Well Done State a Problem Essay - Sample Essay

I have often wondered whether the United States has an obligation to get involved in the internal conflicts of other countries. When does the power to intervene become an obligation to act? I gained some insight into this dilemma when a small part of the Bosnian war spilled into my home last year.During the height of the Bosnian conflict, my family was informed that twenty Bosnian students were airlifted out of the mountains surrounding Sarajevo. A relief organization called Bridge for Humanity sought families in the United States that would take in these Muslim teenagers for the school year. The need was urgent because the U.S. government would not let them board planes until homes had been found.My parents and I spent at least a week contemplating whether we should offer. At first I resisted, fearing the obligations that I would be forced to undertake. I knew it would be my job to help this visitor integrate with the students at our school and to look out for him in social situatio ns. Eventually, my parents agreed, but they left the final decision to me. The deciding factor was my parents reminder of the six-million people who were killed in World War II. Many of these Jews, gypsies, and other undesirables had tried to flee Germany and Eastern Europe, but found no country that would accept them. Being Jewish, I found it easy to imagine how desperate I would have been in the same situation, needing someone to rescue me. The choice was made.Emir arrived last October with one small bag. He told us that he had crawled out of Sarajevo through a narrow tunnel leading to the mountains beyond the city. He crawled for many hours in this hot confined space, terrified of being caught and shot by the Serbs. I doubt that Emir looked back during this journey. The building where he had once lived had been blown up months before. He survived in cellars, with little food, and electricity for only five hours each week. Behind Emir, the bombs fell on his city every day.When Emi r arrived at my house, for the first day he could not stop smiling. He appeared jovial and appreciative of the United States and of my family. Soon, however, it became clear that Emir had not escaped Bosnia completely. His inner rage began to emerge. His hatred of the Serbs permeated his thoughts and judgments. Eventually, he began to hate the United States too. To Emir, Americas failure to prevent Serbian atrocities made it evil. He found it reprehensible that some Americans opposed sending troops to defend the Bosnian minorities. He hated Americans that would not risk their lives to save his people.The six months that Emir lived in my home are the most difficult that I can remember. Many nights I would stay up very late talking to him about his negative attitude toward the United States. As he attacked our society, I found myself becoming defensive, then angry. When my mother found butcher knives hidden in his drawers, anger turned to fear. I began to understand the depth of the t rauma Emir had experienced in Bosnia, even as I pulled away from him. I discovered some limits to what I could give.It is now six months later. I have learned that the casualties of war cannot be measured merely by life and death. Those who survive may live with pain, and those who try to help may feel its repercussions. This experience brought a new dimension to my life, as well as a new appreciation of my advantages in the United States. As we are a privileged nation, I feel we have an obligation to aid both oppressed and impoverished countries. There are risks, there are rewards, and there are degrees of failure. Sometimes those we help may hate us for being less than they imagined. But because we did not look away when we were needed and had something to give, we have lived up to our moral obligation.

Hitlers Mistakes essays

Hitler's Mistakes essays The true nature of a mans ability and worthiness is assessed not only by his triumphs but also his failures. Quite often all that is achieved may suddenly be overshadowed by dark clouds of fallacy, occurring lightning fast, and having thunderous repercussions. Through either ineptness, deficiency in character, or just plain bad luck stemming from uncontrollable events, failure is as inevitable as death and occasionally may lead to this unfortunate ending. Adolf Hitler regarded as a man who almost had world domination in the grasp of his ironclad fist, let it slip through his fingers with a compound of irreparable and unjustifiable mistakes which ultimately cost him the war and his life. Within various arenas around the world, he continuously obliterated all hope the Third Reich had on winning the war and expanding its empire permanently. Key blunders, which were detrimental and caused Hitlers downfall, include the hesitation at Dunkirk, the indecision to wage against Great Brita in, and the betrayal of Russia. The disappointment at Dunkirk, although its affects were not felt suddenly, was distinctly the afternoon that Hitler lost the war. British and French officials noticing the devastating force Germany was becoming after recent victories in Poland and the mutual non-aggression pact signed with military mass Russia, proclaimed war against their sworn enemy. France was amply prepared for their neighbouring rival, protecting their borders with the Maginot Line a series of concrete structures costing France $ 1 billion and consuming over 26 million cubic feet of cement. In an outstanding strategic move, the German generals anticipated the resistance that would be encountered in a foreshadowed attack, and made their way through the Ardennes Forest, thought by the French to be impenetrable, especially by armour units. The swift declaration of B...

Collapse by Jared Diamond Essay Example | Topics and Well Written Essays - 1250 words

Collapse by Jared Diamond - Essay Example All these societies have experienced different climatic, environmental, economic, and technological conditions. How the success or failure of these societies depends on these conditions and how these societies have responded to the changed condition is what the book is all about. The root problem, according to the author, in all but one of these factors leading to collapse is overpopulation. The factor of accidentally or intentionally introducing non-native species to a region has nothing to do with overpopulation. However Diamond feels that environmental damage alone is not a major factor responsible for all collapses. For instance in the collapse of the Soviet Union and the destruction of Carthage by Rome in 146 BC, it was military or economic factors alone that were responsible. Part One describes the environment prevailing in the US state of Montana. It attempts to give a human face to the interaction between society and the environment by focussing on the lives of several individuals. Part Two describes societies that have collapsed.Here Diamond considers the five factors that may affect society, namely climatic change, environmental damage, hostile neighbors and trade partners and lastly the societys responses to the problems caused by the environment. The Greenland Norse : Causes of collapse include climate change, hostile neighbours, environmental damage, loss of trading partners and also because of the unwillingness to change when confronted with social collapse At the end of Part Two Diamond discusses the success stories of three regions, namely the Pacific island of Tikopia, the agricultural success of central New Guinea and the success of forest management in Japan. Diamond describes the terrible situations in Haiti and Rwanda. He also portrays the contemporary Third World where societies have failed because of overpopulation and depletion of environmental resources He is worried about rising mega

Just War Doctrine Essay Example | Topics and Well Written Essays - 250 words

Just War Doctrine - Essay Example In this direction, Orend, Brian (2008) argues that â€Å"just war theory is probably the most influential perspective on the ethics of war and peace.† This means that the talk of just war raises a lot of questions on ethics and morality. Many researchers and theorist have therefore propounded a lot of ideas and theories on just war. One of such is the ‘consequentialist’ moral dynamic for intelligence operations introduced by Arrigo. The Arrigo Paper and believers of it thereof raise a lot of issues of when human source intelligence, counterintelligence, or covert operations pass the â€Å"moral divide† and violate the Just War doctrine. As an expectation of civilians from the military, wars should be started by causes and causes should be found through intelligence. For this reason, a justified war comes with a justifiable cause and for that matter, a justifiable intelligence. It is therefore important that â€Å"a doctrine of just war should coordinate wi th a doctrine of just intelligence, especially for human source intelligence, counterintelligence, and covert operations† (Arrigo, 2001).

