End Stage Renal Disease ESRD Health And Social Care Essay

End Stage Renal Disease ( ESRD ) is defined as an irreversible nephritic failure which needs to have nephritic replacing therapy ( RRT ) or undergo long term dialysis [ 1 ] . There are three types of nephritic failure replacing therapy which are hemodialysis ( HD ) , peritoneal dialysis ( PD ) and nephritic graft. In Malaysia, Continuous Ambulatory Peritoneal dialysis ( CAPD ) patients are increasing from 1525 patients in twelvemonth 1999 to 1744 patients in December 2008, an addition of 12 % [ 2 ] . Malnutrition is really common in end phase nephritic disease patients on care dialysis [ 2 ] . In Malaysia, national information showed that merely 13 % of CAPD patients are good nourished where serum albumen is above 4.0 g/dL [ 3 ] . Majority of patients ( 87 % ) undergoing CAPD are malnourished. Protein energy malnutrition ( PEM ) is one of the most prevailing complications looking in patients undergoing dialysis and it is associated to high morbidity and mortality [ 4,5 ] . Malnutrition is an of import factor associated with increasing hazard of mortality in Chronic Kidney Disease ( CKD ) patients. Hence, it is of import to measure the nutrition position of patients. Screening for malnutrition is an of import constituent of dietary pattern and improves the ability to prioritize intercession to those most at hazard [ 6 ] . Early acknowledgment and intervention can give better outcome [ 7 ] . Nutrition showing is a executable option for placing patients at hazard of PEM [ 4 ] . Screening tools are largely designed for general intents every bit good as for specific topics as aged, institutionalised person and hospitalized patients [ 4 ] . There are several showing tools available for CAPD patients. These are Malnutrition-inflammation mark ( MIS ) , nutritionary hazard showing ( NRS ) , Malnutrition Universal Screening Tool ( MUST ) , Malnutrition Screening Tool ( MST ) , geriatric nutritionary hazard index ( GNRI ) and capable planetary appraisal ( SGA ) . Among them, none was antecedently studied for usage in Malayan chronic kidney disease patients on dialysis. The dietitian plays an indispensable function in nutritionary showing. In Malaysia, entree to dietitian is limited in most dialysis Centres. Hence, nurses will play an indispensable function to place the malnourished patients. On the other manus, a comprehensive nutritionary appraisal is time-consuming and requires both subjective and nonsubjective opinions from the tester. Therefore, important preparation is necessary to guarantee consistent consequences among assorted testers and periods of appraisal. Therefore, there is a demand for a simplified nutritionary showing tool which can be used by dieticians or nurses that can be performed easy.1.1 Objective1.1.1 Main ObjectiveTo place a simplified nutritionary showing tool which compares good with the Malnutrition Inflammation Score ( MIS ) , Subjective Global Assessment ( SGA ) and with assorted single nutritionary steps for Continuous Ambulatory Peritoneal dialysis ( CAPD ) .1.1.2 Specific aimTo depict the human ecology, anthropometr y, biochemical analysis features and dietetic form of CAPD patients. To depict the per centum of malnourished patients harmonizing to BMI, serum albumen, MSGA, and MIS. To formalize the usage of MIS and mSGA in CAPD patients against anthropometric ( BMI, Triceps Skinfold, computed Mid Arm Muscle Circumference ) and biochemical ( serum albumen ) appraisals ; To compare the usage of simplified tools: NRS, MUST, MST and GNRI showing tools in CAPD patients.Chapter 2: Literature Reappraisal2.1 Overview of kidney mapKidney maps to modulate organic structure homeostasis system [ 8 ] . Kidney plays a critical function in keeping circulatory and organ system functional homeostasis. Other than that, kidney is the site of synthesis of some endocrines and an of import catabolic site for several polypeptide endocrines. ( Table 2.1 ) Table 2.1: Components of kidney map Elimination of metabolic waste merchandises ( urea, creatinine, uric acid ) Elimination and detoxification of drugs and toxins Care of volume and ionic composing of organic structure fluids Acid-base ordinance Regulation of systemic blood force per unit area Production of erythropoietin Control of mineral metamorphosis through endocrinal synthesis ( 1,25-dihydroxycholecalciferol and 24,25-dihydroxycholecalciferol ) Degradation and katabolism of peptide endocrines ( insulin, glucagon, parathyroid endocrine endocrines ) and low-molecular-weight proteins ( ?2-microglobulin and light ironss ) Regulation of metabolic procedures ( gluconeogenesis, lipid metamorphosis ) Beginning: Mitch ( 2009 ) [ 8 ]2.2 Causes of kidney failureThere are two types of kidney failure which are acute kidney failure and chronic kidney failure. Acute nephritic failure is defined as sudden decrease of glomerular filtration rate ( GFR ) or loss of kidney map which is reversible [ 9 ] . Table 2.2 shown causes of acute kidney failure. Chronic kidney failure is defined as structural or functional abnormalcies of the kidney for more than 3 months [ 10 ] . It is an irreversible advancement of kidney harm. The causes of chronic kidney failure are shown in Table 2.2. Table 2.2: Causes of kidney failureAcute Renal FailureChronic Renal FailureAcute cannular mortification ( Trauma ) Nephrotoxicity ( antibiotics and drugs ) Infection Urinary piece of land obstructor Acute glomerulonephritis Diabetess Mellitus Uncontrolled high blood force per unit area Familial disease of kidney Obstructive Uropathy Inflammation or infection of kidney Beginning: KDOQI, 20012.3 Nephritic failure and dialysisGlomerular filtration rates ( GFR ) is an first-class step of filtrating capacity of the kidneys. GFR have been used to quantify the degree of kidney map [ 10 ] . There are 5 phases of GFR degree from phase 1-normal, to present 5-severe. A lessening in GFR precedes kidney failure in all signifier of progressive kidney disease [ 10 ] . In phase 5, where GFR is less than 15 ml/min, it is considered as terminal phase nephritic failure ( ESRD ) . Phase of chronic kidney disease was shown in Table 2.3. Table 2.3: Phases of chronic kidney disease Phase GFR Description 1 90-130 ml/min Kidney harm with normal or higher GFR 2 60-89 ml/min Mild lessening in kidney map 3 30-59 ml/min Moderate lessening in kidney map 4 15-29 ml/min Severe lessening in kidney map 5 Less than 15 ml/min End phase nephritic failure Beginning: KDOQI There are three types of intervention for nephritic failure which are kidney organ transplant, hemodialysis ( HD ) and peritoneal dialysis ( PD ) [ 9 ] . Peritoneal dialysis can foster split into three methods, including uninterrupted ambulatory peritoneal dialysis ( CAPD ) , automated peritoneal dialysis ( APD ) and combination of CAPD and APD [ 9 ] .2.4 CAPD processIn Continuous Ambulatory Peritoneal Dialysis ( CAPD ) , semi permeable membrane of the peritoneum is used as the filtration membrane [ 9 ] . A catheter is surgically implanted in the venters and into peritoneal pit. In CAPD, the dialysate is left in the peritoneum and exchanged manually [ 9 ] . A dialysate battalion is connected to the catheter while another tubing is connected to an empty battalion outside to have the waste fluid merchandises. A high-dextrose concentration dialysate is instilled into the peritoneum by the catheter. The dialysate diffusion carries waste merchandises from the blood through the peritoneal membrane and into the dialysate [ 9 ] . The waste merchandises and dialysate work interdependently via osmosis to transport out the waste merchandises. The waste fluid merchandises are withdrawn and discarded. Exchanges of dialysate are done for four to five times a twenty-four hours [ 9 ] . There are different concentrations and volumes of dialysate used which depend on the patient ‘s status.2.5 Nutrition demands for CAPD patientsIn peritoneal dialysis, Calories absorbed from glucose in the dialysis fluid are included in the computation of dietetic energy consumption. Approximately, 90 % of glucose is absorbed during dwells over 8 hours a twenty-four hours and 70 % is absorbed during short dwell [ 11 ] . Therefore, the sum of saccharide absorbed should be calculated to forestall overconsumption of ene rgy particularly for diabetes patient. From KDOQI 2000, the energy demand for chronic peritoneal dialysis patients who less than 60 old ages of age is 35 Kcal/kg organic structure weight per twenty-four hours [ 2 ] . For those who above 60 old ages of age, 30 to 35 kcal/body weight per twenty-four hours is recommended due to more sedentary life style [ 2 ] . Protein need in peritoneal dialysis patient is higher than hemodialysis patient. Peritoneal protein losingss average approximately 5 to 15 g/24 hours [ 2 ] . Generally, dietetic protein demand is to keep positive N balance and prevent malnutrition. Dietary protein more than 1.2 g/kg BW/day associated with impersonal or positive N balance [ 12,13 ] . KDOQI 2000 suggest that 1.3 g/kg BW/day protein for peritoneal dialysis patient and at least 50 % of protein should be from high biological value ( HBV ) [ 2 ] . Continuous Ambulatory Peritoneal Dialysis ( CAPD ) patients have higher cholesterin, triglyceride, LDL and lipoprotein degree [ 14 ] . The abnormalcy of lipid profile for CAPD patients is due to loss of protein from dialysis fluids and soaking up of glucose from dialysis fluid [ 14 ] . Therefore, 25 to 35 % of fat from entire Calories is recommended for CAPD patients [ 15 ] . Calcium and P are mineral demand in our organic structure to keep bone wellness. Conversion of vitamin D from inactive signifier to active signifier is impaired due to kidney failure [ 16 ] . When vitamin D lack develops, it may take to faulty enteric soaking up of Ca. In contrast, phosphorus elimination becomes restricted because of reduced cannular map. Therefore, dietetic phosphate limitation is necessary. Harmonizing to KDOQI guideline, 800-1000mg phosphate per twenty-four hours is recommended [ 2 ] . Furthermore, add-on of unwritten phosphate binder is besides needed to command serum phosphate degree [ 16 ] . The grade of Na sensitiveness is increasing exponentially with declined kidney map [ 17 ] . Nevertheless, sodium limitation can assist to command blood force per unit area. Excessive Na consumption may do thirst and increase fluid gained which in bend cause oedema [ 9 ] . Malaysia Medical Nutrition Therapy ( MNT ) guideline recommends 1500mg of salt intake per twenty-four hours and no add-on salt in cookery. Suggested unstable consumption is up to 1500ml per twenty-four hours [ 15 ] . CAPD patients may be hypokalaemic due to potassium loss during dialysis procedure. Therefore, potassium limitation is non necessary for CAPD patients. Persons with CAPD peculiarly have vitamin lack [ 18 ] . Hence, vitamin addendum is recommended for CAPD patients. Table 2.4 shows the recommended alimentary consumption for CAPD patients. Table 2.4: Recommended foods intake for CAPD patientsFoodRecommendationKilogram calories 35 kcal/kg BW/day for & A ; lt ; 60 old ages old 30-35 kcal/kg BW/day for & A ; gt ; 60 old ages old Protein 1.3 g/kg BW/day, 50 % HBV Carbohydrate 50-60 % of energy consumption Fat 25-35 % of energy consumption Sodium 1500 mg/ twenty-four hours Potassium 3-4g adjust to serum degree Fluid Up to 1500 ml/day Phosphate 800-1000 mg/day Calcium Calcium from diet and phosphate binder non transcend 2000 mg/day Vitamin B: Thaimine Vitamin b2 Vitamin b6 Vitamin bc Addendum to run into recommended day-to-day consumption Vitamin C Supplement up to 60-100 mg/day Beginning: Malaysia Medical Nutrition Therapy guideline, 20052.6 Malnutrition among CAPD patients2.6.1 DefinitionLack of protein and energy consumption or both is mentioning as protein-energy malnutrition ( PEM ) [ 19 ] . PEM is a status ensuing from long-run unequal consumption of energy and protein which can take to blowing of organic structure tissues and increased susceptibleness to infection [ 19 ] . PEM is strongly linked to malnutrition and mortality rate in person who undergoes care dialysis [ 2 ] . CAPD patients are more prone to malnutrition compared to HD patients. In CAPD, protein lost during dialysis procedure will ensue in protein lack and cause malnutrition [ 2 ] .2.6.2 PrevalenceBy the terminal of twelvemonth 2008, there are 3836 patients who are new to dialysis out of entire 19000 patients. The entire dialysis prevalence rate in December 2008 is 680 [ 3 ] . Patients who undergo CAPD are increasing twelvemonth by twelvemonth. Chronic kidney disease patients who underg o CAPD were 1744 patients out of entire 19221 patients in December 2008. The gender distribution is male ( 55 % ) and female ( 45 % ) from a entire 18856 patients [ 3 ] . The primary cause of nephritic disease is diabetes mellitus ( 55 % ) followed by high blood pressure ( 7 % ) from entire 3836 new dialysis patients on twelvemonth 2008 [ 3 ] . Protein-energy malnutrition ( PEM ) is really common among patients with advanced chronic nephritic failure ( CRF ) and those undergoing care dialysis ( MD ) therapies worldwide [ 2 ] . K/DOQI guideline proposed that, both work forces and adult females patients undergoing maintenance dialysis to accomplish BMI of at least about 23.6 kg/m2 and 24.0 kg/m2, severally. There are 14 % of CAPD patients who are scraggy ( BMI & A ; lt ; 18.5 kg/m2 ) . In Malaysia, malnutrition among dialysis patients is of great concern as it remains to be one of the strongest forecasters of morbidity and mortality [ 2 ] . There are 87 % of CAPD patients have serum albumin degree ( & A ; lt ; 4.0g/dL ) which assigned as malnourished [ 3 ] . Table 2.5 shows the categorization of serum albumen degrees. Table 2.5: Categorization of serum albumens degreeStatusSerum albumin degreeWell nourished 4.0 g/dL Mild undernourished 3.5 – & A ; lt ; 4.0 g/dL Moderate undernourished 3.0 – & A ; lt ; 3.5 g/dL Severe undernourished & A ; lt ; 3.0 g/dL Beginning: KDOQI, 20002.7 Factors doing malnutrition among CAPD patientsThere are multiple factors that cause malnutrition in these patients [ 2,20 ] . They are chiefly categorised into three causes: unequal dietetic consumption, disease conditions and intervention or dialytic factors. Inadequate dietetic consumption will take to malnutrition among dialysis patients. Altered gustatory sensation esthesiss caused by unequal dosage of dialysis, emotional hurt, anorexia and unpalatable prescribed diets ensuing in patients ‘ hapless unwritten consumption, and later impair their nutritionary position [ 20 ] . Disease status is besides a factor causes malnutrition in dialysis patients. Uremia is the most of import subscriber to inadequate nutrition in CAPD patients. As the Glomerular Filtration Rate ( GFR ) declines, azotemic toxins accumulate, taking to sickness and diminished appetite. Patients on dialysis have exposed to chronic inflammatory province will increase hypercatabolism and loss of thin organic structure mass when there is negative nitrogen balance [ 2 ] . Inflammation caused by infection, periodontic disease and familial factor will besides take to hapless nutrition intake [ 20 ] . Ascitess patient is at higher hazard of PEM. Ascites is another disease status doing protein loss more than 30g per twenty-four hours particularly after peritoneal dialysis induction. However, the sum of protein loss will decrease over clip [ 20 ] . In dialysis intervention, unequal dialysis might bring on anorexia and decreased gustatory sensation sharp-sightedness [ 20 ] . In add-on, dialysis promotes blowing by taking foods such as aminic acids, peptides, protein, glucose, water-soluble vitamins, and other bioactive compounds, and promotes protein katabolism, due to bioincompatibility [ 2 ] . In CAPD patients, redness of catheter site, bioincompatibility of dialysis solution will impact the nutrition position [ 20 ] . Besides, dialysis therapy may besides take to peritonitis. Transportation of K and azotemic toxin down a concentration in peritoneal capillaries will do protein loss. Furthermore, peritoneal inflammation will do ‘leaky ‘ in peritoneal capillaries and prolong peritoneal redness ensuing in release of cytokine and protein loss, which in bend influence patient ‘s nutrition position. Intra-peritoneal force per unit area is another factor impacting dietetic consumption. An addition in intra-abdominal force per unit area will take to symptoms of decrease in dietetic consumption and early repletion by delayed gastric emptying [ 20,21 ] . The most holds in stomachic voidance happened in those with smaller organic structure surface country [ 22 ] . Gastric emptying clip is associated