Corporate Structure

Demand for disclosure has been spurred by information asymmetry and agency conflict between management and investors. Good corporate structure principles are the foundation upon which trust of investors and lenders is built, corporate governance is a philosophy and mechanism that entails putting in place better structures and processes through which the affairs of a company are directed and managed to enhance long term shareholders value through transparency and accountability. Previous empirical studies on the association between cost of equity capital and voluntary disclosure have documented confusing results, Botosan and Plumlee (2002) found a positive association exists between voluntary disclosure and cost of equity capital while Gietzmann and Ireland (2005) found a negative relationship between disclosure and cost of capital. Increased application of corporate governance all over the world has risen after major corporate scandals due to lack or improper corporate disclosure, this has resulted to investors and lenders lose confidence in the traditional financial reporting. Transparency and disclosure creates and sustains confidence of investors, stakeholders and the winder society and provides opportunity for continuous improvement of business structure and processes this has resulted to re-examination and scrutiny of the existing corporate disclosure thus spurring the need for expanding the existing disclosure policy. Voluntary disclosure, being one key pillar of corporate governance is regarded as an external mechanism for the control of the management, protection of the shareholders and a decrease of the agency costs resulting from information asymmetry between the management and shareholders. Botosan (2002) observed that firms which disclose more information in their annual reports enjoy the benefit of lower cost of capital. The current growing trend towards increased corporate disclosure will soon transform into a veritable river of additional information.Although the purpose of disclosure is to provide adequate and sufficient information to the various stakeholders, managers may choose not to disclosure certain information in orders to protect competitive advantage Kavitha and Nandagopal,(2011). Studies have shown that public firms are careful about disclosing information that might lead to competitive disadvantage, example, information about technological innovations, strategic and specific operation data Elliott and Jacobson (1994). The decision on the optimal level of disclosure is thus affected by the interplay between the costs and the benefits of disclosure. 1.2 Voluntary Disclosure Elements of voluntary disclosure will be classified into four classes of information disclosure as forward-looking, financial, corporate social responsibility and board size. Voluntary disclosure is regarded as an important economic tool that aids communicating information to different market players in an industry with an aim of providing clear view about business's long term sustainability. Information disclosure conveys company's information to the owners, stakeholders and general public about the quality and value of the company Hamrouni et al.,(2015).Corporate disclosure falls into two categories, mandatory disclosure and voluntary disclosure covering all types of information, both of financial and non-financial in nature. Laws, regulations and accounting standards stipulate mandatory information disclosure whereas voluntary disclosure is the information reported beyond the statutory requirements. Meek el al, (1995) defines voluntary disclosure as the free option on the part of the company management to provide accounting and other information deemed pertinent to the decision needs of users of their annual reports. The extent and type of voluntary disclosure is dependent of the industry, size, governance structure, ownership structure and geographic region. Boesso and Kumar (2007) claimed that one of the determinants that led to the emergence of voluntary disclosure was the inadequacy of financial reporting as claimed by investors and shareholders . Investors increasingly demanded openness and disclosure of information relating to performance and strategies. Organizations gains some benefit by virtue of disclosing sustainably over and above the statutory required information. Li and McConomy (1999) found that firms in better financial conditions are more likely to voluntarily adopt new International Financial Reporting Standards (IRFS) on environmental disclosure and hence become more profitable and reduce the cost of compliance. Spanheimer and Koch (2000) noted the primary motive for adopting informative accounting as the access to global funding, worldwide comparability of financial statements, increased transparency and pressure from capital markets. Ross (1997) found that companies that provide more information disclosures reduced the occurrence of information asymmetry between the owners and manager, subsequently get to enjoy low cost of capital. The benefits of disclosure are for example, increased share price will lower cost of capital resulting from a firm's full disclosure Nayak, (2012). Investors and creditors are better informed with a high level of disclosure making them understand the economic risk of the investment Elliott and Jacobsom, (1994). Disclosure is generally done in the company annual report either through the statements or notes accompanying the statements. The disclosure elements in the study for measuring the level of voluntary disclosure will include forward-looking information, financial and capital information, corporate social responsibility information and board size information. Forward-looking information represents one form of corporate disclosure. It provides a confidence signaling power to the stakeholder in the management capability to foresee the future prospects of the business. According to Celik et al. (2006) forward-looking information helps to predict the future of a company in terms of performance and strength of the management. Management credibility is gained by accurately predicting company future forecast over and over. Even though the shareholders frequently question the management about what is going to happen to the company in future, the management cannot predict or gives a certain answer to what is going to happen but they observe market trends and then present the shareholders with explanations about what the company future prospects. Companies that wish to access external sources of finance may tend to disclose more forward-looking information to enable them gain investors confidence Clarkson, Kao and Richardson (1994). Jenkins Report (AICPA, 1994) formulated a number of key recommendations to increase the quality of corporate reporting, which included increasing the attention for and provision of forward-looking information. Financial information disclosure helps stakeholders to evaluate company performance before making any investment decisions about the company. Improved information disclosure does not only bridge the information asymmetry between management and shareholders but also facilitate the functioning of the financial and economic systems. Adequate disclosure is used as a mean of attracting new investors in addition to supporting and building company reputation. To reduce vulnerability, information disclosure should be comprehensive, timely, informative and credible in nature. Financial information is derived from the financial reports prepared from the books of accounts and analyzed in various categories such as the income statements, balance sheet, statement of cash flows and statements of changes in equity. Corporate Social Responsibility (CSR) interpreted as the way firms integrate its social, environmental and economic concerns into their value, culture, operations and strategies. Carroll, (1999) noted CSR as an evolving concept. Centre for corporate governance (2005) issued guidelines which encouraged companies to disclose information on CSR, ownership structure and board size (Barako, 2007). CSR efforts translate into improvements in firms' financial performance. Corporate social reporting disclosure enhances company reputation by gaining trust and support from the stakeholders (Woodwar, Edwards and Birkin, 1996), additionally it helps assess congruence between the social value and social norms (Dowling and Pfeffer, 1975). CSR enables firms to access huge sum of finance that might difficult to obtain.Board size is the total number of directors on a corporate board. The board of directors is the apex organ of a company whose central role being the formulation of polices and strategies to be followed by managers in managing firms operations. Board plays an important role in maintaining effective corporate governance. It is the Board that determines the amount of information disclosure by making strategic decision on the level of voluntary disclosure. Chen and Jaggi (2000) noted that greater number of directors on the board may reduce the likelihood of information asymmetry. It is believed that the size of the board affects the ability of the board to monitor and evaluate management. Increase of directors in the board will consequently increase director's ability to control and promote value creating activities. Larger board bring with them a collection of experience and expertise, therefore expanding the need for higher information disclosure, it is also argued that larger board size may find difficulty in arriving at a consensus in decision which can ultimately affect the quality corporate governance while small board size encourages faster information processing . Brudbury (1992). 1.3 Cost of Equity CapitalThe cost of equity is the return that an investor expects to receive from an investment in a business. This cost represents the amount the market expects as compensation in exchange for owing the stock of the business, it consist of dividends and capital gains. From an investor's perspective, cost of equity capital is the return he expects for a share of stock he keeps in his portfolio. Fama and French (1993) found risk growth and size as the factors that influence the required rate of return by investors. When making decisions which affect the firm, Cost of equity plays a crucial role because it affects the discount rate at which expected future cash flows are valued. In archiving an effective strategic decision making and performance evaluation, the cost of equity should be estimated with accuracy. According to Beneda (2003) the cost of equity is a vital base of comparing investment opportunities. Invertors use the concept of cost of equity as an investment opportunity in a company. Cost of equity is one of the methods used to evaluate investment decisions, example capital budgeting analysis, choice of capital structure and firm valuation. Larger firms are associated with lower cost of capital when compared with the smaller firms since they are in a better position to raise funds from external sources on favorable terms. Equity capital plays a fundamental role in the development of a firm due to its advantages when compared to other financing forms. The cost of equity capital is an important component with significant input in calculating the cost of capital Cotner and Fletcher (2000). It is detrimental to apply less appropriate model to estimate cost of capital, this can result to underestimation or overestimation. Underestimation may result in value destructive investments while overestimation may lead to rejection of promising investment opportunities. The cost of equity capital is a key indicator of operations in the financial markets and is used by managers and financial resource providers. Clear financial statements reduce uncertainties associated with shareholders' equity lending to decrease in the cost of equity while incomplete and unclear financial statements increases uncertainty hence causing information risk to shareholders who hence demand higher return. The cost of equity capital is of importance in two folds: securities valuation models are based on the cost of equity capital and without cost of equity capital it is impractible to invest company money as it is difficult to determine capital structure hence unable to determine investment priority (Ahmend, 2007). Manager being agents of the shareholders try minimize the cost of equity hence maximizing shareholders wealth at this same time improving the value of the company. In most financial decisions, cost of equity is an effective determinant factor. Cost of equity is used in capital budgeting decisions, setting optimal structure and working capital management. Implementing corporate governance practice, the high cost of equity capital problem is overcome. The higher level of voluntary disclosure the lower investor uncertainty, with lower uncertainty investors will be willing to accept lower dividend payouts. A lower dividend stream would decrease the cost of equity capital because of a lower risk premium expected by the investors. Lower risk premium demanded by investors translate into a lower cost of equity capital of the firm. Voluntary disclosure reduces the cost of equity capital in two ways which are based on enhanced stock market liquidity and on the reduced non-diversifiable estimation risk. More voluntary disclosure reduces investor uncertainty and attracts long term investments. Determinants of the cost of equity capital can be categorized into two: variables measured on accounting information only (accounting based) and variables measured on relations between market data and accounting data (market based).