PROMOTING RECOVERY WORKING WITH COMPLEX NEEDS Essay

PROMOTING RECOVERY WORKING WITH COMPLEX NEEDS - Essay Example An increasing number of people in this group also have problems with substance misuse, often resulting in contact with the criminal justice system. These problems often interact and can appear intractable. Recent years have seen a paradigm shift in mental health, from a focus on illness and disability towards the promotion of recovery and social inclusion (Repper and Perkins, 2003). Underpinned by a stress vulnerability model of mental health problems (Zubin and Spring, 2004, 105; Nuechterlein, 2004, 300), a range of psychosocial interventions (PSI) can be used to enable service users to build on strengths and develop skills in order to manage their own mental health more effectively. This in turn can facilitate attainment by service users of socially valued roles and relationships taken for granted by most people. One of the available interventions is a structured approach to the prevention of relapse, developed by Birchwood and colleagues (Birchwood et al, 2000, 5), building on the early work of Herz and Melville (2006) and Birchwood himself (Birchwood et al, 2000, 652). This work had demonstrated that it was possible to predict relapse in psychosis on the basis of recognition of early warning signs. The intervention incorporates a strong educative element. This aims to increase understanding of the typically episodic nature of psychosis and to enhance service users' self-efficacy in relation to the management of their mental health. A Cochrane Review (Pekkala and Merinder, 2002) concluded that psychological education significantly reduces relapse rates, increases compliance with medication, and may have a positive effect on a person's well being. To deliver the relapse prevention intervention effectively calls for the use of a set of specialist knowledge and skills, in addition to general mental health nursing skills. Aims Our primary aim was to enhance the quality of service provided to users of the inpatient areas of the local mental health rehabilitation service by making the relapse prevention intervention available routinely and sustainably. An essential interim aim was to equip the multidisciplinary team with the knowledge, skills and confidence required to deliver the intervention effectively. To address these aims and evaluate whether they were achieved, we developed a project plan in six stages. In the event, workers from community settings also sought out the training, and so the original scope of the project was broadened to include all areas of the mental health rehabilitation service. This paper will focus on the aspects of the project relating to service users. Intervention The project was jointly led by the clinical nurse leader of the mental health rehabilitation services and a lecturer practitioner. At the outset we sought guidance from the Trust's research and development coordinator as to whether we should seek ethical approval for our planned project. The advice received was that the project represented service audi t/evaluation rather than research and, as such, ethical approval was not required. We began by attending clinical meetings at which we described our plans and encouraged discussion and questions by the multidisciplinary team. We refined a previously developed two-day training programme in order to meet the needs of a multidisciplinary group