with adequateness of foods ingestion. Last but non least, psychological factor will besides impact patient ‘s nutrition position. Psychological load causes loss of appetency in CKD patients, ensuing in a diminution of nutritionary position [ 20 ] .2.8 Nutrition Screening2.8.1 Purpose of testingHigh prevalence of CAPD patients with hapless nutritionary position is associated with inauspicious results [ 20 ] . Early sensing of malnutrition patient can diminish the hazard of inauspicious result of hapless nutrition. Therefore, it is critical that a validated and accurate tool used to place those malnutrition patients. Nutritional appraisal acts as an indispensable and introductory clinical process in nutritionary direction [ 4 ] . K/DOQI 2000 recommends nutrition appraisal should be performed routinely with combined method such as anthropometric measurings, organic structure composings measurings, biochemical measurings, dietetic appraisals and subjective appraisals [ 2 ] . However, most of these processs are time-consuming and cumbersome, even when a adept dietician is involved [ 4 ] . Therefore, a simplified and user friendly testing tool is needed for others wellness professional to observe malnutrition among the patients.2.8.2 Introduction of showing toolsThere are entire 6 showing tools will be used in this survey: Malnutrition-inflammation mark ( MIS ) , nutritionary hazard showing ( NRS ) , Malnutrition Universal Screening Tool ( MUST ) , Malnutrition Screening Tool ( MST ) , geriatric nutritionary hazard index ( GNRI ) and modified subjective planetary appraisal ( MSGA ) . The SGA and MIS tools are the gilded criterion showing tools which have proven in many surveies [ 2,23 ] . However, MSGA is used in this survey alternatively of SGA. MSGA is more nonsubjective, easy and practical that utilizing quantitative marking system if compared to SGA which is utilizing semi-quantitative marking system [ 24 ] . Whereas, MIS is validated and proven by Kalantar-Zadeh et. Al ( 2001 ) as a dependable tools to place malnutrition patient particularly in inflammatory province [ 23 ] . A survey by Yamada K. ( 2008 ) obtained the mark from several testing tools such as NRS, MUST, MST, GNRI and Mini nutritionary Assessment-Short Form ( MNA-SF ) and comparing the MIS testing tool as the mention criterion. Among the five showing tools, consequences shown GNRI was the most accurate showing in placing hemodialysis patient at nutritionary hazard. However, this survey did non included CAPD patients [ 4 ] . MSGA is a modified quantitative subjective planetary appraisal which modified utilizing the constituents of conventional SGA by Kalantar-Zadeh and co-workers, 1999. MSGA is a to the full quantitative hiting system with mark from 1 ( normal ) to 5 ( really severe ) . MSGA consists of seven variables including weight alteration, dietetic consumption, GI symptoms, functional capacity, comorbidity, hypodermic fat and marks of musculus cachexia. This survey had shown a relationship between malnutrition mark and the combination of MAMC, BMI, serum albumen and TIBC. MSGA is an nonsubjective, dependable and easy tools which can execute in proceedingss compare to SGA. However, the survey did non include any CAPD patients [ 24 ] . Malnutrition-inflammation mark ( MIS ) was another testing tool developed by Kalantar-Zadeh and co-workers in twelvemonth 2001. It is a utile tool to mensurate nutrition and redness on care hemodialysis ( MHD ) patients. This tools was developed utilizing seven constituents in SGA and added three new elements which are body aggregate index, serum albumen degree and total-iron binding capacity with mark 7 ( normal ) to 35 ( terrible malnourished ) . Kalantar-Zadeh and co-workers proved it is a good tool in foretelling mortality every bit good as nutrition, redness and anaemia in MHD patients. [ 23 ] Nutrition hazard showing ( NRS ) is developed by Kondrup and co-workers in old ages 2002. This tool was designed to steps current possible undernutrition and disease badness patients in order to measure whether tools was capable to separate patients with a positive clinical result from those who non profit from nutrition support. The consequence proved this screening tool is able to separate positive consequence and those who are likely to profit from nutrition support. It scored 0 ( absent ) to 3 ( terrible ) . [ 25 ] Malnutrition Universal Screening Tool ( MUST ) was designed to observe protein-energy malnutrition and the hazard of developing malnutrition in grownup patients. There are three independent standards use in this tool which is BMI, weight loss mark and acute disease consequence mark which mark from 0 to 2. The entire tonss is added and delegate into one out of three classs including 0 ( low hazard ) , 1 ( medium hazard ) and & A ; gt ; 2 ( high hazard ) . Stratton and co-workers concluded that MUST was a speedy and easy performed tool. [ 26 ] Malnutrition Screening tool ( MST ) was developed to observe hospitalized grownup ague patients at hazard of malnutrition by Ferguson and co-workers. It consisted of two inquiries sing appetency and recent unwilled weight loss. The information showed a relationship between patients who are high hazard of malnutrition harmonizing to MST with low average value of nonsubjective nutrition parametric quantities and longer length of infirmary staying. Ferguson and co-workers proposed MST as a simple, speedy, validated and dependable tool to observe malnutrition. [ 27 ] Geriatric Nutrition Risk Index ( GNRI ) was developed by Bouillanne and co-workers in twelvemonth 2005. GNRI was used to observe patients at hazard of malnutrition and related to mortality and morbidity. Nutrition position indexs including albumen, weight and WLo was used to cipher GNRI mark. It had four classs of nutrition related hazard which are no hazard, low hazard, moderate hazard and major hazard categorized by utilizing GNRI mark. This survey showed a strong relationship between albumen and GNRI. It is a simple showing tool for foretelling mortality and morbidity hazard particularly in hospitalized aged patients. [ 28 ]Chapter 3: Materials and Methods3.1 Study designThis research was a cross-sectional survey which done amongst 50 CAPD patients in Hospital Kuala Lumpur ( HKL ) . The research has been approved by the IMU Joint commission Research and Ethics. This research was to place a suited simplified testing tool to observe malnourished patients on CAPD. Six available showi ng tools were tested on patients ‘ nutritionary position. The diagram shows the flow of the survey.3.2 Sample sizeParticipants were chosen by utilizing convenient trying method at the Nephrology unit in Hospital Kuala Lumpur ( HKL ) . The sample size computation was based on the prevalence of malnutrition CAPD patients as reported in National Renal Registry, 2006. ( Z ) 2 P ( 1-p ) e2 Sample size computation, Ns = = ( 1.96 ) 2 ( 0.87 ) ( 1-0.87 ) ( 0.10 ) 2 = 43.4 50 patients Where Z = Z0.95 = 1.96 is read from a standard normal distribution tabular array. Where P = Prevalence of malnutrition CAPD patients = 0.87 ( 87 % ) Where E = Estimated trying mistake = 10 % Therefore, 50 patients were recruited for this survey.3.3 Capable choiceThe inclusion standard of this survey were participants recruited must be above 18 old ages old and undergoes at least 6 months of care dialysis. Participants who admitted in wad or hospitalized were categorized into exclusion standards.3.4 Sampling methodParticipants recruited by utilizing convenient trying method. There were in entire 50 participants in this survey. Participants available at the CAPD unit at informations aggregation period were approached and invited to fall in the survey.3.5 Methodology3.5.1 Questionnaire designThe questionnaire consisted of 8 sectors to obtain information on participants ‘ personal inside informations, socioeconomic background, medical history, drug profile, CAPD prescription, appetite, lifestyle history and dietetic informations. Information was obtained through interview. This is shown in appendix 1. A ) Personal inside informations This subdivision covered inquiries on personal information of the participant ‘s name, gender, age, day of the month of birth, ethnicity, matrimonial position, instruction degree and employment. B ) Medical history Information on cause of kidney failure, intervention history ( continuance, history of kidney graft and parathyroid secretory organ remotion ) and co-morbidities of the participant is obtained. C ) Drug profile This subdivision covered informations on the medicine prescription and besides information of multiple addendum taken and traditional medical specialty. D ) CAPD prescription Information was obtained on figure of exchanges done in one twenty-four hours and the concentration, type and volume of dialysate usage per exchange. Tocopherol ) Appetite Participant ‘s current appetency was questioned by utilizing a graduated table of ranking which included good, just, hapless and really hapless. F ) Physical activity The frequence of exercising and the grounds for non exerting were asked. G ) Dietary Data Food readying, eating wonts and any allergic reaction of nutrients were specified in this portion. H ) Hospitalization Subject ‘s hospitalization ground and surgery history was asked. 3.5.2 Anthropometric informations ( Appendix 3 )3.5.2.1 Height and weightParticipant ‘s tallness and weight was obtained from the medical record. Three measurings of participant ‘s station dialysis weight were recorded at first hebdomad for 3 old months from December 2010 to February 2011. The 3-month weight informations provides the information of topic ‘s weight position ( weight addition or weight loss ) for testing tool constituent. Body Mass Index ( BMI ) will be calculated from topic ‘s tallness and weight, utilizing the undermentioned expression: BMI = Body weight ( kilogram ) / Height2 ( M2 ) *KDOQI 2000 recommended that the BMI of care dialysis patient to be at least 24-28 kg/m2. Table 3.1: Categorization of BMI cut off point for grownupCategorizationBMI ( kg / M2 )Underweight & A ; lt ; 18.50 Normal 18.50 – 24.99 Corpulence 25.00 Corpulent 30.00 Beginning: Adapted from WHO, 1995, WHO, 2000 and WHO 2004.3.5.2.2 Mid arm perimeter ( MAC )Mid arm perimeter was performed with mensurating tape ( preciseness  ± 0.1 centimeter ) . Landmarking was done on the center of acromiale and radiale. Cross manus technique was used to mensurate the perimeter.3.5.2.3 Tricep skinfold ( TSF )Triceps skinfold was performed with Harpenden Skinfold Caliper ( John Bull, British Indicators Ltd. England ; preciseness  ± 0.1 centimeter ) . Landmarking was carried out prior to skinfold measuring.3.5.2.4 Mid arm musculus perimeter ( cAMA )Mid arm musculus perimeter is a computation derived from mid arm perimeter ( MAC ) and Tricep skinfold ( TSF ) : MAMC ( centimeter ) = MAC ( centimeter ) – [ ? – TSF ( centimeter ) ] Calculate mid arm musculus country ( cAMA ) provides a more accurate appraisal of musculus mass by gauging bone-free arm musculus country, corrected with gender differences. Calculate mid arm musculus country, cAMA = [ ( MAC ( centimeter ) – ? – TSF ( centimeter ) ) 2 ] / 4 ? – 10.0 ( work forces ) = [ ( MAC ( centimeter ) – ? – TSF ( centimeter ) ) 2 ] / 4 ? – 6.5 ( adult females ) Table 3.2: Cut off point of arm musculus perimeter ( AMA )PercentileClass 5th Wasted & A ; gt ; 5th but ? 15th Below norm & A ; gt ; 15th but ? 85th Average & A ; gt ; 85th but ? 95th Above norm & A ; gt ; 95th High musculus Beginning: Frisancho AR. 1990. Anthropometric criterion of the appraisal for growing and nutritionary position. 3.5.3 Biochemical informations ( Appendix 4 ) Serum albumen, serum beta globulin, serum Total Fe binding capacity ( TIBC ) , serum cholesterin, serum creatinine, Kt/V and serum carbamide were obtained from participant ‘s latest blood trial consequence. Table 3.3: Cut off point biochemical value Biochemical constituents Normal scope Serum albumen & A ; gt ; 4.0 g/dl Serum Tranferrin Serum TIBC Serum Cholesterol Serum Creatinine Serum Urea Kt/V & A ; gt ; 1.7 3.5.4 24 hours dietetic callback ( Appendix 5 ) Dietary consumption was obtained utilizing 24 hours dietetic callback. Participant ‘s dietetic consumption of 1 weekday and 1 weekend were recorded. Dietary appraisal tools ( bowls, spoon, matchbox and cup ) were shown to the topic at the first interview subdivision. The subsequent information aggregation was done through phone call. Food functioning size recorded was converted to unit gm and analysed via Nutrient composing of Malayan Food ( Tee E Siong, 1997 ) and Nutritionist Pro. Programme.3.6 Screening toolA sum of 6 showing tools were used in this survey.3.6.1 Modified Subjective planetary appraisal ( MSGA )This tool was designed by Kalantar-Zadeh group in twelvemonth 1999. This testing tool was developed by utilizing the constituent of conventional SGA and consists of seven variables: weight alteration, dietetic consumption, GI symptoms, functional capacity, co-morbidity, hypodermic fat and marks of musculus cachexia. Each constituent was scope from 1 ( normal ) to 5 ( te rrible ) . The entire mark used to find the nutrition position of the patient.3.6.2 Malnutrition-inflammation mark ( MIS )MIS was developed by Kalantar-Zadeh et. Al 2001 based on 7 constituents of SGA method and 3 extra constituents of BMI, serum albumen and serum TIBC. The medical history buttockss weight loss during the predating 6 months, dietetic consumption, GI symptoms, functional capacity ( nutritionary related functional damage ) , and co-morbidity including figure of old ages in Dialysis ; while physical scrutiny assesses loss of hypodermic fat and musculus cachexia. Each constituent was scored from 0 to 3, the entire mark of all 10 constituents ranged from 0 to 30 ( higher figure indicates more terrible ) .3.6.3 Nutrition hazard showing ( NRS )Nutrition hazard showing ( NRS ) was developed by Kondrup and co-workers in old ages 2002. The concluding tonss were categorized into absent, mild, moderate or terrible malnourished with a entire mark 0-6. It contain of two testing c onstituents, initial and concluding showing. There were four variables included in initial screening- BMI, recent weight loss, alterations in nutrient consumption and wellness status. In concluding showing, two chief constituents were tested by each hiting 0 ( absent ) to 3 ( terrible ) . The entire mark was added and one extra mark for participant above 70 old ages old.3.6.4 Malnutrition Universal testing tool ( MUST )MUST was developed for multidisciplinary usage by the Malnutrition Advisory Group of the British Association for Parenteral and Enteral Nutrition. MUST consists of 3 independent constituents which are current weight position measured by BMI ( mark: 0 to -2 ) , unwilled weight loss ( mark: 0 to -2 ) , and acute disease consequence bring forthing no nutritionary consumption for & A ; gt ; 5d ( mark: 0 or 2 ) . The amount of these 3 tonss was calculated.3.6.5 Malnutrition testing tool ( MST )The MST was developed by Ferguson et. Al 1999 had been used for acute infirmary patients ; it incorporates 3 constituents which are weight loss ( mark: 0 or 2 ) , sum of weight lost ( mark: 1-4 ) , and hapless nutrient consumption or hapless appetency ( mark: 0 or 1 ) . The entire mark was calculated for each patient.3.6.6 Geriatric nutrition hazard index ( GNRI )The GNRI was developed by modifying the nutritionary hazard index ( NRI ) for aged patients. This index was calculated from the serum albumen and organic structure weight by utilizing the undermentioned equation: GNRI = [ 1.489 – albumen ( g/dL ) ] + 41.7 – ( organic structure wt/ideal organic structure wt ) ]3.7 Statistical AnalysisAll the information was analysed by utilizing Statistic Merchandises and Services Solution, SPSS ver. 18.0. Each variable is presented as the mean  ± Standard Deviation ( SD ) . Descriptive frequence trial was used to prove the distribution of the variables among gender. T-test was besides used to show the correlativity between the variables. P & A ; lt ; 0.05 was considered as statistically important. Sensitivity, specificity, positive prognostic value ( PPV ) and negative prognostic value ( NPV ) were used between testing tools and nonsubjective variables. Crosstab was used to transport out the sensitiveness and specificity trial. Formula of computation: Sensitivity = true positives/ ( true positives + false negatives ) Specificity = true negatives/ ( true negatives + false positives ) Positive prognostic value ( PPV ) = true trial positives/all trial positives Negative prognostic value ( NPV ) = true trial negatives/all trial negatives