International Assignments Essay

1. Determine four to six (4-6) components that the pre-departure training will need to cover. Provide a rationale for the use of using the training components in question. The four components that pre-departure training will need to cover are cultural awareness training, preliminary visits, language instruction, and assistance with practical, day to day matters. A well-designed cultural awareness training program seeks to foster an appreciation of the host country’s culture so that expatriates can behave accordingly, or at least develop appropriate coping patterns. A preliminary trip to the host country provides a preview to assess their suitability for and interest in the assignment and country. It helps to encourage more informed external stakeholders as well as host-country nationals. Language skills are a critical component in assignment performance and a gauge on ability to adapt and perform on assignment. Hiring of language competent staff to increase the â€Å"language pool† and up-to-date information on language skills is important and critical. Practical assistance helps provide guidance and assistance with relocation to the host country. Having one fend for themselves in a new country can result in a negative response towards the host country so any assistance from relocation specialists is of value to the candidate/employee (Dowling & Festing, 2009). 2. Propose three (3) criteria that management will use to assess the performance of expatriates working abroad. Support your proposal with examples of the fundamental ways in which these performance requirements have improved performance. An assessment of an expatriate employee’s performance is critical to the success of an international assignment. Issues such as the criteria and timing of performance reviews, raises, and bonuses should be discussed and agreed on before the employees are selected and placed on international assignments. Each international office should use a different appraisal system. Employers should not use a performance appraisal system that was  used for domestic employees and try to modify it for use with expatriate employees because many variables need to be understood and taken into consideration. Performance criteria and goals are best established by combining the values and norms of each local environment with the home-office’s performance standards. An individual country profile should be developed and should take into account the foreign subsidiary’s environment. This profile should be used to review any factors that may have an effect on the expatriate employee’s performance. Such factors include language, culture, politics, labor relations, economy, government, control, and communication. 3. Recommend the recruiting and selection strategy that you believe your firm should use when offering international assignments. Provide a rationale for your recommendation. International assignments, or the act of sending employees to different countries on project assignments, are a growing trend. Because international assignments are typically very expensive, failure can have big impacts on the business. It is imperative to hire more reliable and effective international assignees. The following are criteria that should be used to select the appropriate candidate: 1-Use of a selection panel which consists of a manager from the function being recruited for, staff who have detailed knowledge of living working and conducting business in the intended assignment destination, HR staff from home and host country and international HR. 2- Choose candidates that have successfully completed similar international assignments. Candidates should have previously succeeded in the target country or in a similar culture setting. Consideration should also be taken for those who have studied abroad or performed some other role in the country. 3-Prioritize candidates who are fluent in the language of the assignment destination. 4- Use of intercultural adaptability assessment tools potential of candidates to innovate, lead, manage, collaborate and socialize in different cultures. 5- Candidates should be provided with a realistic job assignment preview so that they know both the good and bad aspects of the assignment. 6- Allow candidates a reconnaissance trip after an offer has been made so that they  see if they are a good match for the work and life in the host country, pending budget plans. If these criteria are taken into consideration, then the assignment has a greater chance of succeeding (Ladimeji, 2012). 4. Compare and contrast two (2) staffing alternatives for foreign operations at your multinational firm. Select the staffing alternative that you believe to be the best fit for your scenario and provide a rationale for your selection. Two staffing alternatives are ethnocentric and polycentric staffing approach. The ethnocentric staffing approach involves the Parent-country nationals, or people from the home country of the corporation who are employed to fill key managerial positions because they are familiar with the goals, policies and procedures, technology and products of the parent company. They are in a much better position to report to the company, especially where there is an inadequacy of managerial skills at the local level. It is the preferred method with a centralized approach to globalization. The second approach is the polycentric and uses HCNs to fill key positions. This is more effective when a company wants to act â€Å"local.† It is also usually less expensive to hire locals, however, there could be difficulty in the areas of coordinating goals between the main and regional offices. 5. Analyze the importance of providing a high-quality mentoring system for international assignees. Provide o ne (1) example of a high-quality mentoring system for international assignees to support your analysis. A successful mentoring system can only succeed if the following are taken: Commitment from senior management, creation of a program that has some flexibility and not too much formality, training for mentors that helps them to support rather than teach assignees, understanding that mentoring needs to fit in with senior employees’ heavy workloads. Just like any job, there needs to be guidance and instruction and a good mentorship will aid the candidate in their international assignment (Cowell, 2004). 6. Suggest the manner in which you plan to measure return on investment (ROI) for international assignments. Provide a rationale for your decision. The best evaluation for ROI investment assignments is to set expectations  for several baseline competencies that will be gained from the international experience. The creation of new networks in the host countries as well as new hires or development of intercultural skills. References Cowell, P (2004, November 8). Mentoring: a step towards successful repatriationRetrieved August 15, 2014. http://www.expatica.com/hr/story/mentoring-a-step-towards-successful-repatriation–10573.html Dowling, P. & Festing, M. (2009). International human resource management: Managing people in a multinational context (5th ed.). Mason, OH: Thomson/South-Western. Ladimeji, K. (2012, August 31). How To Pick the Right People for International Assignments. Retrieved August 15, 2014. http://www.recruiter.com/i/how-to-pick-the-right-people-for-international-assignments/ Major Alternative Staffing Approaches for international operations. (2004, July 19). In WriteWork.com. Retrieved 15 August, 2014, from http://www.writework.com/essay/major-alternative-staffing-approaches-international-operat