Causes and Impacts of disruptive Behavior (DB) in Healthcare

Causes and Impacts of disruptive Behavior (DB) in Healthcare Introduction Persons may be fascinated to study and work in the nursing occupation because it is trustworthy and esteemed; though, the reputation of nursing is at risk as nurses are vulnerable to violence at their work more than other professions (Carter 2000 cited in Norris 2003). Indeed, nursing profession is four times more dangerous than most other careers (Gallant, R 2008). Nurses deliver care for displeased patients and families, whether they are mentally or emotionally ill, or they are offenders. They also need to deal with staffs and other healthcare members within the organization who evoke distress and nervousness. Lateral violence (LV) in health organizations has come to be so widespread and troublesome that it has gained the concern of the policy makers, managers and the healthcare organizations. During the past years LV has gained special attention in organization research. According to National Council on Compensation Insurance (NCCI) in 2006, 60% of workplace assaults are presented and intensified in health organizations, social facilities, and personal care employments. Investigators have reported alarming findings about the negative consequences related to disruptive behavior (DB) for the individuals, the health organizations, and the patients. As for the impacts on the organization, DB has been reported to be associated with higher turnover and intent to quit the organization, higher absenteeism, and decreased commitment and productivity (Hoel, Einarsen Cooper 2003). In addition, victim bullying has been reported to experience stress, job dissatisfaction, psychological and physical illness, and possible expulsion from the Job (Hoel Cooper 2000, Keashly Jagatic 2003 cited in Hoel et al. 2003, Vartia 2001) while patient bullying has been reported to result in reduced s afety and quality of care (reference). Although LV is considered a global epidemic (International council of nursing (ICN) (2007) and has long been a concern among healthcare providers, it has frequently gone uninhibited, or even pernicious, accepted as part of the organization. Thus, leaving these behaviors unaddressed, health organization quietly maintained and reinforced them. Fortunately, DB has lately come under better scrutiny. The American Medical Association (AMA) (2002) has commented: Personal conduct, whether verbal or physical, that affects or that potentially may affect patient care negatively constitutes DBs. The American Association of Critical Care Nurses (AACN) in 2005 has noted that the presence of DB is negatively impacting the collaboration among healthcare workers, which is principal to instituting and supporting a productive work environment. Furthermore, Alspach (2007) stated that LV in nursing is insidious, costly, disgusting and affects patient care. These behaviors urge TJC in 2008 to warrant the healthcare organizations of the safety risk caused by intimidating behaviors and asked them to increase their awareness of the individuals and organizational risk resulting from these behaviors. Those exposed to DB can live through stress, frustration, and psychomatic disorders. Sadly, Griffin (2004) found that 60 % of newly appointed nurses quit their work within six months of service upon exposure to LV, 20% leave the nursing profession forever. While, Veltman (2007) stated that DBs pushed the nurses to leave a particular job, and this drain on resources further affect patient care. In order to address this threat TJC (2009) introduced a leadership standard requiring that facilities looking for accreditation must formulate policies to tackle DBs in healthcare organizations. Now all Healthcare givers should be charged with understanding and addressing this needed culture change within health organizations. In this paper, the causes and impacts of DB for both patients and healthcare workers will be reviewed. Strategies to address and combat DBs among healthcare givers will be discussed. LV, DB and bullying are the terms that I will be using throughout this assignment. Laying the foundation Several terms have been used in nursing research to describe the negative behaviors of nurses in health services. These include LV, bullying, relational aggression, intimidation, horizontal hostility, horizontal violence, sabotage, verbal abuse, psychological abuse, oppression and interactive workplace trauma. (Alspach 2007,Dellasega 2009,Longo Sherman 2007, Lutgen-Sandivk 2007, Rocker 2008,Rowell 2005, Rosenstein ODaniel 2008, Stanley 2007, The Joint Commission(TJC) 2008) . Griffin (2004) identified the most common ten features of DB in the nursing literature (Duffy1995; Farrell1997, 1999, McCall 1996, cited in Stanley 2007): non-verbal innuendo, verbal affront, undermining activities, withholding information, sabotage, infighting, scapegoating, backstabbing, failure to respect privacy, and broken confidences. These kinds of DBs may be perpetuated by healthcare providers, patients or their families. High jobs pressure such as nursing tends to create stresses that are often released when further stressors are added. The discharge of the unbearable stress can result in LV. Irrespective of the initiating stress, no one merits to be abused. When LV erupts, everyone is influenced (Rowel 2010).Some researchers argued that nurses are an oppressed group who intern contributes to the oppressive behaviors indicative of LV (Stanley et al. 2007). Moreover, oppression, vulgarity, and sexual harassment are key elements of LV (Lutgen-Sandivk 2006). But these issues are not the only means that DB may manifest itself in personal communications. Norris (2010) added that hostility may take the form of apparent detesting, patronizing language, annoyance with questions from neophyte nurses or unlicensed employees, disparaging, impoliteness, concealing information, and even temper tantrums. DB is used to depict the workplace negative behaviors that may affect the health status of patient (TJC 2008). Dellasega (2009) refers LV to the act of intimidating, degrading that result in physical, psychological or emotional injury on a colleague or group while Rosenstein and QDaniel (2008) described LV as any unsuitable conduct, conflict, or confrontation ranging from verbal abuse to bodily or sexual harassment. According to Piper (2003) DB is any aggressive behavior that may endanger the stability of patient, unit, and the ability of the organization to achieve its mission. The ICN (2007) defined bullying as a behavior that dishonors, demeans, or otherwise shows disrespect for the dignity and value of an individual. Habitually, the fundamental cause of DP turns around communication mishaps (Ratner 2006, cited in Rowel 2010) or intentional obnoxious behaviors. Sheridan-Leos (2008) stated that the term LV has been used for more than 25 years in the nursing literature and described it as an act of antagonism that occurs between nursing colleagues within an organizational hierarchy. DB may be obvious or subtle. Farrell (2001, cited by Leiper 2005) uses the terms active or passive to categorize DP while the TJC uses the terms overt or covert. Active or overt actions range from intimidating body language designed to discomfort another or others to overtly criticizing a colleague in the presence of others, shouting at others and even physical attack (Leiper 2005, Longo Sherman 2007). Passive, covert aggression may take the form of gossiping, cover-up information needed to perform the job, or demonstrating unhelpful approaches during routine doings. Griffin (2004) found that many experienced nurses are not acquainted with the term LV and thought new nurses were making up the term. Likewise, many forms of DB may be so delicate that certain actions are considered nothing more than a personality conflict between two persons. Jackson (2002) contends that DB is an axiomatic phenomenon in health organizations and is recognized by many organizational cultures as a part of doing business. However, when asked precisely about personal experiences with DB, most healthcare providers confess that they know it when they see it, and many acknowledge exposure to some sort of experience with it during their professional life (Alspach, 2007). Owing to the seriousness and continuity of the side effects of LV on patient outcomes, a great attention has been paid to this topic in the literature. Here are some examples of reported cases: In a study conducted by the joint program and reported by the international council of nurses (ICN) (2007).Researchers found that the most common forms of LV are Verbal abuse, bullying and sexual harassment where verbal abuse ranks the highest among them. Verbal abuse had been experienced by 39.5% in Brazil, 32.2% in Bulgaria, in Portugal, 52% in the health center complex and 27.4%in the hospitals, 40.9% in Lebanon, and up to 67% in Australia. Additionally, bullying has been suffered by 30.9% in Bulgaria, 20.6% in South Africa, 10.7% in Thailand, in Portugal ,23% in the health center complex and 16.5% in the hospital, 22.1% in Lebanon, 10.5% in Australia and 15.2% in Brazil. Furthermore, sexual harassment impacted 64% in India, 90% in Israel and 56% in Japan, 69% for the UK, 48% in Ireland and 76% in the US. The Institute of Safe Medication Practice (ISMP) surveyed over 2000 healthcare providers in 2004 including nurses (1565), pharmacists (354), and others (176) and reported that 88% of the surveyed staff suffered bullying by other workers in the form of haughty language or voice intonation. 87% felt impatience when questioned and 79% were unwilling or refuse to respond to questions or telephone calls. The Nursing journal website (2006) asked guests in the last 6 months have you observed any nurse dealing inappropriately with others? 