Benchmarking conflict management

Benchmarking is a process of determining what is best, may it be a company, organization, business or individual. This is done by setting standards and who attains the set standards. Benchmarking is done by comparing two or more companies in order to get which emerges the best among them. The companies or individuals that do the same kind of work or business are best benchmarked. In benchmarking, also known as geodetic control points there need to be a process to follow in order to get the winner, what process the winner followed to get there.Benchmarking is a quality improvement initiative this encourages companies and organizations to improve their quality to avoid being the last. (Galdin, 2005) Conflict is the struggle between the incompatible or opposing needs, wishes or individuals. Benchmarking conflict management is trying to come up with the best method to solve the conflicts between the companies or individuals with the same goal or wish e. g. two companies wishing to buy th e same piece of land for expansion. Benchmarking Conflict approach Gadency bus services are a company operating from Manchester city to London city.It is a public transport company having a fleet of more than a hundred buses. It wanted top buy a piece of land to build a garage, it targeted a piece of land owned by Manchester city council. The conflict arises when the city council refuses to sell the land to the company. Conflict rose when the city authority declined to sell the piece of land to them. The company had to look for means to solve the conflict. In this situation the bus company is responsible for the city council actions. Conflict situations offered the company an opportunity to choose a style for responding to the conflict.The most effective conflict prevention and management is to choose the conflict management style appropriate for the conflict. The company chooses a compromising style to solve the conflict which was very important to them to satisfy their interests, the company compromised to split the difference between them and the city council. The company chooses to ask for lease which was granted for the council was not ready to sell the land. Gadency bus acquired the land for choosing the best method to solve the conflict. (Cavenagh, 1999)London breweries are a brewing company situated is western suburb of London city. It wanted top buy a piece of land to build a warehouse, it targeted a piece of land owned by London city authority. The conflict arises when the city authority refuses to sell the land to the company. Conflict rose when the city authority declined to sell the piece of land to them. The company had to look for means to solve the conflict. In this situation the bus company is responsible for the city authority actions. Conflict situations offered the company an opportunity to choose a style for responding to the conflict.The most effective conflict prevention and management is to choose the conflict management style appropria te for the conflict. The company chooses an accommodating style put their interests last and let the city authority have what they want. The brewing company believes that keeping a good friendship is more important than anything else. The city authority declined completely to sell the land to the company and the company moved on by the decision of the city authority’s decision and did not acquire the land. This was as a result of the conflict solving style used by the company. (Simons, 2002) ConclusionBenchmarking conflict management between the two companies would solve the conflict between them and also improve the quality of their services. By the setting of some standards by the city council has also encouraged the companies to choose appropriate style that is preferred in solving the dispute. Interaction of the Manchester city council and London city authority helped in improving the group behavior and avoiding completely spoiling of the inter-group relation and also hel ped in solidifying the groups. By each company applying different conflict solving style, this determines the result each company gets.

Claudio’s fall from grace in Much Ado About Nothing Essay

It is often said that Shakespeare meant Claudio to be the hero of the play as the climax of the play (the court scene) revolves around his love story and he finally achieves his beloved in the denouement. However, as the play progresses Claudio fails to live up to the expectation of being a hero and is barely tolerable through the course of the play. Claudio is a young Florentine and serves as Don Pedro’s right hand man. The very first impression that the audience gets of him is very deceptive just as the rest of the play is. He is said to have achieved ‘the feats of a lion in the figure of a lamb’. As the exposition scene progresses, Claudio reveals his feelings regarding Hero to Don Pedro. However, this impacts Claudio’s image negatively as he allows Don Pedro to woo Hero in his place. His manliness is put to question as he is not even brave enough to declare love to the person he loves. ‘The prince woos in Claudio’s name’ and discloses Claudio’s feelings to Leonato. In the meanwhile, Claudio acting like a fool is deceived by Don John into believing that Don Pedro has wooed for himself. Claudio appears to be a gullible character as he is deceived by the very devil into mistrusting his dearest friend. He is a brave person and a likeable man but his exasperating credulity takes the merits from all these qualities away and leaves Claudio hinging between a smart and a petty character. Though foolish and naà ¯ve in judgement, Claudio is still loved and trusted by his friends. Claudio plays a crucial role in the gull of Benedick as he becomes the via media of information from Hero about Beatrice’s love for Benedick. His presence in the scene makes it more believable and thus Claudio becomes an important character in the development of the plot in the story. The play progresses and Borachio and Don John approach Don Pedro and Claudio to carry out their master plan. On hearing, what Don John has to say, Claudio reacts impulsively without giving the situation a second thought. He believes in what Don John is saying and aggressively declares ‘If I see anything tonight why I should not marry her, tomorrow, in the congregation where I should wed, there will I shame her. Claudio’s gullibility is again showcased as he believes Don John that the person he loves is disloyal Moreover this is the person who’s compared to Diana for her virtues and Claudio readily believes her to be disloyal because the villain says so. It is in Act 4 scene 1 that all hell breaks loose and Claudio loses all respect in the eyes of the audience. Claudio openly slanders Hero. He appears to be a petty man who is only capable of judging people superficially and incapable of reacting in a calm and mature manner. He mirrors a typical Elizabethan man who is very misogynistic in his attitude. Shakespeare critics the chivalric notion of honour through Claudio and shows the co-existence of the two paradoxical notions of chivalry and misogyny. Claudio’s self-deception of being righteous and his lack of true judgement leaves the audience disgusted at him after the court scene. This feeling of disgust is heightened as Claudio fails to show any signs of guilt in his behaviour and looks for entertainment from Benedick. Even when he is informed of Hero’s death by Leonato, he doesn’t even show an iota of remorse. However, when the truth comes to light, he agrees upon repenting for his mistakes. So far so that, he doesn’t even protest taking Antoni’s daughter’s hand in marriage. This reflect upon his superficial love and how he never felt any love but was simply attracted towards Hero. His behaviour again undergoes a complete volte-face as he discovers that Hero is not dead and instantly falls in love with her again. These incidents lead us to believe that Claudio is a loosely basted character who’s behaviour is everchanging and is easily gullible and extremely impulsive in nature. Shakespeare gives to Claudio the affluence of vitality, which necessarily creates an extenuating perspective for his conduct. This makes the worst of his aberrations tolerable and thus slightly likeable. Also, Claudio’s presence in the play gives us a contrast between courtly love and true, deep-rooted love. His fall from grace gives a contrast to Benedick’s character as Benedick continuously grows from being a bit of a nonsensical character as to being a man of morals and solidarity. It is Claudio’s fall from grace and Benedick’s rise to manliness that bring about the main developments in the plot during the course of the play.

