% of eligible voters cast their vote, which was the lowest turnout in Morocco. Moreover, the number of spoiled ballots was 19%, a figure higher than in the 2003 election. What was very astonishing about this is that most of the spoiled vote occurred in big cities where literacy is widespread, which means that those spoiled votes were reactions of the Moroccan citizens who are dissatisfied with their political system. In order to explain the low turnout that occurred in the last election, we have to consider various factors. First, Moroccan voters know that whoever won the election does not really make a difference, as the king still runs the show. For instance, in the election of 2003 the king appointed the prime minister from his entourage regardless of the election result, a fact which made many Moroccans to feel dissatisfied with the government’s spending of money on an election that is not going to be the base of forming the cabinet. Moreover, people feel that whatever is the election result, it is not going to bring change as long as the king retains supreme power, as it is noted in the Economist article, “there is a well-founded conviction amongst the populace that parliament is an ineffectual institution owing to constitutional constraints, which ensure that real power resides with the king.” [21] Second, the number of political parties in Morocco makes it very hard for the voters to understand their agenda, with 33 parties that were busy criticizing the Islamist party while forgetting to address the real issues of the constituents such as unemployment and rising prices. Third, Moroccans tend to distrust politicians and view them as corrupt and inefficient, a label which tends to apply to all the Moroccan parties except the PJD, the Islamist party which is seen as honest and pro-reform. However, unlike the Palestinians, Moroccans did not cast their votes for the PJD, because as Abdou Filali-Ansary said “Moroccan voters were plainly unhappy with their government’s performance…But contrary to what many would expect, voters did not turn massively toward the Islamists. Electors voted against the election, but they did not vote for the PJD.” [22] Finally, voters were dissatisfied with the performance of the last government, especially as the crucial issues like unemployment, rising prices, and poverty were not really addressed. Parties that used to be in the opposition wing (USFP and PI) are now becoming more and more pro-palace. Political parties in Morocco are very fragmented, and each year new parties tend to be formed. This balkanization of Moroccan political parties is due to: “The pluralist nature of Morocco’s party system, which is fostered by low barriers to party formation and electoral rules that give small parties a decent chance at achieving parliamentary representation.” [23] Basically there are 33 parties that were registered to participate in the election of 2007. However, only three of those parties have won many seats in the election. First, the PI, the independence party, which is a conservative party that was formed before the independence of Morocco in 1940 and maintained its name as the party that struggled for the independence of Morocco, used to be an opposition party until the late years of King Hassan 2nd, when the king absorbed the party into the pro-palace under “Alternance”, the alternation of power between opposing parties and pro-palace parties to rule a given government. The party’s affiliation is from the center right therefore, it advocates persevering Morocco’s traditions and religion while opposing socialism and extreme secularism. Second, the USFP, a progressive opposition party which had split from the PI, is the second largest party in Morocco. In 1959 the party was known for its opposition to the palace and during the years of lead a number of its militants were jailed, exiled or even assassinated like Mehdi Ben Barka. However, following the example of the PI, the USFP also changed from an opposition party to a pro-palace party due to its acceptance of the king’s Alternance policy which was one of the maneuvers of king Hassan II to exert and justify his power to the country, because “if the government of Alternance succeeded, the king could claim credit; if it failed, the opposition parties would be discredited.” [24] Moreover, the party accepted to head the government, with Abderrahman Lyousfi as its prime minister, in 1998 though the king did not accept its condition to dismiss the minister of interior Driss Lbisri, who was responsible for many atrocities against opposition parties during the years of lead. In the recent election of 2007 the party suffered from a lot of factionalism due to internal problems as well as lack of organization and collaboration between different groups that form the party. As a result, the party came in fifth. Finally, the PJD is the third largest party in Morocco and was formed in 1998 after a merger with an old pro monarchy party, the MPDC (The Democratic and Constitutional Popular Movement), and the Islamic organization MUR (Movement of Unity and Reform). The party has strong popularity especially in big urban areas partly due to its social programs and also to its manifesto to fighting corruption and bringing about reforms. In the last election, the party proved to be very organized in contrast with the USFP that was suffering from internal problems. The question of the rise of Islamism in Morocco goes hand in hand with the mediocre performance of the previous governments composed of parties of the opposition instead of pro place parties. In addition to the PJD manifesto, that was more constructive and directed towards reform and fighting corruption than the ones proposed by the other parties which focused on attacking the Islamist party indirectly and warning of the absence of democracy if Islamic party won. It is worth noting, that although the PJD came second in the 2007 election, it is not the largest Islamist party in Morocco, because the largest Islamist party the GJC (Justice and Charity Group) boycotted the elections because it does not recognize the monarchy and seeks to apply Sharia law to Moroccan society. Both the PJD and the GJC are non-violent political parties and are popular for their social services to the needy and their image as honest and pro reform entities. The rise of the Islamist parties