55% of all visitors claimed yes. This was demonstrated by a survey administered in 2007 to 663 nurses; 46% informed that LV was very serious or somewhat serious issue in their healthcare area and 65% reported witnessing DB repeatedly (Stanley 2007). Ulrich (2006) surveyed 4000 nurses; 18% reported verbal abuse from another nurse, while 25% of all participants rated the quality of teamwork and communication with other nurses as fair or poor. A minor study in Boston (2001) involving 26 new graduate nurses reported that 96% of respondents had seen LV during their first year of work, 46% stated that the act was against them. Acts of LV included being set them up to fail with an unreasonable assignment, sabotage, undermining, or not being available (Griffin 2004). According to a survey written by the Workplace Bullying Institute in 2010 and commissioned by Zogby International survey (2010), an estimated 35% of the U.S. workforce has been bullied at workplace; 62% of bullies are men; 58% of targets are women,68%of bullying is same-gender harassment; an additional 15% witness it. Half of all Americans have directly experienced it. Simultaneously, 50% of targets and witnesses never report the incident (silent epidemic). Leymanns (1993, cited in Einarsen1999) asserts that four elements are noticeable in prompting bullying at workplace: (1) lacks of work design, (2) deficits in leadership performance, (3) a socially visible status of the victim, and (4) reduced ethical standards in the working department. Einarsen et al. (2003) designed a workplace bullying framework; which gives an overview of how factors on different levels may interact at different stages in the multifaceted bullying process. This framework calls the attention not only to individual factors (in victims and perpetrators) but also to contextual, organizational and social factors. Salin (2003b) adapted this framework (Fig. 2), which builds and argues a planned adjustment of the framework by constructing on organizational factors of intimidation and its tolerance/intolerance by using terms such as enabling/disabling factors (Fig. 3). The Problem A survey conducted by TJC (2008) involving 4350 healthcare providers revealed that 77% witnessed DP by doctors and 65% by nurses. These behaviors are frequently demonstrated by professionals in positions of power and include unwillingness or rejection to answer questions; return telephone calls or pagers; patronizing language or voice intonation, and impatience with questions. In response to these events, TJC (2008) issued a patient safety alert affirming that the existence of threatening and unapproachable behaviors weakens the effectiveness of teamwork, erodes professional behaviors, and creates an unhealthy work environment. This sort of toxic environment can lead to malpractice risk (Rosenstein and ODaniel 2005, Morrissey 2003, ISMP 2008), patient dissatisfaction and to preventable adverse outcomes, (Rosenstein and ODaniel 2005, Gerardi 2008, Ransom and Neff et al 2000), increase cost of care, (Gerardi 2008, Ransom and Neff et al 2000) and causes competent clinicians, administrators and managers to look for new workplaces in more professional settings. Lutgen-Sandvik (2009) stated that nurses employed in a toxic, threatening environment often dread going to work and many face the day with feelings of impending doom. Recurrent exposure to bullying headed some nurses to retreat into silence, which led to disruption in communication and teamwork. Furtherm ore, continuous bullying may alter nurses self-confidence, initiativity and innovation resulting in psychological and occupational impairment (WBI 2003). All of these factors combine their effects to disrupt the stability of employees, the organization, and the patients safety. Unfortunately, there is no research study in the United Arab Emirates (UAE) handling the issues of LV except for a minor one conducted in Saqr Hospital in Ras Al Khaimah. The executive director stated that DB by physicians, including Sexual harassment and verbal abuse is a major cause of nurses stress and dissatisfaction at the hospital. Such abuse pushes the nurses to turnover (Zain 2010). Moreover, unhealthy nurses-physicians rapport and authority abuse by the doctors have contributed to nurse turnover in the UAE (khaleej, T 2009).The absence of studies involving the whole emirates does not mean that the problem does not exist. Based on my observation as part of the healthcare system, many nurses especially Asians suffer from different kinds of hostility from physicians, superiors, peers, patients and their families in their work. This hostility take the form of shouting, oral degrading expressions, oral ironic remarks, raised eyebrow, unflattering face gestures, apparent detesting , and sexual harassment. Literature Review History The notion of LV is not a new phenomenon. Horty (1985, cited by Piper 2003) defined the disruptive doctor as as a very clinically competent to the extent of considering himself as the most experienced in the healthcare organization. The troublesome physician is naturally very tough to contact and hence argumentative and antagonistic. In the 1990s, DBs by doctors began to be labeled in the literature as a form of physician impairment (Piper 2003). Gawande (2000) revealed in his article When Good Doctors Go Bad how the medical community was not set to suitably address physicians DB. Rosenstein et al. (2002) found out that lack of physician awareness, appreciation, value, and respect for nurses were serving to fuel the countrywide nursing shortage, profoundly impacting job satisfaction and morale for nurses. So what motivates TJC to ask the medical community to act against violence after two decades? Researchers agree that two milestone matters brought the dispute of LV to the front (Lu tgen-Sandivk 2007, Rocker 2008, Rosenstein ODaniel 2008, Seidel, 2006). The Institute of Medicine (lOM) published in 1999, To Err is Human. The report determined that medical errors cause between 44,000-98000 deaths yearly- more than result from vehicle accidents, breast cancer or AIDS (Baker 2009). The report emphasized the necessity to consider organizational resources and human factors that harmfully influenced patient care (Rosenstein ODaniel 2008). The risk of a nursing shortage. Aiken et al. (2001) found in his global study in a sample of 43,329 nurses that job dissatisfaction was highest in the USA (41%) followed by Scotland (38%), England (36%), Canada (33%) and Germany (17%). More striking, however, was that 27-54% of nurses less than 30 years of age intended to quit within 12 months of data collection in all countries. The U.S.A had a shortage of 150,000 nurses and that number is expected to reach 800,000 by the year 2020 (Childers 2005). Consequently, the nurses will be incapable to meet the forthcoming patients needs if this continues. One reason of turnover is the frustration caused by DBs. Rosenstein et al. (2002) noted that nurse-physician relationship is the key element for retaining nurses. Rosenstein surveyed 2562 from 142 hospitals from 11 Voluntary Hospital Association regions. The sample included 389 physicians, 1615 nurses and 104 senior level executives. More than 90% informed witnessing DB by physician and over 33% of nurses tend to turnover. Using a scale of 1-10 to identify the level of nurses satisfaction and moral; LV ranks pretty high (8.01) Figure 4 Theoretical Framework Rowell (2010) suggested five theories about LV. (See Appendix I). Causes of LV Physicians related Several researchers stated that the physicians training at the hospitals make them vulnerable to DB (Kuhn 2006, Rosenstein ODaniel, 2008). During their training; doctors learned to think individualistically and to become accountable for their activities. This mentality promotes self-reliance, self-sufficiency and an autocratic, bullying conduct which is the antithesis of teamwork (Rosenstein et aI. 2002). According to Kuhn (2006), the absence of quality control starting in university and it is nearly difficult to be fired from internship. This leads the physicians to see themselves as the so-called captain of the ship but possibly do not have the necessary skills to keep it right. This also produces a hierarchal model of healthcare which builds passive roles for nurses and other subordinates (Rosenstein ODaniel 2008) Piper (2003) found that DB is usually demonstrated by excellent clinicians who are accepted by their patients and the society. As they habitually have a notable record of accomplishments; victims may be unwilling to intervene considering the behavior as an exceptional one. Moreover, Piper stated that hospital managers who are supposed to implement the policies are confronted with the challenge of whether to ignore the behavior, or take a difficult decision of firing a great physician who shows too much enthusiasm. According to Rosenstein ODaniel (2008) some hospital directors are disinclined from averting the aggressive attitudes of the physicians because they are not hospital employees and willingly admit their patients to the hospital and thus considered a source of organizational income. Growing external forces such as governmental supervision, pressures for more productivity, managed care restrictions, lower payment, and increasing liability risk cause disruptive physician behavior (Rosenstein et al. 2002). Practicing physicians are overwhelmed with paperwork. As a result, demoralization, and anger will develop leading to oppressive conducts. Another likely cause is the stress inherent in todays medical environment such as mental exhaustion and environmental stressors experienced by physicians lead them to commit medical errors (Kuhn 2006). Staff related The oppression theory will be applied to understand the nurse-to-nurse aggression. Healthcare institutions are controlled by the administrators and physicians who use their authority to rule subordinates. It is obvious that when any oppressed group recognizes that it is not possible to direct its power upward, the group then places their powerlessness and frustration on one another. These peer-to-peer hostilities, which reduce self-esteem, are called LV (Sheriden-Leos2008, Griffin 2004, Leiper 2005). Dunn (2003) confirmed in a study involving 500 nurses in the operating theater that the great numbers of nurses were verbally attacked by the surgeons. This sort of offensive abuse led the oppressed group to develop personal characteristic such as disunity and inability to oppose the physicians because of their positions, authority and ability to revenge from the nurses. Rowell (2005) estimated that 81% of oppressors are bosses, 14% peers, and 5% lower rank staff. Referring to Griffin (2 004) this form of oppression causes the nurses to feel helpless, disrespected and self-loathing. Stanley and Martin (2007) have suggested an applied model of oppressed group behavior to demonstrate how LV seems to manifest itself in the workstation (Fig. 4).It also useful in predicting nurses retention and satisfaction. Gender is another factor. Many studies revealed that females are more susceptible to LV than males. Dunn (2003) rationalized that women tend to suppress their feelings of bitterness. In addition, women are habitually considered inferior to men within society in general and healthcare organization in specific. Accordingly, it is not astonishing to see recurrent acts of sabotage in the nursing