Case study Example | Topics and Well Written Essays - 500 words - 4

Case Study Example Hence the only available option is $1250 thousand dollars. 5. The formula to calculate terminal value using the perpetuity method is given as: FCFn X (1+g) / WACC –g, where FCFn is the FCF for the last 12 months of the projection period, g is the perpetuity growth rate and WACC is the weighted average cost of capital. Using this formula, 6. Total interest expense from 1971 to 1976, based upon Exhibit 7 equals 3049 thousand. The actual Interest tax shield (interest expense X tax rate) in a given year equals the minimum of the calculated Its and the projected taxes before the ITS is applied. ITS for each year is thus given as follows: 7. The Adjusted Present Value method may be calculated as the sum of the FCFs discounted by the cost of the assets plus the interest tax shields which are discounted at the cost of debt. The present enterprise value of the corporation for 1971: The free cash flow available in 1971 is $726 thousand. The terminal value is $10,010. Therefore, the sum of PCF and TV is 10726. The interest tax shield available in 1971 is $99372; hence the present adjusted value of the enterprise is $10825372 or about $10 million. 8. Since the investors are prepared to provide $4750 thousand at the rate of 9%, the interest payable amounts to $2,137,500. In order to ensure that the investors are motivated to offer the large amount of capital, the company needs to make sure that they are allowed purchase at least 6 million shares as

Case Analysis Study Example | Topics and Well Written Essays - 500 words - 2

Analysis - Case Study Example Notably, all investments are marveled with investment risks that must be handled in a given way; otherwise, the affected business is headed to collapse. Risk management skills are learned. Therefore, such skills follow a given professional way since they often apply varied different models of problem solving skills. For instance, the discretionary wealth hypothesis is a perfect model of comprehensive risk management comprising of both interim shortfall constrains and downside risks that are based on ln(w-c) utility. Therefore, every business risk scenario follows a different and distinct way of management or handling. The Jarrod Wilcox’s article, Risk management: Survival of the fittest has represented different scenarios that require different and distinct risk management skills to handle. The first case scenario, Option income funds, is where brokers owned and distrusted stocks or bonds. Moreover, they distributed premiums in forms of income (Wilcox, 2004). These activities led to an intense disappointment and withdrawal of investors following gradual decline of opportunity and reduction of money flow. To build the investor confidence is this case; the risk manager should apply the Kelly’s rule of the stock portfolios. In this case, the investor should confront single period return distributions. By calculating statistical parameters such mean and variance thereafter looking into kurtosis and skewness of the date in distribution data, it is possible to predict the data distribution. This process will enable mangers to restrict or regulate rockers’ distribution habit thereby building the investor confidence (Wilcox, 2004). The Extreme CPPI case desires to protect the investor from the downside risk in order to reduce portfolio insurance. In other words, the case reflects a scenario where investors are only interested in business when profits are high. Despite timings, the investor may sometime

International Business - Overseas Market Entry Actions Essay

International Business - Overseas Market Entry Actions - Essay Example However, the cosmetics industry in Iceland has escaped most of the fallout resulting from financial market collapse in the country, which has opened up internationalization as a viable strategic objective. This paper will focus on Blue Lagoon Cosmetics Company and its potential entry into the Kuwaiti market, including the most viable international business strategy, its marketing actions, and appropriate organizational structure. In order to do this, the paper will use literature studies on international business strategy and apply theoretical models to the entry of Blue Lagoon into Kuwait. Blue Lagoon was started in 1976 as a way to take advantage of a geothermal plant constructed in the Reykjanes-peninsula. The geothermal plant produces water rich in natural minerals that are also integrated into the white silica clay on land, which Blue Lagoon collects and sells as cosmetic products (Icelandnaturally.com, 2013: p1). Blue Lagoon Ltd. was established in 1992 due to the popularity of its warm spa water, after which bathing facilities were opened in 1999, which made it one of the most popular tourist destinations in Iceland with at least 70% of all tourists visiting Iceland also visiting the Blue Lagoon. The company has three state-of-the-art geothermal spa facilities, which host restaurants, conference rooms, an indoor pool, and modern changing and shower rooms. In addition, Silica mud is also part of the company’s assets, in which visitors can bathe. Blue Lagoon has dedicated its activities to developing the health of visitors, building on the presence of geoth ermal water that contains blue-green algae, silica, and salt (Icelandnaturally.com, 2013: p1). The company began producing skincare products as Blue Lagoon Iceland made of unique chemicals, which were first marketed in the late 90s. In the early part of the 2000s, they launched

Characteristics of Partner Violence Essay Example | Topics and Well Written Essays - 750 words

Characteristics of Partner Violence - Essay Example They are also excessively jealous and will always say that jealousy is a sign of love however jealousy is a sign of possessiveness and lack of trust. They accuse you of flirting with everybody. Abusers exhibit controlling behaviour and this is shown by at the beginning they will claim that they are concerned about your safety. They will be angry when you are late and closely question you about your whereabouts and who you talk to. Later on they will not let you make personal decisions and you end up asking for permission to leave the house (L.Petherbridge 2009). Abusers have unrealistic expectations or demands in which they expect a perfect partner, lover or friend. They expect that you take care of them emotionally, physically and sometimes economically. They use isolation to keep their partners off all resources so that you are centred on them. They will isolate you from your friends by accusing them of causing trouble (L.Petherbridge 2009). Abusers are prone to hypersensitivity as they are easily insulted and may take the slightest setback as a personal attack. They have dual personality as they can be charming and cruel at the same time. This characteristic makes it difficult for the victim to reach out for support from family and friends because they function well around work, friends and family and sometimes only the spouse is aware of the battering (L.Petherbridge 2009). Abusers are victims and his poor choices are everybody’s fault, he is never at fault and uses phrases like â€Å"you make me hit you†. They are critical and no matter how hard you try you will never be able to satisfy this kind of a person. They will degrade and insult you. Abusers are insincerely repentant and will swear never to â€Å"to hit you again† (L.Petherbridge 2009). Domestic violence is a pattern of controlling behaviours that are purposeful and directed at achieving compliance from and over a victim without regards for his or her right (M.C Dunbar 2002). One of the characteristics of an abuser in domestic violence is the person ridicules, criticizes and condemns. They put other people down to feel better about themselves. One should not allow someone to condemn, ridicule or criticize them (D.V Hoeff 2007). An abuser of domestic violence is not able to control their anger and usually anger easily. They are unable to reason through issues and difficulties often resort to abuse to get what they want (D.V Hoeff 2007). Another characteristic of an abuser is they are irresponsible and will use you and will not take responsibility for him. He then blames everyone else for his failures. He will also blame you for his own emotional reaction and bad behaviours (D.V Hoeff 2007). Abusers use forced sex on their partners or pressurise their partner to agree to forceful or violent acts during sex or want to act out fantasies where you are helpless. They are not interest in intimacy and their partner’s filings (D.V Hoeff 2007). Alcohol is t he most common substance of abusive and most people think that it causes domestic violence while in reality many perpetrators of domestic violence do not drink heavily. Substance of abuse does not necessarily cause someone to be violent but it often makes the violence worse. They are popularly used as scapegoats (S. Myers 2001). Alcohol and other drugs are used to

Women rights in Brazil and Egypt Research Paper

Women rights in Brazil and Egypt - Research Paper Example This brought a completely new religion and an all new language. To highlight a current issue of this country, I have gone through a number of media sources and newspapers. The Daily News Egypt is a newspaper that examines various national and global affairs from an Egyptian frame of reference. Al-Masry Al-Youm, on the other hand is an independent news agency that is operational in Egypt. These are the key resources that will be utilized to discuss, elaborate and examine the chosen current issue (Tignor 2011). Brazil, with its capital Brasilia is the second region under debate. The country has a population of 195.4 million. Social conditions can be bitter in big regions of Sao Paulo and Rio de Janeiro, where up to third of total population resides in slums. To point out a current issue of this country, I have gone through a book called Latin American women: historical perspectives By Asuncion Lavrin. I have also analyzed details available on BBC.co.uk, an online news source that provi des political, cultural and economic insights (BBC 2010). As I researched the above mentioned sources, I found out that women’s right is an issue that is highly being focused.... Many women gathered at Tahrir Square on 8th March, 2011. Their ultimate aim was to remind the government that women make up half of the country and that they should have a say in the construction of a new Egypt. Throughout the uprising of Egypt, while women have played important roles in street protests, they remained silent regarding gender rights in their country. Due to this, they have not only faced aggressive discrimination but also received minimal legal aid against sexual abuse and widespread violence. The second article â€Å"Paving a Way for Women in Brazil† which has been written by Luisita Lopez Torregrosa (2011) and published in the New York Times highlights Dilma Rousseff’s speech at the U.N. General Assembly in the month of September. She, as the first ever female president of Brazil declared this century to be one for the women adding that her motive is to spread democracy and provide equal rights. Ms. Rousseff has taken steps to appoint women at prestigi ous posts such as chief of staff, institutional relations minister as well as planning minister. It has been observed that Brazilian women have made considerable advancement on closing gaps in fields of education and health but there are still gaps in wages, labor force, and the ratio of women’s unemployment and in their contribution to superior levels of hierarchies in businesses. If we compare the two, in order to emerge as prosperous nations, both these countries need to solve women’s right issues on a serious note. As compared to Brazil, women in Egypt are not given much chances as of yet, to contribute in the political sector. Even though they played a prominent role throughout Egypt uprising, they are not been given enough chances to grow and