in Morocco is due also to the failure of former governments in ameliorating the situation of Moroccans with rising unemployment, poverty, illiteracy and widespread corruption as it is stated by Pierre Hazan: Both radical and more moderate Islamist movements were becoming increasingly popular. They expressed the frustrations of many Moroccans facing a social crisis fueled by the high level of unemployment among young people, including college graduates; the absolute poverty that forced some 20 percent of the population to live on less than a dollar a day; an illiteracy rate of more than 50 percent; and rampant corruption. [25] However, from the low turnout of 37% we can discern that Moroccans were dissatisfied and angry with their political system but not to the extent of allowing Islamist to rule, which can be seen by the 20% of those who voted who choose to spoil their vote instead of voting for the PJD. [26] It is worth mentioning that the PJD has moderate Islamist agenda compared by other Isalmist groups that are radical like the Salafist who were responsible for the terrorist attacks of 16 may 2003 in Casablanca. The Moroccan government responded to the rise of Islamist by closing unauthorized mosques, building a plan to provide better living conditions for the dwellers of shanty towns, the place where most of the terrorists were coming from. On the other hand, the king recruited his minister of the Isalmist Affairs from Zawiya Boutchichiyya , a Sufist religious group that encourages peace and tolerance, a move that was implemented by the king to encourage peaceful Islam and decrease the prevalence of radical Islam in the Monarchy. The ethnic minorities in Morocco are not really represented in parliament, especially the Berber minority who are the native people of Morocco. This discrimination can be seen when the government banned the establishment of the PDA (Al-Hizb Addimocrati Al-Amazighi), the Berber Democratic Party, under the excuse that it is unconstitutional for a party to represent an ethnic group as it is stated here “Moroccan law…voids any political party based on ethnic or linguistic grounds,” [27] the Berbers used to be represented by The People’s Party, which has support in the rural areas of Morocco where most of the Berbers live. Nevertheless, the party was not very progressive in addressing the needs of the Berber community such as teaching Berber language at public schools. Moreover, the party was formed in order to separate the Berbers of the Atlas from uniting with the Berber of the north, Riffins, who were marginalized and attacked by planes in 1961 as they were outspokenly opposing the king and asking for independence. The animosity between Hassan II and the Riffins continued from the 1960s till his death to the extent that during his reign Hassan II never paid a visit to the region of Riff in Northern Morocco. Unlike his father, the new king Mohammed VI promoted many reforms for the benefit of the Berbers, mainly by erecting the Amazigh Cultural Council (IRCAM) and by introducing Berber language in schools. However, those reforms were not enough for the Berber community, who is looking for more representation in the government and to make the Berber language an official language of Morocco in addition to Arabic and French. [28] Concerning the future of democracy in Morocco, as noted above, the new king Mohammed VI did introduce new reforms. However, those reforms are not enough as long as the king still retains his powers. Therefore in order for democratic reforms to continue a lot of things must be done. First, the king should change his monarchy from an executive to a constitutional one, meaning that the king should give more power to the parliament and more freedom of press especially when it comes to taboo issues like Western Sahara and the king and his family. However these reforms, can not take effect while a number of journalists are banned from practicing their profession because their comment did not please the regime, in addition to a number of newspapers that have to pay excessive fine for denouncing corruption like the daily newspaper al-Massaa which has to pay 612 million dirham fine for mistakenly mentioning that one of the kings agent was present in a gay marriage that occurred in Laksar Lakbir in 2007. [29] Second, the judicial system should be reformed to make it more independent and impartial. First, by making laws applicable to all Moroccan regardless of their class or family as well as rejecting the 1974 law that prevents Moroccan judges from forming unions. [30] Second, the Justice Department suffers from lack of human and financial resources as there are only “3,320 judges working on more than three million cases per year.” [31] These shortages pose problems in the quality and soundness of the rulings therefore, creating new courts and recruiting new magistrates is a cornerstone to the amelioration of the judicial system in Morocco. Finally, the number of parties in Morocco is not very healthy and tends to confuse the voters and the electoral system or at least the electoral formula prevents any party from winning a majority thus ending up with a fragmented government. Therefore, the electoral formula should be changed to allow one party to win more than one seat in a given district. In addition to that, the Moroccan parties should put some pressure on the king to bring about more reforms and relinquish some of his powers to the parliament instead of attacking the Islamist parties and only allowing those who seek to please the palace. To conclude, although there are still many reforms that are needed in order to bring a complete democracy in Morocco, the gradual reforms introduced by the new king give a promising hope for the Moroccan citizens to anticipate a better future for the monarchy. The king s changed the family code to give more rights to women, released political prisoners, and paid compensation for the victims of the years of lead. And in spinet of the low turnout in the recent election of 2007 the transparency of the regime in no longer falsifying the rate of participation and the election results paves the way for more reform to be initiated especially in the domain of freedom of press to tackle such issues as Western Sahara, Corruption and the Royal family. Morocco Electoral System And Promise Of Democracy Politics Essay