as 90% of nurses are females. Leiper (2005) has a parallel opinion and said that females generally underestimate their efforts and have lesser self-esteem than males so they can be irritated more easily and have a predisposition to yell at others. Dellasega (2009) concluded that males express their anger more frequent with bodily violence and this is usually accepted and women exhibited it through character insult, mortification, disloyalty and rejection. ISMP (2004) surveyed 2095 nurses (86% female and 14 % male) and found that DB was nearly equal. Thomas (2003) agrees with this finding. Not all Researchers support the oppression theory as the mechanism for DBs. Ratner (2006) view the oppression theory as condescending to nurses, making them appear as the powerless victim. Another standpoint suggests that organizational cultures, sustained struggles for authority, inconsistent work standards and management styles results in LV (Hallberg 2007). Further organizational causes include shortage, work overload, lack of administrative support, relations among groups, and organizational reform (Rocker 2008). Patient/Family related Patient or family members with a history of DB should be considered at high risk for becoming violent. Violence results from those who are frustrated, rampant, mentally ill, and substance abuser. Finally, LV is not frequently reported by victims and therefore run unaddressed. Fear of revenge, the stigma related to blowing the whistle on a peer, a wide-ranging averseness to oppose an oppressor (TJC 2008), the status quo, lack of confidentiality, lack of administrative support, and lack of awareness or reluctance among doctors to change inhibit the reporting (Rosenstein et aI. 2002). Similar to other kinds of mistreatment, staff violence is repeatedly viewed as an isolated matter and individuals are occasionally unwilling to talk about it (Gammons 2006). On several occasions, LV is not informed because it isnt identified. Some practitioners doubt that bullying has happened except when somebody shouts or uses attacking language (Beyea 2004). Forms and Manifestations OF LV: (see Appendix II) Effects of LV on: Nursing workforce, Organization and Patient The Nursing workforce Defamation of professional dignity, stress, anxiety, frustration, and anger (Rosenstein ODaniel 2008), sleeping disorders, reduced self-esteem, low morale, disconnectedness from their colleagues, depression, apathy, and excessive sick leave (Alspach 2007, Longo Sherman 2007), Suicide attempt (Griffin, 2004). According to the WBI, 45% of respondents had stress-related health problems which include debilitating anxiety, panic attacks, clinical depression (39%), and even post-traumatic stress. Not astonishingly, the adverse effects of LV are not only restricted to the targets. Co-workers witnessing LV report stress and job dissatisfaction. Witnesses who never report are confused how to stop assailant. Unluckily, their silence often leads them to despair and turnover (Lutgen-Sandvik 2007). Healthcare Organization Manifestations include: increased patient illnesses, increased healthcare costs, unplanned absences, law suits (Rowell 2005), malpractice risks (TJC 2008) and turnover (Rosenstein QDaniel 2008, Griffin 2004). Rocker (2008) states that between one third and one half of all work related absences and illnesses are a result of office bullying. According Yamada (2009) some victims pursue compensation or disability benefits as they are no more able to endure work stress and intimidation. Along with Stanley (2010) the overall increase in nurses turnover induced by LV from 2002 to 2007 is 32%. Turnover costs the organization per RN for 2007 $82,000 88,000. Additional costs are decreased productivity and loss of experienced and knowledgeable nurses. Malpractice of physicians and other healthcare providers, which is estimated at 4-6%, has a vast impact on organizational costs. Patients and families detect aggressive work environments (TJC 2008) and are ready to sue when they are faced with arrogant or insensitive behavior from healthcare workers (Aleccia 2008 as cited by TJC 2008). The Patient Rosenstein (2008) surveyed 4530 participants from 102 USA organizations from 2004-2007. The survey questions were intended to assess the respondents perception of the link between DB and patient care. The links were as follow: 66% adverse events, 71% medical errors, 53% compromises in safety, 72% detrimental impacts on quality of care, 25% patient mortality,18% were aware of a specific adverse event, 75% of them believe that the adverse event could have been prevented. According to Dunn (2003) some nurses may control patients by putting off their response to the patients needs- pain medicines, etc. Displeased nurses can also keep patients family uninformed about the patients health status or not support them when needed. Stanley (2010) reported that 1.5 million patients are harmed by medication errors yearly. DISCUSSION In todays sophisticated healthcare setting, each system brings particular skills to patients care. Whether the clinician is a nurse, or any other healthcare workers; each has a unique set of expertise and acquaintance that enable them to view the patient from a particular standpoint. Each field is taking care of the patient at distinctive times and intervals of the day. The doctor visits the patient one or two times a day for 15-20 minutes whereas the nurse employs several successive hours bedside his patient. Therefore, the nurse is the first one who detects and attends the alteration in patients status, not the physician. The patient and the efficacy of the healthcare team are dependent on each other to thoroughly and assertively communicate the changes in the health status of the patient. Unhappily; DB hinders this communication process which affects patients outcomes. It is of merit to mention that the international picture of LV is no difference from UAE.I have been working in the clinical setting for 16 years in different hospitals as a nurse and in a health institution as a teacher and clinical instructor. I have been exposed to and witnessed many episodes of Dbs. For example, I remember a situation when the head nurse asked the Surgeon whether he wants to start the patient on diet or continue keeping him nothing by mouth. The doctor replied in an offensive manner; give him Shoes. The head nurse asked him to write this in the order sheet. Sadly but true, the doctor did it without giving consideration to anything. The nurses felt that they were disrespected and were frustrated because of the recurrent response from the administration when DB is reported as status quo. That instance happened before 9 years but this troublesome situation impacted my psychological status that I recall it as if it occurred yesterday. Another incident, Though I do no t like to recall it, but its profound effect keeps it all the time in my imagination when the nurse came to the nursing counter crying once an aged patient got the money from his pocket and asked her to satiate his sexual desire. Furthermore, nurse on nurse aggression is also clear and take different forms ranging from verbal and non-verbal attack such as intentional rolling of eyes, folding arms, gazing into space when communication is being attempted, backbiting, withholding informationà ¢Ã¢â€š ¬Ã‚ ¦etc. to physical assault such as pushing each other. These DB extended also to the patient particularly the dependent and the unconscious patients who were insulted either by bad words or inappropriate care. The negative effect of these DBs was manifested by medical errors, reduced patient safety and care, decreased performance and productivity, frustration, dissatisfaction, turnover, and poor hospital reputation. Although these are merely anecdotal notes, there are comparable events recognized in the research. Rosenstein ODaniel (2006) presented selected comments acquired from a survey of 4530 healthcare providers. They include terms such as RN did not call doctor about change in patients health status because the doctor had a history of abusive behavior and particular surgeons give the impression that they have the right to be impolite and verbally offensive. It is hard to maintain a high level of performance when repetitively scared of being yelled at (Rosenstein ODaniel2006). Unhappily, DB is not solely restricted to doctors. Rosensteins survey data supports the issue that DB spread to other non-physicians employees. Remarks include; DB from nurses is much more upsetting. I expect it from the surgeons but not from my peers and please realize that most stress is from RN managers, not MDs. According to Rosenstein ODaniel (2008), the most common situation that triggered DP by doctors, as conveyed by nurses, was calling physicians to report a decline in the patients condition. This shows a failure in communication that ought to bring dreadful results on the patient. For instance, if the physicians order is inaccurate or not clear. The nurse many not carry out the order until clarified by doctor. If the nurse is anxious about making a telephone to the doctor due to fear of an annoyed eruption, she might postpone the call or make another work around by evading the doctor entirely and including another party. If there is inaccurate order of medicine, this situa tion can be revealed in various ways, all with awful outcomes for the patient. Primarily, the issue will not be verbalized as the practitioner did not desire to confront the stellar reputation of the doctor or because they were demoralized by previous behavior (ISMP 2008). Consequently, the incorrect medicine will be given. If the nurse calls the doctor and feels that the physician is irritated, the incorrect medicine can still be given and secondary repercussions such as being unable to correct the order in the future can result. Unfortunately, several nursing staff has to live with the guilt of a serious error because they did not follow up on a questioned situation (ISMP 2008). The negative outcomes of such an error can result in stress and frustration for all involved and thus can bring about DB. Limitations Workplace LV is a complicated issue. A diversity of expressions is used to reveal similar behaviors .Although they possess distinctive meanings, the terms are frequently used interchangeably in the nursing literature. There are also a many workplace abuse that might be categorized as DB. First, the paper has focus merely on psychological and/or verbal abuse and not physical or sexual harassment. Second, the majority of literature focuses on LV in nursing profession in particular and to a certain degree