The Use of Intraosseous Vascular Access

The Use of Intraosseous Vascular Access Table of Contents Title Page†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 1 Table of Contents†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 2 Executive Summary†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 3 Body of Paper†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 4 Plan†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã ¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 6 Do†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 7 Check†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 7 Act†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦8 Research to Support Change†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â ‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦8 Change Theory†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 6 Conclusion†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 18 References†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 20 Timeline†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚ ¬ ¦. 22 Executive Summary First introduced by Drinker and colleges in 1922, intraosseous (IO) vascular access was a method used during World War II for accessing the non-collapsible venous plexuses within the bone marrow cavity to provide access to a patient’s systemic circulation. This method later fell out of use after the development of intravenous catheters.Then during the 1980s IO vascular access was again introduced as a rapid way of gaining vascular access for swift fluid infusion particularly during resuscitation attempts of pediatric patients. (Tay & Hafeez, 2011) Plan-Being by implementing a policy for the use of IO vascular access within the Emergency Department of Hays Medical Center (HMC) for critically ill patients. This would expedite critically ill and severely injured patients in receiving the intravenous fluids and medications.Currently there is no policy in place for the placement of IO devices as opposed to peripheral intravenous catheters, or central veno us catheters. However, if there was a policy in place the staff would know when it was appropriate to insert an IO device, as opposed to having to make a difficult decision based on personal judgment. Do- Create a group of physicians and nurses to write a policy outlining when it is appropriate for the placement of an IO device compared to traditional techniques for gaining venous access. Once the policy has been written implement its use within HMC’s ED.Check- Keep a careful record of when an IO device is placed, in accordance to the new policy. Monitor the outcomes of these patients. Evaluate the effectiveness of the new policy and determine if any changes need to be made. Act- Based on the information obtained during the check phase of this project, management will determine whether the policy will be continued, improved, or discontinued. The Use of Intraosseous Vascular Access in Critically Ill Patients The origin of the intraosseous cavity as an access sight to the circu latory system was originally discovered during World War II.Medical personnel during this time used an IO route to resuscitate patients suffering from hemorrhagic shock. It was first documented in medical journals by Drinker and colleges in 1922. It was later rediscovered by American pediatrician James Orlowski. During his time working in India, Orlowski observed medical personnel during a cholera epidemic using IO access to save patients in whom IV cannulation was impossible and who might have died without access. He later wrote about his experiences in a paper entitled, My Kingdom for an Intravenous Line. Wayne, 2006) Since Dr. Orlowski brought the use of IO access in pediatrics back into the medical spotlight, the implications for its use within the adult population were soon being addressed. In 2005, the American Heart Association stated in its Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care that â€Å"IO cannulation was appropriate to provide acc ess to the non-collapsible venous plexus found in the bone marrow space, thus enabling drug delivery similar to that achieved by central venous access. (American Heart Association) Intravenous access can mean the difference between life and death when dealing with critically ill patients. IV access means that patients can receive fluids, blood products, and life-saving medications. During situations when time is precious, and access is critical is not when nurses should be making their fifth attempt at a peripheral intravenous catherization (PIV). It also shouldn’t be when chest compressions are stopped, so that the doctor can try for a central venous line (CVL).The average time necessary for PIV catherization is reported to add up to 2. 5-13 minutes and sometimes even up to 30 minutes in patients with difficult to access peripheral veins. (Leidel, Chlodwig & Bogner, 2009) This is one of many reasons why it is imperative to have a policy in place so that the staff knows that IO access should be a go to option rather than a last resort. There are very few contraindications when it comes to the placement of an IO device. However, to untrained medical personnel the thought of having to place an IO device is very daunting.I didn’t realize until this semester that it is within the scope of practice for a RN to place an IO device, but it is absolutely is! â€Å"It is the position of the Infusion Nurses Society that a qualified RN, who is proficient in infusion therapy and who has been appropriately trained for the procedure, may insert, maintain, and remove intraosseous access devices. † (â€Å"The role of,† 2009) There is also the fact that of having to explain the procedure to the patient and the patient’s family. The fear of needles is a real one.The thought of an intramuscular injection can send certain patients into a full blown panic attack. So the thought of actually having their bone pierced with a needle is a frightening o ne. Thankfully most patients who are critically ill enough to necessitate the placement of an IO device are unconscious. In cases where patients are not unconscious, an IO device can be placed with minimal discomfort if proper anesthetic techniques are used. These techniques should be taught along with placement so that nursing staff is aware of how to place an IO with minimal discomfort to the patient.It needs to be noted that â€Å"the pain associated with insertion of the EZ-IO needle is similar to that associated with insertion of a large peripheral intravenous needle and may be alleviate with infusion of lidocaine solution. † (Luck, Haines & Mull, 2010) Unlike PIVs and CVLs, IO access can be obtained from multiple sites with less chance of being unsuccessful. The locations include: proximal tibia, distal to the tibial tuberosity, distal end of the radial bone in the upper imb, proximal metaphysis of the humerus, distal tibia, proximal to the medial malleolus, distal femu r, above the femur plateau, the sternum, and also the calcaneus (Tay & Hafeez, 2011). However, IO access is typically obtained via the proximal tibia or proximal metaphysis of the humerus. There are currently three different ways to gain IO access. The first and oldest way is a manual insertion of the IO device. In this way the device is placed using the force applied by the clinician, and is done in a rotating motion. The second technique is the use of an impact device.In this case, a spring-loaded IO device is to insert the needle into the bone using direct force. The last technique is a powered drill. The small, handheld device drills the IO needle into the bone with a high-speed rotating motion. Plan To implement a policy within the Emergency Department at Hays Medical Center that clearly outlines when the placement of an intraosseous access device should be used as opposed to more traditional techniques for gaining venous access. A committee would be assembled to look at the re search on IO placement.This committee would consist of three physicians and three nurses, and will be given three months to write a policy for the department. This committee will determine in which situations an IO should be placed. The American Heart Association guidelines for intraosseous vascular access should play a major role in this decision. Once criteria has been chosen a checklist will be created that can be hung on the walls of the trauma rooms and handed out to staff. This checklist will aide in helping the staff to be able to more quickly determine in which situations placement of an IO is within the department’s policy.The appointed committee would also be in charge of deciding on which type of IO device the department should use. They will research the availability of the device chosen and what the cost will be to stock the department which the device. Do Once the research is gathered, the assigned research committee will reassemble to compose the policy that wi ll become implemented within the Emergency Department. After the policy has been written, a mandatory unit meeting will be called to introduce the new policy and answer any questions that the staff might have.During this meeting, a demonstration will be given on the correct technique for IO placement, depending on which type of device is chosen during the planning phase. After the demonstration the staff will then be asked to practice placing IO devices using practice bones. One member of the department will then be voted upon to keep track of which patients coming through the department have IO devices placed. They will keep track of for the next six months. The data collected will include any outcomes that the patient experiences, good or bad, in regards to their IO placement.Check The member of the department will look at the data collected from the outcomes of patients who had IO devices placed within the ED in the last six months. This data will then be taken back to the origin ally assigned committee. The committee will be responsible for analyzing the data. They will look at the outcomes and determine if changes need to be made to the original policy. They will also look at the outcomes to determine if there need to be changes made in the placement technique used by the department.For example, is the rate of successful placement higher or lower when done via the humerus verses the tibia? Or is there a problem with post procedural infection? Should the technique be changed from aseptic to sterile? Etc†¦ They will also ask staff within the department to fill out a survey indicating their comfort level in placing IO devices. Act Depending upon the findings of the committee they can either be decided to leave the policy in place, as is. The committee could find that the policy needs to be altered and then reviewed in another six months’ time to see if the changes were effective.Or they could find that within the ED at Hays Medical Center IO devic es for venous access should not be used although the review of literature will prove why this outcome is highly unlikely. Research to Support Change An article published in the Journal of Emergency Medicine, collaborated by three different physicians who work in Emergency Departments in Philadelphia talks about the technical side of intraosseous access. The article states that â€Å"intraosseous vascular access is indicated in the critically ill patient of any age when rapid and timely access via the intravascular route cannot be established or has failed. The article goes on to list conditions in which this might occur, including: cardiopulmonary arrest, shock, sepsis, major traumatic injuries, extensive burns or edema, and status epilepticus. (Luck, Haines & Mull, 2010) Indications may also include obese patients on who multiple PIV attempts have failed. Because studies have shown that IO infusions have the same onset of action, as that of intravenous infusions the authors recomm end that the dose used for IV fluids and medications should remain unchanged when using the IO route.They go one to state that other studies have shown that the results of several different blood test values drawn from bone marrow aspirates are comparable to those taken from venous samples. These include blood gas analysis, blood group typing, and electrolyte, drug, and hemoglobin levels. (Luck, Haines & Mull, 2010) The authors also talk about the relatively few contraindications for IO insertion. These include a fracture to the bone that the IO device is to be placed, an extremity with a vascular injury, placement to an area with an overlying skin infection or burn.IO insertion is also contraindication in patients with certain conditions that make their bones fragile such as osteogenesis imperfect and osteoporosis. The last contraindication is a new IO insertion where another IO needle may have recently been placed. This is because the opening left by the last needle can cause flui ds to extravasate. In their research of other studies, the authors found that success rates for IO insertion vary between 75%-100%, and successful infusion achieved within 30-120 seconds in the majority of cases. Luck, Haines & Mull, 2010) The most common complication was found to be extravasation of blood, fluids, and drugs into the soft tissues surrounding the site, but this occurred less than 1% of the time. With a 0. 6% chance of incidence, the most serious adverse complication was osteomyelitis. However, this was attributed to prolonged infusion. For this reason, it is recommended that the IO need be replaced by either a PIV or a CVL once the patient has stabilized and no longer than 24 hours after IO placement. (Luck, Haines & Mull, 2010)This article concluded that the use of IO access devices is a safe, reliable, and timely way of attaining vascular access. Although vital for critically ill and injured patients, it is also a technique that can be applied in non-emergent cases where multiple attempts at peripheral and central IV access has been unsuccessful. (Luck, Haines & Mull, 2010) In a study conducted by physicians at the University of Medicine Berlin’s Department of Emergency Medicine, they looked at ten consecutive adult patients who each received an IO device and also a CVC placement during a resuscitation situation.The results showed that the success rate on first attempt was 90% for IO access versus 69% for CVC placement. They also found that the mean time required for the IO access procedure was significantly shorter, 1-3 minutes, compared to the mean CVC placement time of 4-17 minutes. While conducting this study, one IO cannulation failed â€Å"due to operator mishandling by not selecting the correct insertion site at the proximal humerus. (Leidel, Chlodwig & Bogner, 2009) The physicians of this study also noted that four CVC cannulations failed on the first attempt at insertion and had to be reattempted. The study then went on to st ate that the failed placement of one IO cannulation was the only complication regarding the IO devices placed. There was â€Å"no malposition, dislodgment, bleeding, compartment syndrome, arterial puncture, haeatothorax, pneumothorax, venous thrombosis, and vascular access related infection observed. † (Leidel, Chlodwig & Bogner, 2009)In conclusion the researchers go on to state â€Å"IO vascular access is a safe, reliable, rapid option in the acute setting of adult patients under resuscitation with inaccessible peripheral veins in the emergency department†¦ Therefore, a change in practice from CVC to immediate IO access for the initial emergency resuscitation should be strongly considered as a reasonable bridging technique to increase patient’s safety in the emergency department. † (Leidel, Chlodwig & Bogner, 2009) Another study found was performed by physicians and researchers in the Department of Emergency Medicine of Singapore General hospital.It is a l arge urban hospital that handles nearly 120,000 patients annually. 