MGT300 Colorado State Social Benefit or Social Disaster Twitter Case Analysis

MGT300 Colorado State Social Benefit or Social Disaster Twitter Case Analysis.

Option #1: Case Study Analysis: Social Benefit or Social Disaster?Read and respond to a case study to demonstrate your understanding of, and ability to apply, the most important concepts of the module, especially regarding the potential pitfalls of communication media.Review a case study of Twitter in the 10th edition of the course textbook attached in the Module 5 folder.In an integrated essay, analyze the case from the perspective of a business organization, providing support for your analysis by replying to each of the following:Explain the advantages and drawbacks for organizations using social media to communicate with various employees, customers, or the global communities.Describe how communication barriers surface when using social media versus using traditional media.Outline specific steps managers should take to be sure they communicate effectively when using social media.Explain rules or policies (if any) business organizations should implement for employees using social media after office hours. Be as specific as possible.Discuss the communication barriers a manager might encounter when using social media to create an organizational internship program.From your recent readings and experiences, suggest guidelines managers and organizations could follow.Your well-written paper should meet the following requirements:Be 3-4 pages in length.Be formatted according to the CSU-Global Guide to Writing and APA (Links to an external site.)Links to an external site..Cite a minimum of three scholarly sources, at least one of which is not provided in, or linked from, the course. The CSU-Global Library is a great place to find scholarly sources.Write clearly and logically, as you will be graded on content, analysis, and your adherence to the tenets of good academic writing—which should be succinct where possible while also exploring the topics appropriately. Remember that you can always improve your work by providing support from outside scholarly sources, which help both to bolster your own assertions and supplement your ideas.
MGT300 Colorado State Social Benefit or Social Disaster Twitter Case Analysis

SDSU Introduction to Barriers to Trade Essay

help writing SDSU Introduction to Barriers to Trade Essay.

Select a developed country that has implemented a tariff, and a developing country that manufactures products that are impacted by that same tariff. The current US and China tariff “war” cannot be used since these are the two largest economies in the world. Investigate the impact of the trade barrier on the developing country’s business sector and quantify the impact, if possible. Would you recommend that the developed country eliminate the tariff? Explain your reasoning.Embed course material concepts, principles, and theories, which require supporting citations along with at least one scholarly, peer-reviewed reference in supporting your answer unless the discussion calls for more.- writing standards and APA style guidelines.- Be sure to support your statements with logic and argument, citing all sources referenced- Write 4 paragraph essays (Introduction, body and conclusion)sincre Regards,
SDSU Introduction to Barriers to Trade Essay

Discussion Questions

Discussion Questions. I don’t understand this Health & Medical question and need help to study.