LAN networking :: essays research papers

If you want to add additional computers to your network in the future, all you need are more Network Interface Cards and 10BaseT cables. Simply plug the new network cards(s) into your computer an run a cable form the card to one of the hub’s open ports. For even greater expandability, the hub can be joined, or uplinked, to other hubs. If you look closely at the front of the hub, you will see a port marked Uplink. To uplink a hub, simply insert a standard, straight-through 10BaseT cable between the Workgroup Hub’s Uplink port and any of another hub’s regular 10BaseT ports. A maximum of three hubs can be connected together. For example, like most hubs, a 5-Port Hub’s port number 5 and Uplink port are joined internally. This means that when port 5 is in use, the uplink port cannot be used, and vice-versa. If you plan on using the uplink port, you’ll need to disconnect any cables that are connected to port 5. Setting up your network card’s software involves installing a network driver onto your computer. The driver will allow the card to communicate with your Network Operating System (NOS). Software package. Some of these NOS include Windows for Workgroups, Windows 95/98, Windows NT, and Novell. All the network cards that you buy should come with a 3.5† software disk where it includes drivers for different NOS. They should also have instructions on how to install them, but this hand out will help you understand and teach you how to install drivers. After installing your network card hardware in your computer, follow the instructions below to install the card’s software. 1.  Ã‚  Ã‚  Ã‚  Ã‚  Install the network card hardware if you haven’t already 2.  Ã‚  Ã‚  Ã‚  Ã‚  Start up your computer and Windows 95/98. 3.  Ã‚  Ã‚  Ã‚  Ã‚  Windows 95/98 will automatically detect the presence of your network card hardware in your computer.   Ã‚  Ã‚  Ã‚  Ã‚   If Windows 95/98 goes immediately to the windows desktop, and does not display a new hardware detected message. Go to my computer > control panel > system > device manager tab > select the network adapter and remove it from the list > restart computer and you should get a windows asking for drivers. Important: When you reboot Windows 95/98 may ask you for the Operating System CD ROM. Please provide them as necessary. 4. Windows 95/98 will detect your network card and display a †New Hardware Found† window as shown bellow 5. Put your 3.5† in drive A with the network card drivers that came with the it.