9% of these patients are priority 1 patients, or patients that need resuscitation. The inclusion criteria for this study were â€Å"patients who presented to the ED with age greater than 16 years or >40kg body weight requiring intravenous fluids or medication and in whom an intravenous line could not be established in two attempts or 90 seconds. They also had to be seriously ill or injured and meet at least one or more of the following: altered mental status, respiratory compromise, haemodynamic instability, or cardiac arrest. (Ngo, Oh, Chen, Yong & Yong, 2009) The study ran from March 1, 2006 through July 30, 2007. During this time 24 patients were met the qualifications for this study. Of all the IO cannulations, only three attempts failed on the first attempt. No failures were recorded on the second attempt. The researchers also did a comparison between junior operators and senior operators and found that there w ere no disparity regarding success rates between the groups, they both had a 100% success rate. The average insertion time for both groups was approximately five seconds. Ngo, Oh, Chen, Yong & Yong, 2009) There were only two complications regarding the insertion of an IO device with this study. The first was when an operator’s glove was caught on the need during insertion. However, this could have been prevented if the operator was holding the drill properly. The other complication noted was that of extravasation of fluid at an insertion site. This is the most common type of complication, and is seen when the need is misplaced or there is an excessive amount of movement during or after the insertion. Ngo, Oh, Chen, Yong & Yong, 2009) The results of this study concluded that â€Å"the EZ-Io is a feasible, useful and fast alternative mode of venous access especially in the resuscitation of patients with no venous access or when conventional intravenous access fails. Flow rates may be improved by the use of pressure bags. Complications encountered such as extravasation of fluid and gloves being caught in the drill device can be easily prevented. † (Ngo, Oh, Chen, Yong & Yong, 2009)The third research article was a prospective, observational study conducted by researchers in the Department of Emergency Medicine at Singapore General Hospital in Singapore. The study was conducted on a convenience sample of 25 medical students, physicians and nursing staff. They were recruited to secure intraosseous access using the EZ-IO powered drill device. Unlike the previous two studies they only need to secure access on a plastic bone model rather than a live patient. (Ong, Ngo & Wijaya, 2009)The study participants were allowed multiple attempts in placement with the aim of ensuring success in placement. Their placement times were measured by an independent observer with a stopwatch, from the time the participant placed the need set into the driver and attempted to insert the needle with the ES-IO into the plastic bone. The participants then recorded their perception on the difficulty of insertion using a visual analog scale with 0 representing very easy and 10 representing very difficult placement. (Ong, Ngo & Wijaya, 2009) The results showed 96% success rate for placement.Twenty-three of the 25 participants only required one attempt at place the IO device, and only one participant was unsuccessful at securing placement of the device. This failure was attributed to â€Å"unfamiliarity with the equipment and procedure, and hesitating beyond the allocated time given for insertion. † (Ong, Ngo & Wijaya, 2009) The results of this study also showed that the mean placement time was 13. 9 seconds. The researchers also found that 87% of their participants reported that using the EZ-IO was easier compared to intravenous cannula. Ong, Ngo & Wijaya, 2009) The researchers of this study concluded that â€Å"the I/O access device (EZ-IO) evaluated in this study appears to be easy to use with high success rates of insertion with inexperienced participants. There is potential for use in the Emergency Department. (Ong, Ngo & Wijaya, 2009) The next piece of research was a randomized trial conducted by Dr. Reades from Methodist Hospital System, in Dallas, TX, Dr. Studnek from Carolinas Medical Center and the Center for Prehospital Medicine, Charlotte, NC, S.Vandeventer from Mecklenburg EMS Agency, Charlotte, NC, and Dr. Garrett from Baylor Healthcare Systems, Department of Emergency Medicine, Baylor University Medical Center, and Dallas, TX. The purpose of this study was to determine whether the tibial or humeral placement site was more effective for intraosseous placement during out-of-hospital cardiac arrest. â€Å"All patients eligible for inclusion in this study had their first attempt at vascular access randomized to one of 3 locations: proximal tibial intraosseous, proximal humeral intraosseous or peripheral intravenous. ( Reades, Studnek, Vandeventer & Garrett, 2011) Randomized note cards were distributed to the paramedic staff at the beginning of their shifts, and told them which access site was to be initially used if they came had a patient who met the inclusion criteria. There were two outcomes that were being monitored in this study. The first was a first-attempt success at the assigned method of vascular access. This qualified in one of two ways, either as an initial success or an overall success.The second measured outcome was the â€Å"total number of attempts required for successful vascular access, time to successful vascular access, time to first ACLS medication, and total volume of fluid infused during resuscitation. † (Reades, Studnek, Vandeventer & Garrett, 2011) Overall there were 182 patients randomized to one of the 3 vascular access methods. Fifty-one patients had humeral IO placements, 67 had PIV placements, and 64 had tibial IO placements. The results showed that first-atte mpt success was greatest in patients randomized to tibial IO access at 91%, compared to both humeral IO access at 51% and PIV access at 43%.The result of the secondary outcome was also significantly shorter in patients with tibial IO access. These patients had their devices in place and ready to use in an average of 4. 6 minutes. Those assigned to the humeral IO access site averaged a 7. 0 minute placement time, which was also the same time for a PIV access site. (Reades, Studnek, Vandeventer & Garrett, 2011) This study demonstrated that there is a significant different in the frequency of first-attempt success when placing tibial IO access devices as opposed to humeral IO access devices or even PIV catheters.The researchers go on to state that the â€Å"results from this study may help stakeholders such as EMS medical directors choose the most appropriate site for first-attempt vascular access†¦Ã¢â‚¬  (Reades, Studnek, Vandeventer & Garrett, 2011) The last article was a cons ortium on intraosseous vascular access in healthcare practice, published in a journal entitled critical care nurse. It too outlined the history of IO access, dating back to World War II. It discussed the clinical considerations for the use of IO access, and the clinical situations in which IO access should be considered.It went on to talk about the types of IO devices and how they’re used. It mentioned the contraindications for IO use, and also the possible complications. All of the aforementioned material was consistent with research already discussed. This article lends credibility in support of change because it discusses the education and training needed to implement IO device use in the clinical setting. It states that â€Å"to insert and maintain an intraosseous device in a patient, the clinician must demonstrate adequate knowledge and psychomotor skill competency in the procedure. (Phillips, Brown, Campbell, Miller, Proehl & Young-berg, 2010) The article then went on to discuss the economic considerations that must be looked at when considering implementing an IO insertion policy. It states that â€Å"the cost of intraosseous devices and needles should be compared with the cost of central catheter kits, ultrasound evaluation, and human resources required for their insertion. † (Phillips, Brown, Campbell, Miller, Proehl & Young-berg, 2010) The authors also note that â€Å"the economic factors must be weighed along with potential complications of therapeutic strategies should be considered. (Phillips, Brown, Campbell, Miller, Proehl & Young-berg, 2010) This article also brings to light the issue of risk management and patient safety. In this day and age where liability concerns continue to drive clinical decisions, it is important to note that delays in treatments are often cited as the cause of injury leading to malpractice claims. If there is an evidenced based option to safely and quickly provide fluid and drug resuscitation, when vascu lar access is not readily attainable, then it needs to be closely looked at.After reviewing the data the Consortium on Intraosseous Vascular Access in Healthcare Practice reached eight consensuses: 1. Intraosseous vascular access should be considered as an alternative to peripheral or central intravenous access in a variety of health care settings, including intensive care units, high acuity/progressive care units, general medical units, preprocedure surgical settings where lack of vascular access can delay surgery, and chronic care and long-term care settings, when an increase in patient morbidity or mortality is possible. . Intraosseous vascular access should be considered as part of an algorithm for patients treated by rapid response teams in whom vascular access is difficult or delayed. 3. A new algorithm that includes the intraosseous route should be developed for assessing the appropriate route of vascular access. 4. For patients not requiring placement of central catheters ei ther for long-term vascular access or hemodynamic monitoring, intraosseous access should be considered as the first alternative to failed peripheral intravenous access. 5.Techniques of intraosseous catheter placement and infusion administration should be a standard part of the medical school and nursing school curriculum. 6. In evaluating the economic implications of adopting intraosseous technology, the following should be considered: the expense of diagnostic tools to guide and confirm placement, the cost of human resources, the known and unknown risks to patient safety, and the cost of complications related to delayed treatment. 7. Organizational policies, procedures, and protocols that establish the responsibility of insertion, maintenance, and removal of intra-osseous access devices should be developed. . Further research should be conducted on, but not limited to, the safety and efficacy of use of intraosseous access in all practice settings, its economic impact on patient car e, and to support the use of intraosseous access in all health care settings. Change Theory The change theory focused upon in this paper is Gordon Lippitt’s Theory of Planned changed. According Lippitt, â€Å"Planned change or ‘neomobilistic’ change is defined as a conscious, planned effort which moves a system, an organization, or an individual in a new direction.This theory is applies because it can be applied at an individual, group, and institutional level. The basis for Lippitt’s theory of change is center around an agent for change. This agent should be a person skilled in the changed wanted to apply. It is this person who is in charge of planning for the change, initiates the change, and is credited for the accomplishment of change. Lippitt’s theory is centered around 7 phases of change. His phases are not set in stone, and there is no time frame on how long each phase should last. There should be a fluid movement back and forth between thes e seven phases.The first step is identification and diagnosis of the problem. In this case, the problem is HMC not having a firm policy in place recommending when the use of IO access devices should be implemented. The second step is the change agent assessing the client systems motivation and capacity for change. In this case, myself being the change agent, I would talk with the administrators of the ED department and determine if they agreed with my assessment for a policy to be implemented. The third step would be the initiator assesses his or her ability in helping the situation.In this case this flows back to the first step, because I saw the need for change and felt that I was equipped with the skills needed to bring about such a change. The fourth step is the change agent then chooses an appropriate role in the phase. In this case, I would choose to be part of the policy committee who is responsible for researching. The fifth step states that the change agent may be actively involved in the implementation of change, serve as an expert in fathering and providing data, or function as a liaison within the organization. I feel like in this case, I would function as a liaison within the policy making committee.The sixth step consists of maintenance of change. This involved the â€Å"Do† portion of the plan for change. This is where the decisions made by the policy are provided to the department, and the employees become responsible for implementing and maintaining the new policy. The final step is termination of the helping relationship. This step is accomplished when all parts of the PDCA plan have been completed. (Ziegler, 2005) Conclusion In a day and age where medical technology is advancing, the research about IO access devices proves that newer technologies are not always the best for a positive outcome.IO access applications have great potential in patients who are critically ill, injured, or are incapable of having PIV or CVL access. The fact that IO access is fast, reliable, and safe proves that competent placement of IO devices is a medical technique that all Emergency Departments should have in their repertoire. References (2009). The role of the registered nurse in the insertion of intraosseous access devices. Journal of infusion nursing,  32(4), 187-188. American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2005;112(24):57-66. Leidel, B. Chlodwig, K. , & Bogner, V. (2009). Is the intraosseous access route fast and efficacious compared to conventional central venous catherization in adult patients under resuscitation in the emergency department? a prospective observational pilot study. Patient safety in surgery,  3(24), doi: 10. 1186/1754-9493-3-24 Luck, R. , Haines, C. , & Mull, C. (2010). Intraosseous access. The journal of emergency medicine,  39(4), 468-475. Ngo, A. , Oh, J. , Chen, Y. , Yong, D. , & Yong, D. (2009). Intraosseous vascular access in adults using the ez-io in an emergency department. International journal of emergency medicine,2(3), 155-160. oi: 10. 1007/s12245-009-0116-9 Ong, M. , Ngo, A. , & Wijaya, R. (2009). An observational, prospective study to determine the ease of vascular access in adults using a novel intraosseous access device. Annals of the academy of medicine, singapore,  38(2), 121-124. Phillips, L. , Brown, L. , Campbell, T. , Miller, J. , Proehl, J. , & Young-berg, B. (2010). Recommendations for the use of intraosseous vascular access for emergent and no emergent situations in various health care settings: A consensus paper. Critical Care Nurse,  30(6), e1-e7. Reades, R. , Studnek, J. , Vandeventer, S. , & Garrett, J. (2011).Intraosseous versus intravenous vascular access during out-of-hospital cardiac arrest: A randomized controlled trial. Annals of Emergency Medicine,  58(6), 509-516. Tay, E. T. , & Hafeez, W. (2011). Intraosseous access. In R. Kulk arni (Ed. ),  Medscape reference: Drugs, disease & procedures. Retrieved from http://emedicine. medscape. com/article/80431-overview Wayne, M. (2006). Adult intraosseous access: an idea whose time has come. Israeli journal of emergency medicine,  6(2), 41-45. Ziegler, S. (2005). Theory-directed nursing practice. (2 ed. , p. 204). New York, NY: Springer Publishing Company, Inc. Timeline for Change 1/20-11/27Researched the benefits of having a policy about intraosseous access within the ED at HMC 11/28Spoke with the Director of Nursing for the ED and the Director of Emergency Medicine about my research findings 12/1A committee of three physicians and three nurses is assembled to draft a preliminary policy regarding intraosseous access 12/1-3/1The committee is given three months to compose their policy 3/2-3/10The policy is given to the Director of Nursing and Director of Emergency Medicine, who present it to the board of directors for approval 3/15A mandatory staff meeting is held outlining the new policy and answering any questions or concerns the staff has 3/16-9/16The new policy is put into effect and data is collected 9/16-10/16The original committee will analyze the data, and changes are made as needed. 10/20The final committee approved policy is present to the Director of Nursing and Director of Emergency Medicine 11/1The Director of Nursing and Director of Emergency Medicine, take the final recommendations for the policy to the hospital board of directors for approval