Good Evening,

I am needing assistance with the following question.
Please follow the grading criteria.
I need this APA and sources can not be Medscape or older then 5 years has to be legit sites like etc.
The Affordable Care Act (ACA) is a comprehensive health care reform law that was signed by President Obama in 2010. The law has three primary goals:

Make affordable health insurance available to more people.
Expand the Medicaid program to cover all adults with income below 138% of the federal poverty level.
Support innovative medical care delivery methods designed to lower the cost of health care.

Following the passage of the ACA, the National Prevention Council released a comprehensive plan to increase the number of healthy Americans at every stage of life by:

Building healthy and safe community efforts;
Expanding quality preventative services in the community and clinical settings;
Empowering people to make healthy choices; and
Eliminating health disparities.

For your discussion board assignment, please answer one the following questions and support your answers with reputable literature/publications/guidelines, etc. Respond to at least one of your classmates (must be a different question/topic than yours). If you agree with your classmate, support your discussion with a reputable resource. If you disagree with your classmate, explain why and support your discussion with a reputable resource.

How has the ACA helped rural communities build healthy and safe communities?
What preventative services have played a major role in improving communities?
Has the ACA empowered people to make healthy choices? Explain
What impact has the ACA had on health disparities among rural communities?

Discussion Questions

Integrated Occupational Therapy Practice Case Study

Introduction This report will focus on the occupational therapy (OT) process for Meera (Appendix A), a 56-year-old woman with a left cerebral vascular accident (CVA). Stroke is the death of brain cells due to the lack of oxygen (Bartels et al. 2016).It can either present as haemorrhagic or ischaemic in nature. Risk factors of CVA include hypertension and hypercholesterolemia which Meera has. Stroke may lead to neurological, psychological, speech and musculoskeletal complications. Meera’s symptoms of right hemiplegia, right sided neglect and speech difficulties can be attributed to the occlusion of her left middle cerebral artery (Mtui et al. 2016). A multidisciplinary inpatient stroke rehabilitation unit was involved with Meera’s post-stroke rehabilitation. Stroke patients who underwent treatment inpatient stroke care were found to have improved independence (Stroke Unit Trialists’ Collaboration 2013). Treatment was aimed at managing vital problems through restorative and compensatory approaches in order to prepare her for discharge (Edmans 2010). Thus, this service was most appropriate for Meera due to her recent onset of stroke. The OT process was guided by recommendations from the College of Occupational Therapist, National Institute for Health and Care Excellence (NICE)(2013) and Intercollegiate Stroke Working Party (ISWP)(2016)(Edmans 2010). Assessments and Problems Identified An initial assessment was gathered through an interview using the Kawa Model. It portrays a person’s life as a river and various objects such as rocks, river banks and driftwood depict circumstances experienced by a person (Teoh and Iwama 2015). Younger stroke patients such as Meera may require services which cater particularly to their needs which most stroke units were found not to do so (ISWP 2016). As Kawa focuses on the view of the client, it allows the therapist to know what is important to Meera in order to formulate priorities for intervention. The assessment is shown below: Life flow and priorities (river) Past Medical History: Hypertension Hypercholesterolemia Roles and Occupations: Independent in self-care Proud ‘Stay at home’ mother Took charge of matters at home such as: Cleaning Shopping Gardening Laundry Enjoys cooking for family Present Medical History: Stroke Roles and Occupations: Patient Needs assistance in most self-care tasks Loss of previous role and not engaging in occupations meaningful to her Future Meera felt afraid and pointless to talk about the future, worrying that she may have another stroke if she engaged in activity. Obstacle and Challenges (rocks) Occupational performance challenges: Right hemiplegia with increased spasticity in right arm and leg, causing difficulty in: Sitting Coordination of movement Tasks that require her hands due to being right handed Unable to feel sensations on right hand Feels she cannot remember things as easily and may not know the time and place she is at Right sided neglect with visual agnosia, resulting in difficulty : washing right side awareness of people approaching from affected side interacting with others Expressive dysphagia hinders communication with others. Feeling low mostly Feels useless Embarrassed that people are taking care of her Fatigues easily Concerns Family unable to function as she is unable to manage the household A burden to family, especially her husband who needs to manage the household together with the pressure at work now that she is in hospital Children’s studies and social life may be affected as they may be concerned about Meera and visiting her in hospital may affect their daily life Physical and Social Environment (river banks) Physical (Home) 3 room semi-detached Bathroom, toilet and bedroom on the upper storey Kitchen, combined living and dining room on ground floor Nearest bus stop and convenience store 10 minutes’ walk away Social Close knit family Meera usually supports family members as they will confide her during difficulties Looks forward to dinner every day where family will gather together Family is most vital source of support for Meera Frequent interaction with neighbours and will help each other with chores if needed Occasionally communicates with extended family overseas on phone Personal resources (driftwood) Personality Hardworking Afraid of trying new things Kind and caring Responsible With information from the initial assessment, the problem list was formulated in a client-centred manner (ISWP 2016). Stroke survivors felt more engaged in the therapeutic process when their perspectives were taken into account (Peoples et al. 2011). Interventions were based on Meera’s perceived problems in order to increase her motivation in therapy which she lacked. However the Kawa model only shows the problems perceived by Meera but not the therapist’s views. In order to gather a clinical and therapeutic point of view, standardized assessments were conducted as well. The table below depicts the various assessment conducted, reasons for use, limitations and results. Assessment Reasons for use and limitations Results Assessment of Motor and Process Skills (AMPS) (Fisher and Jones 2010) AMPS evaluates motor and processing skills of clients through observation of appropriate tasks (Fisher and Jones 2010). Self-care, specifically showering, dressing and cooking tasks which was important to Meera, were used to assess. This allowed the OT to break the tasks down and acknowledge the challenges Meera faced in order to formulate an appropriate intervention. AMPS was found to be valid, reliable and standardized among cultures but results has to be computer generated in order to be valid which may make the process tedious (Fisher and Jones 2010). Less than 1 for both motor (Moderate increase in physical effort) and process (Moderate inefficiency and disorganization) skills. Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) (Itzkovich et al. 2000) LOTCA evaluates the orientation, visual and spatial perception, visual-motor organization and thinking operations through the use of various activities included in the kit (Itzkovich et al. 2000). This allowed the OT to assess Meera’s right sided neglect and to discover any underlying cognitive deficits. The LOTCA is reliable and valid for use in people with stroke but needed to be conducted in more than one sitting as assessments were long and tedious for Meera who experience fatigue (Katz et al. 2000). Meera was able to sequence tasks but was unable to complete tasks involving her right field of vision. She needed prompts to complete orientation tasks. Activities involving memory were also a challenge for her. Rivermead Motor Assessment (RMA) (Lincoln and Leadbitter 1979) The RMA consists of tests evaluating the gross, leg, trunk and arm function of a stroke patient (Lincoln and Leadbitter 1979). This was conducted together with the physiotherapist. The RMA allowed the team to know which movements Meera had difficulties in order to formulate appropriate interventions. This assessment was found to be reliable and valid but due to being strenuous and long, it had to be conducted in a few sessions due to Meera showing signs of fatigue (Kurtais 2009) Meera was not independent in transfers and mobility, she required assistance of one for transfers and used a wheelchair for mobility. She also had minimum trunk and leg control at her affected side and require assistance for movement. However, she is able to hold objects using her affected arm but cannot reach for an object far away due to scapular instability. From these assessments, 3 problems Meera faced, in order of significance was developed: 1. Loss of independence in self-care affected Meera the most. From the assessments conducted, it was found that challenges in motor, cognition and perception affected her