Behaviorist Revised

By properly incorporating repeated practices and mechanisms in the study of business math, an educator can actively create participation and appreciation of the course objectives. Also by properly incorporating mechanisms for motivation, students can appreciate the way the subject is taught. The overall rationale in creating world problems in teaching business math is to incorporate students the proper attitude and behavior that is deemed to address each problem. This specifically coincides with the notion of a behaviorist approach by Skinner.Skinner is â€Å"one of the behaviorist psychologists saying that a measurable learning outcome is only possible if we change the learner’s behavior. † (Faryadi, 2007, p. 2) Basing from such idea, educators must incorporate the understanding that the students are responsive in the environment they are given into. It is through this that educators must understand the meaning of classical conditioning. This process usually involves h aving a stimuli and response from people.Conditioning students can be a very effective tool for them to acquire the information that they need. â€Å"The most efficient use of conditioned reflexes in the practical control of behavior often requires quantitative information. † (Skinner, 1976, p. 10) The use of examinations can be a gauge to determine their individual development as a student in accordance to guidelines and objectives of the subject. By incorporating exercises and exams, educators can control the tempo and analyze the way students grasp the subject they are studying.In addition, such world problems can help facilitate observable facts that the teacher can use to improve the subject he/she is teaching. It is the overall environment that It is through this rationale that the idea of behaviorism can be applicable in the realm of education. It seeks to foster a different way of arriving on how people learn. â€Å"In other words, behaviorism states that the mind do es not help a person acquire knowledge but instead it is the psychology of the environment which a person lives. † (Faryadi, 2007, p. 3)Recognizing this, there is a need for educators and teachers to create motivational scenarios for students. These activities are called ‘positive reinforcement’ in behaviorism. One example of an activity would be creating a reward system for students who go above the expected results. This will motivate students to study harder on the notion of achieving extra credits. To conclude, creating examinations and exercises by teachers can be very helpful in determining the grasp of student in the subject according to the behaviorist approach.By carefully understanding its relative tenets, educators can facilitate better teaching and imparting of information which is vital in the overall learning process. In the end, such actions can motivate students to learn more given the proper amount of reinforcement. References Faryadi, Q. (2007) B ehaviorism and the Construct of Knowledge in Education Resource Information Center (ERIC). Retrieved March 16, 2008. Skinner, B. F. (1976) Behaviorism. United States; Random House Inc.

Business Reasearch Method Part 1

Business Research Methods Part I Sara Gonzalez QNT/561 March 19, 2013 Business Research Methods Part I A business organization must make tough decisions when faced with a dilemma. They could be rising costs, employee turnover, or in the case of British Petroleum (BP), safety. The recent explosion, deaths, and environmental impact of the deepwater Horizon oil drilling platform in the Gulf of Mexico brought the question of drilling platform safety to the forefront of the news, continuing to do so over two years later. The disaster is one of the more recent events and â€Å"is the largest marine oil spill in history† (Cleveland, 2013).Research Question The dilemma that BP faces is keeping their employees safe while working in an industry known for its immediate danger. Are there warnings in the form of safety incidents that show likelihood that an event similar to the deepwater Horizon could happen again? Research Design A case study, â€Å"also referred to as the case historyâ €  (research text) is used to â€Å"obtain multiple perspectives of a single organization, situation, event, or process at a point in time or over a period of time†. (Cooper & Schindler, 2011, p. 81) The research for this case study will include safety reports from many global oil companies. The purpose for researching many companies is because â€Å"When multiple units are chosen, it is because they offer similar results for predictable reasons† (Cooper & Schindler, 2011, p. 181). It is expected that researching different oil companies will show a common factor in safety incidents leading to catastrophic events. Sample Design A non-probability sample design will be used for collecting data. However, to select effectively a sample design certain questions must be answered.They include, â€Å"What is the target population? What are the parameters of interest? What is the sampling frame? What is the appropriate sampling method? What size sample is needed† (Coop er & Schindler, 2011, Chapter 14, Steps in Sampling Design)? Target Population Our target population will consist of the employees at BP that can provide or have access to statistical data related to our research question. This includes workers who are exposed to the possibility of injury while performing regular day-to-day job duties. Parameters of InterestPopulation parameters will describe the â€Å"variables of interest in the population† (Cooper & Schindler, 2011, Chapter 14, Steps in Sampling Design). These include the sample mean, sample variance, and proportion of safety incidents to incidents resulting in injury. Sample statistics will serve as a â€Å"basis of our inferences of the population† (Cooper & Schindler, 2011, Chapter 14, Steps in Sampling Design). Sampling Frame The sampling frame will be a list of the subjects that make up the population of our sampling design. Characteristics can include age, work experience, and position within BP.Appropriate Sa mpling Method Our sampling design is limited to team member Scott Thrasher’s exposure to BP’s employee population. Again, a non-probability sampling design is the most appropriate method because it does not require the entire affected population at BP and only relies on the subjects who are readily available to him (Crossman, n. d. ). Sample Size At this point we have not established a standard for sample size. It is, however, agreed that a larger sample will provide the most accuracy, precision, and least chance for error (Cooper & Schindler, Chapter 14, Steps in Sampling Design, 2011).References Cleveland, C. J. (2013). Deepwater Horizon Disaster: Deepwater Horizon oil spill. Retrieved from http://www. eoearth. org/article/Deepwater_Horizon_oil_spill? topic=50364 Cooper, D. R. , & Schindler, P. S. (2011). Business Research Methods (11th ed. ). Retrieved from The University of Phoenix eBook Collection database. Crossman, A. (n. d. ). Types Of Sampling Designs. About. com. Retrieved from http://sociology. about. com/od/Research/a/sampling-designs. htm