Approach to Care, Treatment Plan and Patient Education Essay - 2

Approach to Care, Treatment Plan and Patient Education - Essay Example Apart from the diagnostic procedures, the treatment regimen is usually composed of several drugs with different dosages and frequency of intake. In this paper, a case of a patient with Cardiomyopathy and Congestive Heart Failure will be covered including the general approach to care, treatment and teaching plan. Mr. P, 76 years old, diagnosed with Cardiomyopathy and Congestive Heart Failure, was brought to the hospital for management of acute exacerbations of symptoms. Aside from the peripheral edema, crackles in lung fields, and dyspnea, further evaluation revealed that the patient is having a difficulty complying with the diet restrictions and drug regimen. In this case, the approach for the patient should include the stabilization of the condition, patient and caregiver education, and psychosocial support. Physiological stabilization is comprised of ventilation assistance, hemodynamic regulation, and energy management (Ignatavicius & Workman, 2010). Specifically, ventilation assistance should focus on assessing respiratory rate and rhythm, administration of prescribed supplemental oxygen, proper positioning to promote optimal lung expansion and minimize respiratory efforts, and regular auscultation of breath sounds to discover areas of decreased or absent ventilation and presence of adventitious sounds. Furthermore, hemodynamic regulation should focus on monitoring heart rate and rhythm, peripheral pulses, monitoring intake/ output, urine output, changes in patient weight, and prompt administration of prescribed inotropic medications. Moreover, energy management should focus on monitoring the patient’s cardiopulmonary response to activity and determination of the physical limitations. All these measures form the vital components of patient care to promote functional mobility and prevent aggravation of the condition. Needless to say, it is necessary that the patient and his caregiver receive clear information using  simple language about the condition to promote compliance with the treatment regimen.  

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Watch movies and talking about why its harmful to voters.( you could Essay

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Foreign Direct Investment in India and China - Essay Example Statistics reveal that in 2001 alone, China received around US $ 53 billion FDI while India's figures did not cross even US $ 4 billion indicating that it was below 10 % of what China had attracted ( Internet, Ong, China, FDI : China V.S. India / chart). If you go further, China had attracted a phenomenal amount of US $ 60 billions in 2004 while India had received a meagre sum of US $ 5.3 billions in that year (Internet, Venkitaramanan, 2005, Para 9). Now it is clear that inflow of FDI into China had increased from $ 53 billion in 2001 to $ 60 billion having a growth of $ 7 billion in just 3 years while India had seen an increase of just $1.3 billion during the period. This difference has been continuously growing year after year making China the most sought after destination for the investing MNCs. And India has been really struggling to attract more and more FDI into its soil. This difference is really vast considering that both countries have opened up their economies and moved ahead with economic reforms becoming the Asian giants. Both of them are high potential consumer markets too because of their huge populations. But, these two countries are still the developing economies and have been desperately looking for huge volumes of FDI for economic growth. Because of the severe resource crunch at home, developing nations have been increasingly looking at alternate investment resources for boosting up their industrial growth and creating employment opportunities. Globalisation and internet revolution have only strengthened the importance of FDI but truly the investing multinational corporations / enterprises go by several factors in choosing the final destination of their huge investments. Krugell argues that the aim of MNCs in internationalising their production is to generate more profits and earn more money through the full exploitation of local markets and cheap factors of production (Krugell, 2005 P 53). It is therefore natural for MNCs to invest in countries that would fetch them cheap but efficient labour and highly rated technical expertise among other things. Let us examine and discuss in detail how these and other factors have been playing different roles in attracting FDI and creating the disparity in relation to China and India. 3 Main essay China has certainly reached an enviable position in relation to attracting FDI. It has become a favourite spot for all MNCs for pumping in their investments. In fact, China had overtaken the US as the top global destination for FDI in 2003 (Internet, Business line, 2004, Para 1). The USA had of course regained its number one position in the very next year, followed by United Kingdom and China (Internet, Venkitaramanan, 2005, Para 3). Standing next only to the US and the UK, China has been consuming major share of the FDI among all the developing nations. When we compare the Chinese position with that of India, we are bound to conclude that India is not that much favoured by the MNCs. But there is a world of difference on the perception of FDI between these two countries. United Nations Organisation (UNO, 2003, P 88) reveals that India does not treat as FDI reinvested earnings by foreign companies, overseas commercial borrowings, investments between direct investors / associate companies / subsidiaries and investments by offshore and domestic venture capital funds. On the other hand, China considers a good number of heads as

The History of Italian Mafia Annotated Bibliography

The History of Italian Mafia - Annotated Bibliography Example The History of Italian Mafia Pickering-lazzi, Robin â€Å"Mafia and outlaw stories from Italian life and literature† Toronto: University of Toronto Press, 2007. This is a collection of literature by most significant figures in the Italian literature field, some of the renowned writers that have been included in the book are Livia De Stefani, Grazia Dekedda, Anna Maria Ortese, Silvana La Spina and Giovanni, Verga. The book also presents some of the famous witnesses who have had first hand experience with the Italian Mafia in helping to give the groups inception, growth and activities. The book gives an overview of the Italian perspectives on the Mafia and crime covering the 1880’s and 1990’s. It covers aspects of the legends of Italian Mafia’s that identifies them as a group, the relationship between the Mafia and the State, children, women, the Catholic Church, allied forces during the Second World War among others. The author outlines key period since the inception of the criminal group taking an intriguing approach to the subject. He also points why it has been a challenge for the authorities to wipe out this form of organized crime, one of the reasons pointed out in the book are the high level of secrecy that exists within the Mafia members. It also illustrates on how the Italian Mafia thrive and develop in the presence of a weak and non democratic government.