Writting paper Essay Example | Topics and Well Written Essays - 500 words - 1

Writting paper - Essay Example Even the terrible thought of getting beheaded by the king does not let down the protagonist in the beginning. And even in such a terrible situation the protagonist is brave enough to face the king who is going to behead him. But here also the fate of the protagonist works and the king’s heart melts. The hero then goes through many unexpected journeys of life in which he is also sold as a slave. He is treated inferior to other individuals because of the race to he belongs. And moreover he is conned by many of his fellow beings. The hero is seen as a person who has strong faith in his God because of which he cannot see foul play in this world. He is unaware of the thoughts which the people have in this world about him. And even though he has many opportunities to revenge from the individuals that have done bad to him, he does not take revenge. He rather believes in the notion that he would get a better life hereafter if he lets go these individuals. The hero is seen to be very innocent too as when it is seen that he trusts people too easily. And because of this trust he loses a great amount of property that he has made in his life. The story depicts the life of an innocent individual who is seen to be bestowed with mercy at many instances by the God. It is seen that the individua l at lot of instances has been helped by God. In situations in which he has no one God provides him a path through which he can be able to survive. The story gives a platform for the believers to learn that usually the hardcore believers of God are shown paths by themselves and these believers should not lose hope no matter how harsh the situation is. It depicts that the world is full of individuals who are both nice and ugly. But it is not necessary that the ugly people should be given a bad

Austria - second world war Essay Example for Free

Austria second world war Essay Owing their reputation of fine tastes in art and culture, the nation of Austria is proud of their heritage, especially of their fame over the occupation of the Germans in the Second World War. The said country’s status remained to be uncertain after the Allies drove the Nazis away from the country and eventually occupied by the Allies. Austria became really proud of its rich culture and sceneries that were spared by the Nazis. The nation also celebrated its independence 10 years after the Nazis left the country and the cities flourished. Such events that would lead to the development of a country such as war that depicts change, gives a nation a sense of self-importance that is reflected in its culture and the tastes that the inhabitants acquire. The geographical data of Austria may be described as (according to the Encyclopedia Britannica as: â€Å".. largely mountainous country of south-central Europe. Austria extends roughly 340 miles (550 km) from east to west. It is bordered to the west by Switzerland and Liechtenstein, to the northwest by Germany, to the north by the Czech Republic, to the northeast by Slovakia, to the east by Hungary, to the southwest by Italy, and to the south by Slovenia. The capital is Vienna. Austria has an area of 32,378 square miles (83,859 square km). † Austria is one the verge of development these days but still largely dependent on its agricultural side. Most of the raw materials are still sourced from their agricultural fields and lush greeneries. Despite the advent of globalization on its boundaries, Austria remains to be a country of nature. Furthermore, policies of agriculture has been into practice for years in the country so as to protect their source of raw materials. This may be viewed as a strength since the raw materials that the distillery in question may be sourced from the agricultural side of the nation, a cut from the costs that the company may incur. The introduction of the Euro in place of the Austrian Schilling also had a positive effect in the country’s economy. (Anonymous 2006g) This prompted for developments in investors and this can be viewed as a plus factor in considering whether to expand in the nation of Austria or not. Scotch is one of the products in less demand in Austria. Together with the rest of Europe (excluding France, Spain and Germany), Austria constitutes 17% of the total demand for Scotch Whisky in 1995. The small market size of the nation may be viewed as its weakness since the local distilleries would have had the shares that The Olde Distillerie would want to have. For a small company as the company in question, it would a be a negative sign in investing in a country such as that of Austria. Meanwhile, Austria cannot hide such facts that people of their nation demands objects and products of high taste and rich in culture and history such as the scotch whisky. And like other European countries, its rich taste and heritage may be a possible market for the distillery, for as we have stated earlier, the countries are looking at alcohol as a sort of symbol or identity. Not only is the scotch whisky a lucrative product because of its history, but the taste and flavor of the product may be all in all attractive for the market of Austria. 4. Spain Spain’s strategic location enables it to embody a nation rich in culture and experience. Its location can be described as a crossroad in Europe where, many Islamic states are present for the past 800 years of their existence. (Anonymous 2006h) However, despite the Islamic states that pose as an outside force that may influence the country’s belief, Spain remains to be a Catholic country with a strong sense of culture and self-importance.

Analyse Contribution Of Engagement In Biopsychosocial Assessment Client Nursing Essay