performance in self-care. Managing self-care would focus on these domains as well (NICE 2013). It was hoped that Meera would be more engaged in therapy by focusing on an issue she perceived as critical. This was evidenced by a study where patients were more motivated and engaged more in interventions when treatment was catered to their perceived needs (Combs et al. 2010). This would also help Meera to elevate her mood as low involvement in self-care was found to be a factor for post-stroke depression (Jiang et al. 2014). The psychologist in the team would be managing Meera’s low mood as well (ISWP 2016). By working with Meera on her self-care would also remove some burden from Sanjay, who was assumed to be her main carer when she is discharged from hospital. 2. Problems with visual perception, specifically right side neglect and agnosia, were targeted as it was found to have an influence on self-care (Barker-Collo et. al 2010). This would help Meera in performing self-care tasks. Her visual deficits also affected her social life and transfers. Managing her perceptual problems would allow her to interact more with other patients in the ward which could provide her with social support. 3. Meera’s motor challenges, specifically right side weakness and spasticity were addressed as it was one of the major challenges faced during self-care. It was hoped that through the management of motor deficits, Meera would increase her engagement in occupations. This would also have a positive effect for Meera in future as it was shown that physical function affected quality of life in stroke patients (Ellis et al. 2013). Motor challenges faced by Meera would be managed in conjunction with the physiotherapist (ISWP 2016). Skills in managing motor challenges can also be transferred to other aspects such as cooking and reinstating her role as a homemaker. Treatment Plan Client Aims: Meera wants to be more engaged in her personal care. Therapist Aims: To increase Meera’s engagement in her self-care tasks. To manage Meera’s right sided neglect and agnosia. To manage Meera’s weakness and spasticity in her right arm, leg and trunk. Objectives: Meera should be able take charge of her own shower and dressing every morning for an hour, with assistance of one, in 4 weeks. Meera should be able to independently identify items required on her right field of vision for washing and dressing every morning in 4 weeks. Meera should be able to go from lying to sitting, and pivot transfer from bed to wheelchair as well as from wheelchair to shower chair, every morning with assistance of one in 4 weeks. Intervention Washing and dressing assessment was conducted through the use of AMPS. This allowed the OT to formulate an appropriate wash and dress plan for multi-disciplinary use through identified difficulties in motor and processing skills (Fisher and Jones 2010). Using a meaningful occupation as a basis for intervention was beneficial for Meera. This can be supported by a study where occupation based intervention was shown to be critical in improving occupational performance (Wolf et al. 2015). The intensity of the intervention would be higher than the recommended minimum frequency of 45 minutes, 5 days a week as it was included in Meera’s daily routine (NICE 2013). The washing and dressing plan was adapted from Salisbury District Hospital’s (2013) assessment form. The OT conducted the first session in order to teach Meera the relevant compensatory and visual scanning skills. Other sessions could be conducted by other staff with guidance from the plan. A further review after every few days would also be required in accordance to recommendations (ISWP 2016). Washing and dressing plan for Meera Transfers Bed Mobility: Meera is able to roll to her right side independently. She requires assistance from lying to sitting. Bed to wheelchair: Require assistance of one for pivot transfer Standing: Require assistance of one and grab rail in the bathroom Wheelchair to shower chair: Require assistance of one for pivot transfer Allow Meera to navigate to bathroom Washing Notes: Require the use of a shower chair in the shower Allow Meera to initiate and sequence task independently Only give Meera assistance when she asks for it Place items necessary for shower on Meera’s right side If Meera seems to be searching for something, prompt her to look for it by turning her head Encourage use of right hand to wash herself Meera may require assistance to release her grip on objects Provide assistance if Meera feel fatigue Upper body: Meera is able to wash her right side independently Meera require assistance to wash above her elbows on her left side Assistance may be needed to wash hair and back thoroughly Lower Body: Meera should be able to wash her genitals and front upper