Dreams Essay Example | Topics and Well Written Essays - 1000 words

Dreams - Essay Example Due to their authoritative influence for example in my case, parents may force their children to take up career courses that are not within their interests (Gysbers 2008 p 32). This essay will show that this may lead to poor job performance and conflicts in the work place. It also suggests the best approach that parents should take while discussing their children’s career choice which is to be supportive as well as less authoritative. This essay is a critical evaluation of the parent’s influence, using myself as an example, on the career dreams that their children may have as well as the consequences of such influence. Every parent would be proud to have successful children, in their careers as well as life in general. Similarly, there is no child who would be proud to be a failure in the society. It therefore becomes necessary for the two parties to join efforts to ensure that only the best comes from the children’s life. While in the process, it becomes possible to experience conflicts in ideologies which may either result to a wrong career choice or disappointment in life (Gysbers 2008 p 25). In many cases, parents misuse the opportunity to guide their children into choosing the right careers whereby they tend to force them into what they themselves see as the best for their children. By doing so, they forget that every individual has unique characteristics which determine their interests as well as their hobbies. It would therefore be wrong for anyone be it the parent or friend to try and force his interests in another person. However, I believe that it is always necessary to offer vari ous options to the child using an open minded approach whereby both parties would be willing to listen to the other person’s point of view. My career dream has always been to become a Chef but on the other hand my parents do not support this but instead, they want me to become a nurse. These are two very different careers and it may be

Rethinking corporate governance Essay Example | Topics and Well Written Essays - 500 words

Rethinking corporate governance - Essay Example Jeswald (2002) defines corporate governance as the relationship existing amongst the management, Board of Directors, shareholders, and other stakeholders that revolves around exercising authority, direction, as well as control in an economy or organization. From the perception of Clark, WÃ ³jcik and Bauer (2005), it is true that there is need for economies and organizations to rethink on how to direct, control, and exercise authority in a bid to enhancing sanity within their environs. According to Veasey (2005), every stakeholder has a right to ensure corporate governance compliance within nations or organizations. Indeed, with current happenings in the business environment there is a need to rethink corporate governance. Whilst focusing on rethinking corporate governance various questions of concern arise. First, what as been the impact of ineffective corporate governance on economies and business organizations within the contemporary business environment? Second, what is the relationship between corporate governance and performance within business organizations and economies? Third, what practices result to ineffective corporate governance within the business contemporary? Fourth, what are the practices that organizations and nations should engage in with a view of enhancing effective and efficient corporate governance? Fifth, how will rethinking corporate governance influence the performance of business organizations and nations especially given the turbulences and dynamisms within current business environment? I propose to majorly dwell on the third questions. Identifying some of the practices that have caused ineffectiveness and inefficiency in corporate governance will be a foundation to understanding how individuals, institutions, organizations, and nations can rethink and restructure their corporate governance. In order to attain this, I will have to collect data on various nations and organizations that have failed in corporate

Low Testosterone Levels in Relation to Depression Research Paper

Low Testosterone Levels in Relation to Depression - Research Paper Example This is because; serotonin is a neurotransmitter that relays messages from one region of the brain to the other (Gonzales, et al., 2002). Therefore, the levels of testosterone hormones in an individual, determine their levels of serotonin. It is observed that the older male individuals who have low levels of testosterone have also low levels of serotonin. Thus, with low levels of serotonin, the rate of transmission and relaying messages in the brain is lowered, making an individual less active (Berglund et al., 2011). The less activity of an individual increases their levels of anxiety and consequent low moods, which are symptoms associated with depression. Serotonin is known to influence a higher percentage of brain cells, mostly those related with moods, sexual desire, social behavior, memory and learning, as well as sleep (Devina, et al., 2010). When the serotonin levels in the body are low, the levels of activity in these brain cells are also low; an aspect that promotes low mood s, low memory and low social behaviors and interaction, which on the other hand promote depression. Therefore, whenever the brain cells are suppressed due to low activity or inactivity caused by the low serotonin levels, depression may arise, always preceded by stress as the preceptor of the brain cells (Carnahan & Perry, 2004). Therefore, it is observed that the relationship between testosterone levels and serotonin, have an influence on men’s depression. Depression is likely to be higher in women than men, until the age of 65, when the gender difference disappear, and the men become equally depressed as their female counterparts (Berglund et al., 2011). This is because, testosterone levels decreases with age in males, although the rate at which the decline... This research paper focuses on a positive relationship between testosterone levels and depression in men. Such effective relationship that is a main focus of the essay, takes the form of low testosterone levels triggering depression causative agents, such as anxiety, low social activity, anorexia and insomnia. As male individuals grow older, their testosterone levels decrease. The researcher provides a reference, that for men aged between 20-40 years, only 1% has a diagnosys for low testosterone levels. Therefore, men who are above the age of 55 years are observed to have a low level of testosterone hormones. Low testosterone levels are also observed to affect the Serotonin levels in the body and notably the brain, which in turn impacts on an individual body activity, moods and stress, causing depression. This has a large bearing not only on their psychological and emotional state but also may turn affects on their levels of depression. This essay also discusses the terminology and d escription of adult's depression itself. It is described that depression is likely to be higher in women than men, until the age of 65, when the gender difference disappear, and the men become equally depressed as their female counterparts. Therefore, testosterone treatment and replacement for men who does not respond to conventional depression therapy is highly recommended all over the world nowadays, though with a clear scrutiny into the likelihood of the testosterone replacement in causing cancer.

Hurricane Sandy Essay Example for Free

Hurricane Sandy Essay Hurricane Sandy was considered a super storm that wreaked havoc on the east coast, in the US. Hurricane Sandy was the largest Atlantic hurricane on record, as well as the second-costliest Atlantic hurricane in history, only surpassed by Hurricane Katrina in 2005. Hurricane Sandy formed on Oct. 22 and started to dissipate Oct. 31, 2012. The eighteenth named storm and tenth hurricane of the 2012 Atlantic hurricane season, Hurricane Sandy devastated portions of the Caribbean, Mid-Atlantic and Northeastern United States in late October 2012. The Caribbean’s were the first place to be hit, by devastating hurricane Sandy. After the storm became a tropical cyclone on October 22, the Government of Jamaica issued a tropical storm watch for the entire island. Early on October 23, the watch was replaced with a tropical storm warning and a hurricane watch was issued. At 3 p.m. the hurricane watch was upgraded to a hurricane warning, while the tropical storm warning was discontinued. Shortly after Jamaica issued its first watch on October 22, the Government of Haiti issued a tropical storm watch for Haiti. By late October 23, it was modified to a tropical storm warning. In the US, New York was probably one of the most populated places devastated by Hurricane Sandy. Every single airliner in the state of New York was shut down due to the extremely heavy rains and strong winds. All airliners and railroad systems were shut down on October 27 all the way until Nov. 2. New York City mayor had no need to close down any schools or transits because he felt there was no need to. Until October 28, he realized the severity of the storm and made a public announcement shutting down all transits and school classes. Hurricane Sandy is estimated to have caused around $20 billion dollars in damage. Preliminary estimates of losses in businesses are around $50 billion. At least 191 people were killed by hurricane Sandy’s path through 7 different countries. Many organizations have contributed to the hurricane relief effort. Disney–ABC Television Group held a Day of Giving on Monday, November 5, raising $17 million on their television stations for the American Red Cross. NBC raised $23 million during their Hurricane Sandy: Coming Together telethon. News Corporation donated $1 million to relief efforts in the New York metropolitan area. The United Nations and World Food Program said they will send humanitarian aid to at least 500,000 people in Santiago de Cuba.