A female with chronic diarrhoea and loss of weight Essays - Medicine

A female with chronic diarrhoea and loss of weight Essays - Medicine A female with chronic diarrhoea and loss of weight : Analysis of a case : A 25-year- old female, Valli, from Chennai, India , visited the medical outpatient department for complaints of diarrhoea and flatulence off and on for the past 5 years , more so since 3 months . She said that she had lost a considerable amount of weight and always felt weak and exhausted. She also admitted having low backache since 3 months. She said her faeces were bulky, greasy and foul smelling. Throughout childhood, she had persistent diarrhoea but the symptoms subsided in adolescence. She was referred to a gastroenterologist. The consultant arranged for blood and faecal analyses. The faecal tests showed that she had steatorrhoea and the blood examination revealed a dimorphic anaemia with a low serum calcium. Her serum electrolytes and prothrombin time were within normal limits. The consultant suspected coeliac disease and arranged for an endoscopy. An endoscopic biopsy of the mucosa taken showed flattening of the villi with excess of plasma cells in the submucosa. What is coeliac disease? It is an abnormal reaction to gluten, a constituent of wheat flour, leading on to diarrhea and malabsorption. It is also called gluten-sensitive enteropathy, with the onset of symptoms occurring at ages ranging from the first year of life through the eighth decade What is the basic defect in this condition? The basic defect is enterocyte damage causing atrophy of the villi and malabsorption caused by Gluten, a constituent of wheat flour. The damage is due to an abnormal immune response to gliadins ,especially -gliadin, components of gluten. What is its aetiology? It is genetic, immunologic and environmental. It is a T-cell mediated disease. Antibodies to the enzyme transglutaminase released in tissues during inflammation are present in 98 %.Deamidation of gliadin by transglutaminase generates a recognition site for CD4 T lymphocytes; the locally activated lymphocytes trigger production of cytokines which then cause the damage. Gliadin peptides interact with gliadin-specific T cells that mediate tissue injury and induce the release of one or more cytokines (e.g., IFN-) that cause tissue injury. Transglutaminase antibodies also affect the differentiation of epithelial cells, by interfering with the action of the enzyme. What is the HLA associated with celiac disease? All patients express the HLA-DQ2 or HLA-DQ8 allele, though only a minority of people expressing DQ2/DQ8 have celiac disease. Absence of DQ2/DQ8 excludes the diagnosis of celiac disease What are the clinical features? The symptoms of celiac disease may appear with the introduction of cereals in an infant's diet, although spontaneous remissions often occur during the second decade of life that may be either permanent or followed by the reappearance of symptoms over several years. Alternatively, the symptoms of celiac disease may first become evident at almost any age throughout adulthood. In many patients, frequent spontaneous remissions and exacerbations occur. The symptoms range from significant malabsorption of multiple nutrients, with diarrhea, steatorrhea, weight loss, and the consequences of nutrient depletion (i.e., anemia and metabolic bone disease), to the absence of any gastrointestinal symptoms but with evidence of the depletion of a single nutrient (e.g., iron or folate deficiency, osteomalacia, edema from protein loss). Some have manifestations that are not obviously related to intestinal malabsorption, e.g., anemia, osteopenia, infertility, neurologic symptoms ("atypical celiac disease"); while an even larger group are essentially asymptomatic though with abnormal small intestinal histopathology and serologies and are referred to as "silent' celiac disease. What are the likely causes of diarrhoea in coeliac disease? High concentrations of unabsorbed nutrients in the chime would lead to osmotic diarrhea.However the delivery of large amounts of fat into the colon can result in the production of hydroxylated fatty acidsby colonic bacteria. These act as cathartics. Diarrhea may be secondary to (1) steatorrhea, which is primarily a result of the changes in jejunal mucosal function; (2) secondary lactase deficiency, a consequence of changes in jejunal brush border enzymatic function; (3) bile acid malabsorption resulting in bile acid-induced fluid secretion in the colon, in cases with more extensive disease involving the ileum; and (4) endogenous fluid secretion resulting from crypt hyperplasia. How do you arrive at a diagnosis? A small-intestinal biopsy is required to establish a diagnosis of celiac disease. The classical changes seen on duodenal/jejunal biopsy are restricted to the mucosa and include (1) an increase in the

Retail Service Management Key Indicators Essay Example | Topics and Well Written Essays - 1000 words

Retail Service Management Key Indicators - Essay Example Since the data sheet had already summarized the major monthly indicators (with little or no primary data sets), the analysis below concentrated on the examining the temporal patterns across the three months. For the purposes of tracking the repair order, mailing reminders and financial summaries across time, key indicators were analyzed across the months January through March. Since most of the data was categorical (by month), histogram polygons were constructed. To provide a frame of reference for the period under analyses, where relevant and necessary, average and standard deviation of the respective indicators were calculated. For purposes of clarity, results of only some of the most important indicators, namely active number of customers, number of customers lost, percent sales of Smart link, investment returns on each US $ 1 spent are presented and discussed. This is an important variable indicating the proportion of the various maintenance and repair jobs undertaken at the company. Accordingly, based on the data provided, frequency histogram was constructed to depict the proportion of the different maintenance tasks undertaken. ... 3. Retail revenue sales trend: Based on the graph already provided in the data sheet, discussion is provided on the contribution that Smart Link sales have made over the gross sales during the different days of the survey period. 4. Percentage share accounted by the different zip codes: The relative contribution made by the different zip codes for their share of the services and how these have changed from month to month has been analyzed. The mean per cent share of the different zip code was computed across the three months. Results: Repair order, mailing and financial summary results: Over the three months of reporting, a total of 4056 services were completed, with January accounting for the highest (37% of the services) and March, the least (30% of the services) (Figure 1). The mean number of active customers over the three months was 233954 (average standard deviation) with little variation across the months (Figure 2). The number of completed services ranged between 1210 (in March 2006) to 1490 (in January 2006). On an average there was only a 6 to 8 per cent loss of customers over the three months (Figure 2). Figure 1: Per cent services completed by Smart link from January to March 2006.Total customers serviced for the three months=4056. Figure 2: Frequency histogram of active and lost customers from January to March 2006 by Smart link. Two of the most important financial status parameters, namely, per cent of Smart link sales and the investment return for every dollar spent, increased from January to February but thereafter decreased in March 2006. For example, the investment returns increased from $215.52 in January to

Mktg Essay Example | Topics and Well Written Essays - 250 words - 5

Mktg - Essay Example When the correct market for Pradaxa has been identified, the product would be easily sold. In case, the company is attracting few people who are in dire need of Pradaxa, it is important to search for a remedy by focusing on large and correct market segments. In addition, it is good to have a clear understanding of the target market who in this case are patients with atrial fibrillation. The more the market is understood, there is high possibility of developing trust in customers who purchase the product. In addition, it is important to identify the age of your market so as to avoid targeting wrong age (Moehlman 46). For instance, Pradaxa product would target people aged sixty and above because most people of this age in U.S suffer from atrial fibrillation. The company should make an assessment to establish if the customers are satisfied with the product, if not, then the company should attempt to find a solution to their needs by improving on its product. Another important aspect of target market is that the company needs to look at the available competition. By doing this, Pradaxa product should be supplied to under-served markets. It is prudent to assess the strength and weakness of your competitors and try to find mechanism that can be different from them. Pradaxa has for long time faced competition from Warfarin. There is need to utilize opportunities such new uses in surgery patients and eliminate threats such as bad publicity dealing with side effects so as to compete favorable with Warfarin and attract more