thighs independently Assist Meera in standing with the grab rail with one person supporting at all times Another person will assist Meera in cleaning her bottom and her rear upper thigh Encourage Meera to wash her lower thighs but prevent her from falling from the shower chair Assist in cleaning the rest of the lower thighs Dressing Upper Body: Encourage Meera to put on the bra independently using the one arm method. Allow Meera to use the one hand method to wear her t-shirt. Prompt her by reminding her of the steps if she is struggling Lower Body: Meera requires assistance to put on her trousers while assisted in standing. Both the restorative and adaptive approach was used to guide the intervention. Restorative approach is grounded upon neuroplasticity where relearning takes place when new neural connections form in the brain during constant exposure to various stimulus (Gillen 2016). By practising various movements of her affected side during self-care, Meera should have a reduction in her impairments. This is supported by a study where patients who went through functional motor relearning therapy were found to have improved balance and performance in self-care (Chan et al. 2006). The compensatory approach is where tasks are modified to be easier for the clients to achieve (Edmans 2010). Even though this approach has been criticized for hindering motor recovery in people with stroke, it is still appropriate for Meera (Jones 2017). The compensatory method of using the one hand dressing method served as a feedback mechanism which could improve motivation as supported by Popovic et al. (2014). This would thus encourage Meera to engage in therapy. Risk Management Plan Meera might be fatigue and may not be able to do some of the tasks required. The staff in charge will assist when required and allow Meera to rest when needed. Due to the intimate nature of a wash and dress, Meera might feel embarrassed and down during the process. In order to preserve her dignity, sensitive areas would be covered whenever necessary and observation would be subtle. Environmental hazards would be checked before commencing any transfers or wash and dress in order to prevent falls. Relapse prevention In the hospital setting, encouragement for frequent engagement in occupation and usage of relevant motor and cognitive skills would prevent Meera’s occupational performance from deteriorating (Brainin et al. 2015; Ullberg et al. 2015). According to NICE (2013), long-term health and social support should include education on symptoms and dysfunction relating to stroke, services available and participation in meaningful occupation. As such, Meera and her family would be briefed on these strategies. Outcome Measures Evaluation of treatment outcomes is important to conclude if the intervention was successful and used to change the treatment plan according (Mew and Ivey 2010). The outcomes were evaluated by using goals and comparing standardized assessment at baseline and outcome. Firstly, intervention was evaluated through the achievement of goals. Goal achievement was linked to client satisfaction and a significant client-centred outcome (Custer et al. 2013). Meera was able to achieve the objectives as expected. Secondly, the AMPS was conducted again, using the task of showering and dressing (Fisher and Jones 2010). Meera scored higher in these tasks but still required some assistance in achieving them. Thirdly, Meera improved on the LOTCA tasks which involved visual scanning, little to no improvement was seen on the orientation and memory tasks (Itzkovich et al. 2000). Lastly, the RMA was conducted again (Lincoln and Leadbitter 1979). Meera improved in the trunk, leg and upper limb function but there were still signs of weakness and instability involved. Further plans Other domains of concern would be managed as according to initial assessment and outcome measures. Further interventions would include management of cognitive function such as memory and orientation through cooking. Including Meera in a social group such as breakfast club in the ward would be beneficial to her as well (Venna et al. 2014). To prepare for discharge, Meera would be referred to the Early Supported Discharge team. The team would help Meera and her family by introducing appropriate adaptations at home and relevant education on stroke (ISWP 2016). A smooth transition from hospital to home was found to improve patients’ function in activities of daily living and service satisfaction (Fearon et al. 2012). This would thus be beneficial for both Meera and her family. References Bartels MN, Duffy CA and Beland HE (2016) Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors IN: Gillen G (ed) Stroke Rehabilitation: A Function-Based Approach (4th Edition). Missouri: Elsevier 2-45 