Effect of Massages During Pregnancy

Effect of Massages During Pregnancy Nikita S. Windham Pregnancy and Massage Research has discovered new information that maybe something can be done to help make pregnancy more tolerable that is not only safe but also effective. This solution is known as prenatal massage. Prenatal massage simply put is massage that is personalized specifically to the ever-changing bodies of pregnant women. One benefit of prenatal massage is that it can bring relief to aching muscles and joints. During pregnancy, a womans center of gravity is shifted. This new distribution of weight can put pressure on joints and cause muscles to ache. Massage can provoke the body to release endorphins, which are a natural pain reliever. (Nguyen, 2017) Along with relieving pain, the release of endorphins also contributes to calming the nervous system. The parasympathetic, or rest and digest, system is activated. This allows for better sleep and digestion, which in turn plays a part in decreased stress levels and improved mood. (Nyugen, 2017) Prenatal massage also increases blood circulation. This helps to reduce swelling (edema) and stiffness in muscles as more blood flow travels to those areas. Increased circulation also means that more oxygen and nutrients are pumped to the mother and ultimately the baby. This blood flow stimulates the lymph system, which in turn boosts immunity and toxin elimination. (Nyugen, 2017) Cautions and Contraindications Despite all the many benefits of prenatal massage, there are some instances where massage becomes inadvisable due to the potential harm that it could cause to the mother and baby. Circumstances in which massage should not be given can include sudden migraines, high blood pressure, edema from high blood pressure, preeclampsia, a history of preterm labor, and high-risk pregnancy. (Yogawiz, 2016) High-risk pregnancy can refer to certain conditions such as gestational diabetes, eclampsia, and heart conditions. Pregnant women under 15 or older than 35 and women carrying multiple babies are also considered high risk. Regardless, it is always best for the mother to consult with her doctor before attempting to receive a massage. (Cutler, 2014) Prenatal Massage Controversy There has been much controversy over what areas can and cannot be massaged during certain trimesters of pregnancy. There are specific reflexology points on the body that many have argued should not be pressed or massaged. The ankle is said to be the reflexology point that stimulates uterine contractions. Per Haller, there was a great study in 2014 in which researchers attempted to induce labor in 221 post-due date women by applying acupuncture needles. Even when poking these gals every other day for a week, none of the findings supported reflexology claims. (2015) There is also confusion over whether massage in the first trimester should avoided. It has been said that if a woman is massaged within the first trimester, it could potentially cause a miscarriage. Some sources say that there is no scientifically proven evidence that shows massage causes miscarriage. These sources say that contrary to popular belief, gentle massage can actually be soothing and comforting to both the baby and mother. (Soto, 2013) Despite all the conflicting ideas about massage during pregnancy, one thing can be agreed upon. Prenatal massage should be both beneficial and relaxing for the expectant mother. Pregnancy itself is already difficult, so this therapeutic touch can be a form of nurturing support for the soon to be mom. References Contraindications Of Pregnancy Massage. (2016). Retrieved March 14, 2017, from http://www.yogawiz.com/massage-therapy/pregnancy-massage/pregnancy-massage-contraindications.html#continued Cutler, N. (2014, March 18). High-Risk Pregnancy: Massage Caution or Contraindication? Retrieved March 14, 2017, from http://www.integrativehealthcare.org/mt/archives/2010/05/high-risk_pregn.html Haeller, R. (2015, November 30). Debunking Pregnancy Massage Myths. Retrieved March 14, 2017, from http://momsintow.com/news/debunking_pregnancy_massage_myths Soto, M. L. (2013, September 19). Dispelling the Myth of Avoiding First Trimester Massage. Retrieved March 14, 2017, from https://elementsmassage.com/park-ridge/blog/dispelling-the-myth-of-avoiding-first-trimester-massage Nguyen, Y. (2017, February 02). Prenatal Massage: Get Relief for Your Aches and Pains. Retrieved March 14, 2017, from https://www.fitpregnancy.com/pregnancy/pregnancy-health/prenatal-massage-get-relief-your-aches-and-pains