Analyse Contribution Of Engagement In Biopsychosocial Assessment Client Nursing Essay In this essay the process of building a therapeutic relationship and assessing clients own circumstances within the inpatient admission and the framework found in practice will be uses analysed and criticized by using Johns (1994) model of reflection. The framework that has been used in mental health services is the Care Program Approach (CPA), which it has been profoundly criticised since it was introduced. Therefore the reflection will look into other model of nursing, Tidal Model, which offers a different philosophy of care. The reflection will also explore the interpersonal interactions theories which the nursed used during the assessment and how these aided to engage the client in the biopsychosocial assessing process. It also will be discussed other intervention models and the possible usage in similar situations. In order to begin the analysis of the above points, engagement needs to be defined. Thurgood (cited by Norman and Ryrie (2004) p.650) described it as: can be broadly defined as providing a service that is experienced by service users (including carers) as acceptable, accessible, positive and empowering. Although this definition gives an idea of the concept, it lacks to define the key elements of engagement, which Cutcliffe and Barker (2002) identified as forming a human to human relationship, expressing tolerance and acceptance, and hearing and understanding. Both definitions gather the professional values of the service and the interaction itself. Yet, Cutcliffe and Barker (2002) definition can be considered more practical when holistically assessing clients. However, these definitions do not acknowledge factors of engagement that are behind the interpersonal relationship, such as personal or organizational perspectives of engagement. The personal perspective for the nurses practice is underpinned by poor structural organization, occupational cultures and stress, bureaucratic constrains, lack of time and nursing culture driven by measurable targets (Hosany et al (2007) and Addis and Gamble (2004)). On the other hand, clients and their families are conditioned by the mental illness, their past experiences with other services, the trust in the service and the relevance of it. Additionally, the organizational issues effect upon engagement and care by reducing services budgets, by not providing resources and also by politics. Engagement has been recognized as an important part of mental health services users care. The National Service Framework (NSF), the National Institute for Clinical Excellence (NICE) and the Department of Health (DoH) appoint that users under CPA should be provided with resources to build a therapeutic relationship, optimise engagement and reduce risks. These documents also highlight the need to provide a therapeutic environment in order to provide best care and to engage the clients and their families with the service. Taking into account all the above information a reflective account will be taking place in the following pages by using Johns model of reflection (1994). 1. Description of the experience The clinical environment where this assessment took place was in an acute adult ward. The ward is based in an old mental health hospital, which has old and pilling off wooden windows, untidy roofs and old fashioned flooring. The ward had untidy carpets, the curtains did not draw appropriately and the painting on the walls was peeling off. These are the organisational barriers affecting engagement. This particular client was known by the service already, to protect his right to confidentiality he will be referred as John (NMC code of practice 2008). John had been stable for 10 years, but in the past few months his mental state had worsened. His psychosis and levels of anxiety increased; he distrusted neighbours and other acquaintances as well as strangers. Consequently, he stopped going out of his house and began to self medicate with over the counter sedatives. Crisis and Resolution Home Treatment Team (CRHTT) was involved and as they felt that John was not able to cope at home, they decided that an inpatient admission would be beneficial. Before the admission the CRHTT forwarded the CPA form 1A, which updated the ward staff about the latest assessment of the clients biopsychosocial needs. Once John arrived to the ward, he fully understood the situation where he was in. He was able to consent and had capacity to agree with treatment and, thus, he was admitted as an informal client. This facilitated the initial interaction and the initial grounding for the nurse/client relationship. Before the beginning of the assessment Tom (Johns named nurse) introduced everyone to John, roles were explained, a welcome pack with the ward information and a CPA booklet were given and Tom provided all the information in an oral and written manner. The nurse started the assessment by formulating open questions. However John gave single direct answers (yes, not, not sure ). Consequently, the nurse decided to change to more direct questioning. After that the client was very co-operative and was answering all the questions. He reported to be very anxious, which also was noticeable by looking to his body language (he was sweaty, clenching his fingers, rubbing his hands on the chairs arms and removing his spectacles several times during the interview). At this stage the nurse decided to undertake an anxiety assessment by using the scales tools available on the ward the Becks Anxiety Inventory (BAI, see Appendix 1). Following this assessment, John began to answer the questions more in depth and he appeared more eased, stating several times that he was in hospital for help and was going to do everything that was available for his recovery. Following the local trust policies and NICE guidelines, the CPA 1A assessment was concluded (as it must to be completed within 72 hours of the admission); the Integrated Care Pathway for Inpatient Safety and the Patient Property Liability Disclaimer were filled in and signed by nurse and client. 2. Reflection The whole assessment was intended to gather as much information as possible about John in order to understand the clients actual biopsychosocial situation (holistic assessment) and the context that led to the admission, which would highlight the needs and strengths of the client. However, inpatient admissions are more likely to focus on a more medical approach to health, mainly because social interventions cannot be implemented until the clients mental state has stabilized and he is ready to move on to community settings. Along this process the multi-disciplinary team organizes care to build up the grounds to enable recovery (Simpson 2009). This particular ward was focus on treatment and stabilizing, working on one to one interventions (nurse-client), building a therapeutic relationship through structured and unstructured interventions, and used CPA as a nursing intervention framework. Alongside these individual interactions, the activity nurses and the occupational therapist offered daily social and leisure activities. These groups provided skills and entertainment to the clients on the ward, but did not follow a particular model of nursing, such as the Tidal Model, and they offered activities to spare the free time on the ward without promoting recovery. The Tidal Model provides structured group-work centred on recovery (Barker and Buchanan-Barker 2005). This model centres its assessment on a holistic approach for the short and long term needs, viewing the mental illness as a unique experience of each individual, their families and social environment. It looks into the lowest point of the illness (such as an inpatient admission like Johns) as the point where the recovery begins with a positive approach to the illness. There are three working groups recommended in this model: discovery, solutions and information (see appendix 3), where therapeutic relationship is built and issues common to the individual and others are discussed and explored. As mentioned above, the ward nurses had more structured interventions with clients, and the issues discussed in these interviews were correlated to the Tidals Model theme groups. In these interviews the clients engage with their primary nurses and they discuss their concerns in relation to their care or other personal matters. These interventions or interviews were intended to happen at least twice weekly for at least an hour. However, for organizational issues (usually low number of staffing) not all the clients had the opportunity to benefit from these one to one interventions on a regular basis. Initially, the Tidal Model research was criticised for being bias, for lacking to fully describe clients pre and post intervention with the model, not taking into account Hawthorne effect and most of physiological factors and by not reasoning the need for a new model in mental health care (Noak 2001). However, further research and analysis showed that the Tidal Model provides tools and structure to improve care in acute ward admissions filling the gaps in care pointed in the NSF and The Sainsbury Centre for Mental Health (Gordon et al 2005). One could say that this model has been shown to improve mental health services, fulfil the historical gaps within nursing practice and to be grounded on evidence-based practice. However, the author of this essay believes, after reading the relevant literature, that for the implementation of the Tidal Model the levels of staffing (and therefore the service budget) should be increased and nursing practice cultures must be changed by re-educating th e workforce. Arguably both implementations are very difficult to achieve as the health service has seen budgets cut downs in the recent years and nurses practiced has been subject to negative ward cultures towards nursing models. On the other hand CPA, which is the framework used on the ward, was first designed after a series of fatal incidents which involved mentally ill people. It was aimed to be introduced in Wales by 2004 (in England was done by 1991). CPA is person centred focus which promotes social inclusion and recovery, through assessment and planning of individualized needs and strengths, working with the clients and their families or carers (Care Programme Approach Association (CPAA) 2008). Despite the initial intention that the CPA was brought to improve service users quality of care, to increase inter agencies communication and to be a case management tool, some critiques appeared. Simpson et al (2003a) researched showed CPA was thought to be an over-bureaucratic duty within the professionals. The author of this paper has observed in practice, not in this particular assessment, that some professional do not reassess clients when they are admitted. Instead the latest CPA 1A form (usually filled in by the CRHTT) is photocopied or copied-pasted and re-used to speed up the process. This would be acceptable if the client was assessed the day or night before the admission, because the social, psychological or biological needs would have not changed in that period of time. When older assessments are used, changes in circumstances might have not been updated. In the worst case scenario a health professional could have misunderstood the clients needs and have documented them wrongly. This misunderstanding could be carried over, therefore care would be affected. This hypothetical scenario shows that CPA assessments should be done every time when needed. CPA as a case management tool fails to compile the most important features which promote therapeutic relationship. In contrast with other case managements models the role of the care co-ordinator is more of an administrative and as an alternative service prescriber (Simpson et al 2003a). This means that there is no need for a specific training or skills related to therapeutic relationship, partly because other services (or service providers) will engage with the client, and the care co-ordinator just oversees the process of care. Moreover, CPA also lacks a nursing model background and fails to define specific roles within the multi-disciplinary team. These factors reduce the teamness feeling between the health professional (Simpson et al 2003b). Although, it could be argued that the reason, why CPA is lacking nursing background, is that it was not designed as a mental health nursing framework but for the use of mental health services. In this particular reflexion the care co-ordinato r was not present in the admission and never mention during the assessment. Whether it was a usual situation or not it is something that never was discussed, but it shows Simpson et al (2003a and 2003b) critiques of CPA as a case management were factual. CPA and Tidal Model are intended to provide holistic care for clients and their families. However, the Tidal Model is more clients centred than CPA, and it also looks into the more positive side of the clients situation, foreseen the now and future as a whole. It explains the illness as an accumulation of life factors. The Tidal Model complements other health and social care professionals, as well as it searches to nurse by building a special relationship between health practitioner and client. Moreover, CPA always looks for risk signs in the short-term and from a psychiatric approach. As this assessment took place in an inpatient admission it is important to bear in mind that in this particular environment CPA forms (1A, 2, 2A and 4) were used for assessment, planning, implementing and evaluation of inpatient care and for the liaison with other health professional in tertiary care (such as physiotherapist, dietician or occupational therapist). Perhaps CPA would benefit from sharing some principles of a nursing model (like the Tidal Model), by using it as a tool more than as a paperwork and from a better staff training and promoting adherence to nursing models (Barker 2001). Whether the ward uses Tidal Model or CPA to structure care, an inpatient admission is always stressful and uncomfortable experience for clients and their families. John saw the nurse as a stranger in an unfamiliar place, however, Tom was there to guide the client throughout his care, to provide information and to be somebody he could relay on. This first encounter related to the orientation phase described by Peplau (1952) (cited by Sheldon (2005), see Appendix 2). In this phase Johns past experiences, expectancies, culture and believes were to condition the initial interaction. Following this phase John went into the identification stage, where he sought assistance for anxiety relief techniques, shared needs and strengths when and co-designed care plans and began to have feelings of belonging and capability, therefore decreasing negative feelings. This exchange of feelings is going to lead to exploitation and resolution phases, where John will engaged with treatment (medical, physic al and social), having different needs at different times, starting to be informed about all the help available towards the final stage, feeling as an important part of the whole nursing process and finally ending the professional relationship when discharged. The exploitation and resolution phases were not observe as at the time of writing John was still an inpatient. John had had previously one bad inpatient admission. He reported that he was very unhappy when he was in the other hospital 10 years ago. He explained that the bad experience was related to the other clients and organizational issues rather than staff. John stated that he was feeling anxious but happy that he was getting help. His positive attitude helped to engage him in the assessment process and on the ward activities, which were the first steps towards the identification phase. Therefore, John could begin to have professional input from other members of the multi-disciplinary team. Tom interacted in a way that John felt understood, respected and individualized. Tom did not appear to have preconceived ideas of the client after reading the CPA forma 1A. And certainly, Tom treated John respectfully and as an equal human being. He followed the NMC code of practice 2008, which states that: you must treat people as individuals and not to discriminate in any way those in your care. Tom tried to adapt the pace of the questioning to the clients needs, involving him and asking in a respectful manner. Tom also acknowledged Johns anxiety feelings, and showed it when taking further (BAI see appendix 1) assessments to empathize more with Johns situation. This reinforced the approachability and genuineness of the nurse and led John to open and engage with the assessment process and the health professional. 