Brainin M, Tuomilehto J, Heiss WD, Bornstein NM, Bath PMW, Teuschi Y, Richard E, Guekht A and Quinn T (2015) Post-stroke cognitive decline: an update and perspectives for clinical research. European Journal of Neurology 22(2):299-e16 Chan DYL, Chan CCH and Au DKS (2006) Motor relearning programme for stroke patients: A randomized controlled trial. Clinical Rehabilitation 30(3):191-200 Combs SA, Kelly SP, Barton R, Ivaska M and Nowak K (2010) Effects of an intensive, task-specific rehabilitation program for individuals with chronic stroke: A case series. Disability and Rehabilitation 32(8):669-678 Custer MG, Huebner RA, Freudenberger L, Nichols LR (2013) Client-chosen goals in occupational therapy: Strategy and instrument pilot. Occupational Therapy in Health Care 27(1):58-70 Edmans J (ed) (2010) Occupational Therapy and Stroke (2nd Edition). Chichester: Wiley-Blackwell Ellis C, Grubaugh AL and Egede LE (2013) Factors associated with SF-12 physical and mental health quality of life scores in adults with stroke. Journal of Stroke and Cerebrovascular Diseases 22(4):309-317 Fearon P, Langhorne P and Early Supported Discharge Trailists (2012) Services for reducing duration of hospital care for acute stroke patients. Cochrane Database of Systematic Reviews 7: CD000443 Fisher AG and Jones KB (2010) Assessment of Motor and Process Skills Vol. 1: Development, Standardization and Administration Manual (7th Edition). Fort Collins: Three Star Press Gillen G (2016) Stroke Rehabilitation: A Functional-Based Approach (4th Edition). Missouri: Elsevier Intercollegiate Stroke Working Party (2016) National Clinical Guideline for Stroke. Royal College of Physicians. Available from: [Accessed 28 March 2016] Itzkovich M, Averbuch S, Elazar B and Katz N (2000) Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) Battery (2nd Edition). New Jersey: Maddak Inc. Jiang XG, Lin Y and Li YS (2014) Correlative study on risk factor of depression among acute stroke patients. European Review for Medical and Pharmacological Sciences 18(9):1315-1323 Jones TA (2017) Motor compensation and its effects on neural reorganization after stroke. Nature Reviews Neuroscience doi:10.1038. Available from: [Accessed 28 March 2017] Katz N, Hartman-Maeir A, Ring H and Soroker N (2000) Relationships of cognitive performance and daily function of clients following right hemisphere stroke: Predictive and ecological validity of the LOTCA battery. Occupation, Participation and Health 20(1):3-17 Kurtais Y, Kucukdeveci A, Elhan A, Yilmaz A, Kalli T, Tur BS and Tennant A (2009) Psychometric properties of the Rivermead Motor Assessment: Its utility in stroke. Journal of Rehabilitation Medicine 41(13):1055-1061 Lincoln N and Leadbitter D (1979) Assessment of motor function in stroke patients. Physiotherapy 65(2): 48-51 Mew M and Ivey J (2010) The Occupational Therapy Process IN: Edmans J (ed) Occupational Therapy and Stroke (2nd Edition). Chichester: Wiley-Blackwell 49-63 Mtui M, Gruener G and Docker P (2016) Fitzgerald’s Clinical Neuroanatomy and Neuroscience (7th Edition). Philadelphia: Elsevier National Institute for Health and Care Excellence (2013) Stroke Rehabilitation in Adults. Available from: [Accessed 28 March 2016] Peoples H, Satink T and Steultjens (2011) Stroke survior’s experiences of rehabilitation: A systematic review of qualitative studies. Scandinavian Journal of Occupational Therapy 18(3):163-171 Popovic MD, Kostic MD, Rodic SZ and Konstantinovic LM (2014) Feedback-mediated upper extremities exercise: Increasing patient motivation in poststroke rehabilitation. BioMed Research International 2014(2014): Article ID 520374. Available from: [Accessed 28 March 2017] Salisbury District Hospital (2013) Occupational Therapy Washing and Dressing Assessment. Salisbury NHS Foundation Trust. Available from: [Accessed 28 March 2017] Stroke Unit Trialists’ Collaboration (2013). Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews 9:CD000197 Toeh JY and Iwama MK (2015) The Kawa Model Made Easy: A Guide to Applying the Kawa Model in Occupational Therapy Practice (2nd Edition). Available from: [Accessed 28 March 2017] Ullberg T, Zia E, Petersson J and Norrving B (2015) Changes in functional outcome over the first year after stroke: An observational study from the Swedish Stroke Register. Stroke 46(2):389-394 Venna VR, Xu Y, Doran SJ, Patrizz A and McCullough LD (2014) Social interaction plays a critical role in neurogenesis and recovery after stroke. Translational Psychiatry 4(1):e351 Appendix A Meera CVA Meera is a 56-year-old woman who was recently admitted with a left Cerebral Vascular Accident affecting the middle cerebral artery. She has a history of hypertension and hypercholesterolemia. She was admitted via A

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