The Economic Transformation Programme Economics Essay

The Economic Transformation Programme Economics Essay By year 2020,the government had planned that Malaysia will become a high income economy by having the Economic Transformation Program. An agency to only supervised these programmes is under the Prime Minister Department of Malaysia which are Performance Management and Delivery Unit (PEMANDU). September 21, 2010 is the launching date for this programme, it is anextensive economic transformation plan to bring Malaysias economy into high income economy. 11 Economic Transformation Program-me projects and nine under three Economic Corridors with investments totalling RM26.09bil had been announced by our beloved Prime Minister, Datuk Seri NajibTunRazak. It is expected to lift Malaysias Gross National Income (GNI) to US$523 billion by 2020, from US$6,700 to at least US$15,000 in raise per capita income, in order to be the World Banks doorstep for high income country. It is predicted that Malaysia will be able to be inline with the plan if GNI arises by 6% per annum. The 60% of the blueprints investment had been set to revitalize Malaysias private sector would, besides, from these 60 percent, 32% is from government linked companies and left with 28% more is from the government.National Key Economic Areas(NKEA) are called for various sectors for development. Figure 1.0 shows the 11 ETP projects are in seven areas which focused on oil, gas and energy, Greater Kuala Lumpur/Klang Valley, communications content and infrastructure, business services, healthcare, tourism and education. The location for the economic corridor projects are Sabah Development Corridor, Northern Corridor Economic Region as well as Iskandar Malaysia. The biggest in terms of investment is the to regenerate and revitaliseFurthermore,in the investment field,Malaysia had planned for a Greater Kuala Lumpur by remake the old township of Petaling Jaya. The plan in details are that the 40 acres (16ha) of PJ Sentral Garden City development will be a brand new green central business district of Selangor, supporting Kuala Lumpur and also cover the business hubs near by the city and state. A project also had been planned with Nusa Gapurna Development SdnBhd that is expected to produce 36,828 jobs with a GNI (gross national income) impact of RM522.97mil. Another company is GPS Tech Solutions SdnBhd which is public transportation companies and authorities will work with to roll out a web and smartphone application to provide real-time tracking of public transportation. Moreover, buses with wireless connectivity will be provided through MyPUTRAS (Malaysian Public Transportation System).It costs about RM16.29mil project. MyPUTRAS (is) a free online smart portal and smartphone application which will cater real-time tracking of buses, include time of arrival and departure which make it more convenient to all public transport users. The liberalisation of six sub-sectors under the Competition, Standards and Liberalisation strategic reform initiative. These sub-sectors are the legal services, medical specialist services, dental specialist services, international schools, private universities and telecommunications (Network Facilities Providers (NFP) and Network Services Providers (NSP) sector. Thus,it brings a total of 15 from 17 sub-sectors that were announced during the Budget 2012. Another field, engineering and architectural services, as well as quantity surveying (a new sub-sector), will be the amended legislation giving effect to the liberalisation is passed. This ETP are expected to RM10.1b boost gross national Income, in addition to 64,282 jobs created by 2020. Investment is also one of the main attraction of Malaysia due to the global uncertainty.The strong economic growth had attract many foreign investors and had seen Malaysia as a developing country. Our economists had forecasted that Malaysia will have a strong domestic consumption that keeps expanding especially on our structural changes and also the projects that had been in Economic Transformation Programe. The Performance Management and Delivery Unit (Pemandu) also believe that we also have to monitor the plan to be followed accordingly. They make a laboratory in order to know the progress of the ETP. In 2010, 131 entry point projects (EPPs) and 60 business opportunities have been identified in this laboratory in a period of 2 months by 425 people that involve in it between government and private sector .211 organizationshad taken place, which are Shell, Exxon-Mobil, MYDIN, Sime Darby, Genting Plantations, Petronas, PricewaterhouseCoopers, Celcom, Ericsson, Maybank, Tesco, Sunway Medical Centre, Masterskill University College, The Body Shop, AirAsia, Malaysia Airlines, RapidKL and Digi Telecommunications. It is approximated that these initiatives will generate RM500 billion of national income per year and create up to 2.2 million jobs by 2020. The private sector had contributed 92% ot the jobs opportunities. National Key Economic Areas Since 92% of the total investments will originate from private sector, the sector is much involved in the planning of this transformation blueprint. A workshop had been organised by Performance and Delivery Unit (PEMANDU) to identify the 12 National Key Economic Areas (NKEA). The NKEA is the key driver to the success of this program as such activities have the potential to contribute significantly to the growth of the economy of Malaysia. Besides that, there are 131 entry point projects (EPP) identified under the NKEA, which includes a high speed railway connecting Penang to Singapore and MRT in Kuala Lumpur. Economic activities that are categorized as NKRA will be prioritized in government planning and funds allocation. Policies will be amended to facilitate fast track implementation of such activities, including liberalizing the market and removal of bottlenecks. With this policy, private companies are invited to get involved, with PEMANDU pushing for the implementation to speed up the implementation. Among the companies that are involved in the transformation programme are YTL, Shell Malaysia, Airasia, HovidInc, Select-TV, Exxon-Mobil, Dialog Group, TenagaNasional, Cisco. As an example, in oil, gas, and energy sector, that is the strength of Malaysias economic growth. As of 2010 the energy sector has been an essential part of Malaysias economic growth and it contributes 20 percent of GDP. Another strength is the palm oil industry.As of 2010 ,the fourth largest component of the national economy is belong to Malaysia and contribute to RM53 billion of gross national income. The industry cater the value chain from plantations to processing. The development of this industry is largely for private and remains heavily oriented towards plantations. With the contraints in land available to continue the evolution of plantations, the government craving to boostcompetency in production and focus on adapting great value through downstream activities. The Palm Oil NKEA is purposely forgiving high impact in total contributions to national income from the palm oil industry by RM125 billion to forecasted RM178 billion by 2020. The government aims that 41,000 new jobs will be created in this field. Palm oil related EPPs which focused more on upstream productivity and downstream expansion. These EPPs will focus on replanting of aging oil palms, mechanising plantations, stringently enforcing best practices to enhance yields, implementing strict quality control to enhance oil extraction, and developing biogas facilities at palm mills to capture the methane released during milling. Downstream expansion and sustainability will be achieved by capturing the lucrative market segments that focus more on refined products such as oleo-derivatives, food, health products, and bio-fules. These projects are believed will require funding of RM124 billion over the next 10 years with 98 percent of the funding coming from the private sector as being said by the government. The government has given renewed focus to Malaysias international economic relations, including liberalization and increasing interaction with the global economy. This approach is understandable for a small, open economy that is particularly  dependent on export-driven growth, and faces considerable pressure to attract FDI and increase its exports. Malaysia no longer takes a rigid, narrow stance in choosing its economic partners having decided not to confine itself to one particular global orientation, be it east or west and is signatory to several FTAs through ASEAN. These include FTAs that ASEAN concluded with China, India, Australia, New Zealand, Japan and Korea. Beyond this, Malaysia has also entered into bilateral agreements with Japan, India, New Zealand and Pakistan. Reform in other areas will be equally essential. Government procurement, intellectual property rights and the opening of the domestic financial market (as well as other services) will each have to be addressed. Hopefully, the government will also be nudged into fulfilling the states traditional role of providing citizens with greater access to education, health care, housing and a good public transportation system. First, the attempt to forge links with economies as diverse as China, Pakistan and Chile can be criticised for lacking focus. A slower rate of global engagement might have been preferable, but the international race to conclude FTAs would have excluded Malaysia, had this strategy not been pursued. The government wanted to seize the opportunity to cast its net wider for overseas markets, and the 2008 crisis pushed Malaysia to explore such opportunities. In effect, Malaysia may be seeking membership in a multiplicity of arrangements without any overarching strategy. But to define the objective of entering into an FTA as solely to secure more markets is naÃÆ' ¯ve. Second, the government has given a special priority to developing links with Islamic economies. The Developing 8 Preferential Agreement (with eight developing Islamic countries) and the Trade Preferential System among the Organisation of the Islamic Conference countries are two particularly relevant agreements that Malaysia has ratified in this regard. Sidelining economic relations with Islamic economies, even when the rationale is questionable, can evoke sensitivities among certain quarters of the policy community, but Najib has deftly sidestepped these issues and has forged ties as much with Pakistan  as with China. It would, of course, be hugely myopic to ignore China or India in Malaysias international economic relations. The government strategy for global economic engagement has been criticised on several grounds, and as negotiations for the TPP and the EU-Malaysia FTA progress, opposition could mount. Nevertheless, early successes will put Malaysia in good stead to pursue a dual approach of increasing interactions with the global economy while implementing strong domestic reforms. Fiscal Policy in Malaysia Malaysia follows an explicit fiscal policy rule that disallows an operating deficit in any given year. This aims at making a credible commitment to long term fiscal sustainability by applying discipline to annual budgets. As mentioned before in this report, the implementation of Economic Transformation Plan to move towards high income has proven to be vertically taken off with most targets has been achieved and exceeded within the span of more than 2 years. Based on the executive report by bank Negara Malaysia (BNM), Malaysia is moving from a resource based economy into more service centric economy as most of high-income nations globally. Fiscal policy can be further explained as the use of government spending and taxation to further influenced the economy. It is typically to promote a sustainable growth of economy in the long run as well as stabilizing the macroeconomic post crisis such as expanding spending, tax cutting to further stimulate a recovering economy. In the longer term, the government can foster a sustainable economy by improving infrastructures, providing better education and scholarship to boost the professional participation among the public, encourage public participation in corporate as well as academic. In the short term the fall in exports was offset by an unprecedented fiscal stimulus programme launched over two rounds started in 2008. In the total governments countercyclical measures amounted to an estimated RM67, 000,000,000, which were allocated to support private enterprise. The second package which was announced on March 2009, set aside RM 5,000,000,000 to support firms that need access to working capital, with specific involvement in tourism, aviation and auto industries. As such, Malaysia is sought to speed up the implementation of existing infrastructure projects such as the extended rail of Light Railway Transit (LRT), Mass Rapid Transit (MRT), targeting in particular the expansion of high speed broadband network, and also airport upgrades. Although Malaysia has relatively low debt to GDP ratio of around 50%, the global issue of sovereign debt with Greece in early 2010 is likely to put pressure on Malaysia to introduce fiscal tightening measures to prevent increased lending cost. The fiscal deficit target for 2010 has been revised to 5.3% taking into consideration RM12,000,000,000 supplementary budget and the revised 2010 GDP. The 2009 budget gap reached 7% of GDP, largely due to fiscal stimulus plan. The level of government expenditure is forecasted to decline faster with the government promising to introduce an efficiency drive and reduce the subsidies on fuel, food and education. This measure would help to reduce the structural and fiscal deficit, ensuring the governments consolidation efforts have a permanent impact. The spending target set for 2010 is RM 201,700,000,000 in 2010 and the fiscal deficit is expected to decline to 5.3%. Formulation of Fiscal Rules Basically there are 3 major types of fiscal policy rules. First is the balanced-budget or deficit rules comprises of 3 balance between the overall revenue and expenditure; or limit on government deficit as proportion of GDP. Another one is balance between structural and expenditure, and balance between current revenue and current expenditure. The second type of fiscal policy rules is the borrowing rules which prohibits on government borrowing from domestic sources as well as prohibits government borrowing from central bank; or limit on such borrowing as a proportion of past government revenue or expenditure. The third and last fiscal rule is debt or reserve rules which limits on stock of gross government liabilities as a proportion of GDP and target stock of reserves of extrabudgetay contingency funds (such as social security fund) a a proportion of annual benefit payments. In achieving a strong commitment to fiscal sustainability as well as in ensuring the sustainable long term growth, Malaysia is facing implementation constraint; however there is need to adjust the existing procedure to result in enhancing its efficiency. Flexibility can be incorporated into fiscal rules by expanding the horizon for budget formulation including the application of fiscal rules; to cover the course of a business cycle would provide the economy with improved shock-absorptive capacity. For instance, the rule on the annual operating budget for Malaysia could be modified from one year to allow an operating deficit during an economic downturn while observing the balance over the course of a business cycle. It often takes awhile to implement the spending measures, and may be in effect even longer than needed. This would require a medium-term fiscal framework for planning and forecasting. Second, the government can introduce contingency measures during the budget process. It can be either to add stimulus or withdraw as it required. This could include the elimination of a surtax and introduction of a stabilization fund. Although a cut increase in capital spending is effective, but it should be used only as a last resort. This can be triggered during budget execution if actual budge performance deviates significantly from the planned path. Similarly, the scope of stabilizers can be improvised by a more progressive tax system. For instance, tax on high-income household at a higher rate than off the lower income household. There are two types of taxes that can be imposed which are levied to transfer fund from private to public use namely direct taxes levied from income, profit and wealth as well as indirect taxes such as excise duty, sales taxes, quit rent and so on.

Failure of te Two-Party System Essay -- essays research papers

A valuable factor within any democracy is the presence of political parties. As dictated by Webster, a party is meant as "a group, which unites to promote or maintain a policy, a cause, or other purposes, as a political group." This definition can be easily simplified as individuals with a common cause. This is just the case with American political parties. They are ordinary groups of individuals with a common cause in hopes to gain political power. Within the United States, two political parties make up the majority, the Republicans and Democrats. Unlike many other democratic nations around the world, America is unique with their generalized lack of parties. However, there is a growing trend within America that implies the two-party system, which has been the leader in American politics, has started to become weak. When the United States initially formed as a nation, there were few differentiations between the people. Those with voting privileges were mostly white Anglo-Saxons. The greatest differences seemed to be developing around the issue of slavery creating a North versus South political atmosphere. Siding with the intelligence of the era, Thomas Jefferson and Alexander Hamilton, the federalist and anti federalist parties developed around opposing ideas regarding a written Bill of Rights. This form of elitism running the government was not unreasonable in a time when communication to the outskirts and rural areas of the nation wa...