3. Influencing factors John scored 45 points in the BAI (see appendix 1), which is a high scoring. This could have been influenced by the hospital admission and the assessment process. Despite these factors and Johns actual mental state he engaged in the assessment actively. The BAI scales consist of 21 observable and self-rating symptoms of anxiety, rated from 0 to 3 (0 being the lowest score), which can also be easily transformed in direct questions or self rating. At the end of the assessment the scores are added up and compared against the scales. There are several assessment tools available such as Hospital Anxiety and Depression Scales (HADS) or Hamilton Anxiety Scales (a collection of them can be found in the Appendix 1 reference). The BAI is shown to be a quick and reliable when measuring clients anxiety levels and it also differentiates General Anxiety Depression and depression (Fydrich et al 1992). Although, these characteristics appear to be positive, it could be argued that BAI is just a merely adaptation of the DSM-IV panic symptoms and therefore it could also be said that measures panic attacks rather than anxiety levels (Cox et al 1996 and de Beurs et al 1997). On the other hand, HADS which achieves good levels of anxiety and depression screening could have been more appropriate for hospital settings and more accurate (Bjelland et al 2002). It is important to point out that NICE clinical guideline for management of Anxiety (2004) does not recommend a specific tool for assessment of anxiety, which gives to the professional practitioner choice on the usage of available tools. This affects practice as these scales are not used as often as they should be. Most practitioners relay on their observations and experience to perform informal assessments, rather than using research based scales. It is perhaps understandable when dealing with clients unable to fully understand these assessments. But in practice it can be noticed that nurses do not tend to use anxiety inventory even with clients that could engage with the process. Tom designed care plans in partnership with John and made him realise which were more realistic goals in the short and long term. Tom had shown knowledge and understanding of the professional capabilities that the NSF defined in the documents The Ten Essential Shared Capabilities (2004) and The Capable Practitioner (2001). These documents set basic principles that underpin positive mental health practice as well as providing the basic grounding for service workers to continue developing and learning skills. Therefore, it was observed during the placement that along the whole admission the nursing team also guided care and practice as appointed by these documents. They provided patient-centred care, which is accountable for each client and respecting the individual. The team also had a broad knowledge of national legislations as well as local policies and services, and worked under the same professional and ethical principles recognizing the rights of the clients and their families. T hey promoted recovery and self-realisation by identifying people needs/strengths and empowering the individuals. Most of the team members were undertaking further training, to keep their skills up-to-date or be able to transfer their existing skills to new environments. They also worked in partnership with family, carers, lay people and external agencies, such as community care services, voluntary associations and vocational services. 4. Evaluation In the interview Tom used a Rogerian approach (Roger (1961) cited by Sheldon (2005)). He also showed knowledge of Peplaus interpersonal theories and applied them in practice by creating a shared experience of care. However, it also would be appropriate to use the Herons six-category intervention framework (Heron 1989). This framework was designed to enable a practitioner (nurse) taking the lead to facilitate the clients specific needs or arising issues. Therefore this intervention could have been used in the admissions assessment and the following one to one sessions, which have been described in this essay. The framework is made off two categories, which are subdivided in three more. The first category is authoritative which it can be prescriptive, in which the nurse influences and directs behaviour, gives advice and prescribe goals. It also can be informative providing information or giving feedback for the clients behaviour. The third subcategory is confronting, in which the pract itioner challenges the clients beliefs or actions. The second category is the facilitative which is divided into cathartic, in which the nurse tries to release the clients painful feelings and talks about or express them with actions (tears, anger or shouts). Next subcategory is catalytic, where the nurse tries to help the client and encourage self-discovery and learning. Finally, supportive is the category where the client is supported in an unqualified manner. The facilitative stage of the framework would have been the most appropriate to use in the first assessment. Johns mental state would not have benefit from an authoritative approach as he might have felt threatened by the staff, therefore his willingness to engage with the service could have reduced greatly. This approach shares the same goals as the one that Tom used. The outcome would have been the same, which was the beginning to build a relationship towards recovery. However, it is important to know different ways to practice and to interact in order to provide an individualised care. This principle is shared by the models discussed in the essay (CPA and Tidal Model) and also by the nursing professional code (NMC code of practice 2008). 5. Learning Although, it was difficult to deal with Johns anxiety levels and his initial unwillingness to engage with the assessment, it was possible to create a therapeutic relationship between nurse and client. After this reflexion it was learnt that nurses knowledge and usage of the right nursing models, strategies and tools can be adapted to individual situations and their own circumstances. It is also important to share principles of care and to change some nurses cultures regarding models of care. It was positive to reflect upon this experience and, therefore, to realise how the theory learnt was applied in practice. Since nursing studies and practice are moved towards research based knowledge it seems that the human connection and relationship building have lost their place in the nursing profession. As a student it is good to see that values based nursing promoted safe, trustful and supporting environment, which led to a healthy therapeutic relationship (Hewitt 2009). In conclusion, the reflection and analysis of engagement through a biopsychosocial assessment illustrated how personal and organizational factors effect on clients care. It was found out that applying specific intervention techniques, mental health screening tools and the adequate adaptation to the individual and the situation promote engagement and build a healthy therapeutic relationship. Furthermore, the research showed that the relevant mental health regulations and nursing professional code recognise the need to keep up-to-dated knowledge and skills in order to provide the best care. All the above techniques and tools were found to be used in a very individual way between the nursing professionals. In addition to this, it was found that theses personal adaptations to practice and clients care were beneficial when reducing barriers for engagement and personalising the care. The positive and negative characteristics of the actual mental health framework CPA were brought forward and it was found that it lacks a nursing model background. CPA and Tidal Model when compared and contrasted, showed that both mental health frameworks differ gratefully from each other but at the same time they could benefit from each other. Despite the ward worked under CPA and used a more medical approach to nursing, the nursing team shared the same professional capabilities and worked towards holistic goals and recovery. Over all, in order to engage and to provide relevant services for clients and cares biopsychosocial needs there should be a continues connection between practice and theory in nursing. References Addis J Gamble C (2004) Assertive outreach nurses experience of engagement. Journal of Psychiatric Mental Health Nursing 11 (4) 452-460. Barker P (2001) The Tidal Model: developing an empowering, person-centred approach to recovery within psychiatric and mental health nursing. Journal of Psychiatric and Mental Health Nursing 8 233-240. Barker P Buchanan-Barker P (2005) Tidal Model: A guide for mental health professional. Brunner-Routledge. Hove. UK. Bjelland I Dahl A A Haug T T (2002) The validity of the Hospital Anxiety and Depression Scale: An updated literature review. Journal of Psychosomatic Research 55(2) 69-77. Cox B J Cohen E Direnfeld D M Swinson R P (1997) Does the Beck Anxiety Inventory measure anything beyond panic attacks? Behaviour Research Therapy 34 (11/12) 949-954. Cutcliffe J R Barker P (2002) Considering the care of the suicidal client and the case for engagement and inspiring hope or observations. Journal of Psychiatric Mental Health Nursing 9 611-621. Department of Health (2002) Mental Health Policy Implementation Guide: Adult Acute Inpatient Care Provision. Department of Health (2004) The Ten Essential Shared Capabilities. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4087169 Accessed: 29/12/09 de Beurs E Wilson K A Chambless D L Goldstein A J Ulrike Feske U (1997) Convergent and divergent validity of the Beck Anxiety Inventory for patients with panic disorder and agoraphobia Depression and Anxiety 6 140-146. Fydrich T Dowdall D Chambless D L (1992) Reliability and Validity of the Beck Anxiety Inventory. Journal of Anxiety Disorders 6 55-61. Gordon W Morton T Brooks G (2005) Launching the Tidal Model: evaluating the evidence. Journal of Psychiatric Mental Health Nursing 12 (6) 703-712. Heron J (1989) Six-Category Intervention Analysis (3rd EDN) Human Potential Resource Group, University of Surrey, Surrey, UK. Hewitt J (2009) Redressing the balance in mental health nursing education: Arguments for a values-based approach International Journal of Mental Health Nursing 18 368-379. Hosany Z Wellman N Lowe T (2007) Fostering a culture of engagement: a pilot study of the outcomes of training mental health nurses working in two UK acute admission units in brief solution-focused therapy techniques. Journal of Psychiatric Mental Health Nursing 14 (7) 688-695. Johns C Graham J (1996) Using a Reflective Model of Nursing and Guided Reflection. Nursing Standard 11 (2) 34-38. National Institute for Clinical Excellence (NICE) Clinical Guideline for Management of Anxiety (2004) http://www.nice.org.uk/nicemedia/pdf/cg022fullguideline.pdf Accessed: 26/11/09 National Service Framework (NSF) Modern Standards and Service Models for Mental Health (1999) NHS our Healthier Nation. Noak J (2001) Do we need another model for mental health care? Nursing Standard 16 (8) 33-35. Norman I Ryrie I (2004) The Art and Science of Mental Health Nursing: A Textbook of Principles. Open University Press. Maidenhead. UK. Nursing and Midwifery Council (NMC) (2008) The Code. (NMC, London). Sheldon L K (2005) Communication for Nurses: Talking with Patients. Sudbury; Jones and Bartlett. Simpson A (2009) The acute care setting. In Barker P (2009) Psychiatric and Mental Health Nursing: The craft of caring. Edward Arnold Ltd. London. Simpson A Miller C Bowers L (2003a) Case management models and the care programme approach: how to make the CPA effective and credible. Journal of Psychiatric and Mental Health Nursing 10, 472-483. Simpson A Miller C Bowers L (2003b) The history of the Care Programme Approach in England: Where did it go wrong? Journal of Psychiatric and Mental Health Nursing 10, 489-504. The Sainsbury Centre for Mental Health (2001) The Capable Practitioner. http://www.scmh.org.uk/publications/capable_practitioner.aspx?ID=552 Accessed: 29/12/09 Appendixes Appendix 1 Beck Anxiety Inventory Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month, including today, by circling the number in the corresponding space in the column next to each symptom. Not At All Mildly but it didnt bother me much. Moderately it wasnt pleasant at times Severely it bothered me a lot Numbness or tingling 0 1 2 3 Feeling hot 0 1 2 3 Wobbliness in legs 0 1 2 3 Unable to relax 0 1 2 3 Fear of worst happening 0 1 2 3 Dizzy or lightheaded 0 1 2 3 Heart pounding/racing 0 1 2 3 Unsteady 0 1 2 3 Terrified or afraid 0 1 2 3 Nervous 0 1 2 3 Feeling of choking 0 1 2 3 Hands trembling 0 1 2 3 Shaky / unsteady 0 1 2 3 Fear of losing control 0 1 2 3 Difficulty in breathing 0 1 2 3 Fear of dying 0 1 2 3 Scared 0 1 2 3 Indigestion 0 1 2 3 Faint / lightheaded 0 1 2 3 Face flushed 0 1 2 3 Hot/cold sweats 0 1 2 3 Column Sum Scoring Sum each column. Then sum the column totals to achieve a grand score. Write that score here ____________ . Interpretation A grand sum between 0 21 indicates very low anxiety. That is usually a good thing. However, it is possible that you might be unrealistic in either your assessment which would be denial or that you have learned to mask the symptoms commonly associated with anxiety. Too little anxiety could indicate that you are detached from yourself, others, or your environment. A grand sum between 22 35 indicates moderate anxiety. Your bod

I Am Determined to Become the Best Educator I Can Be :: Personal Narrative Writing

I Am Determined to Become the Best Educator I Can Be School had a large impact on my life. Until I was eighteen, I did not experience education in the traditional sense. My homeroom was my bedroom; I had economics in the kitchen and science class was often held outside. I studied the usual subjects: math, reading, science, history, and English. I also studied some non-traditional subjects: Bible, canning, sewing, and cooking. My mother taught me to love reading. My father taught me how to find answers to my questions, and my siblings taught me how to explain concepts in a way they could understand. Being taught at home offered me experiences that I would not have received if I had attended a traditional school. Unlike children who attended traditional schools, I was around my mother, siblings, and other adults all the time. While I did have friends my own age, I interacted mostly with adults. Because my school schedule was flexible, often I found myself helping an elderly person with yard work or cleaning. My father's boss asked my brother and I to help sort cattle or watch gates when the pens were being cleaned during the morning and afternoon. My mother taught me until I reached junior high and then my father took over. He assigned the subjects my brother and I would study for the year, bought our textbooks, and helped review for and grade our tests. But we were responsible to make our lesson plans and finish our textbooks within the school year. At the beginning of a school year, I would find out how many sections or chapters a textbook had. Then I would figure out how many sections or chapters I would have to complete each week to finish the book. At the beginning of every week, I wrote in a day-planner what sections I was to cover on what day. At a traditional school a teacher would do this for his or her students. Making my lesson plans while still in high school has prepared me for making lesson plans for my students when I become an elementary teacher. The area I lived in, Greeley, Colorado, has a strong agricultural base. My house was only ten or fifteen minutes from downtown Greeley; however, my father worked at a dairy farm and we had many friends in the agricultural world. Because our school schedule was flexible, my brother was able to work for a sheep rancher and learn mechanical and animal husbandry skills.

Christopher Columbus vs. Alvez Nunez Cabeza de Vaca Essay -- American

Christopher Columbus and Alvez Nunez Cabeza de Vaca were both explorers for Spain, but under different rulers and different times. The more famous, Christopher Columbus, came before de Vaca’s time. Columbus sailed a series of four voyages between 1492 and 1504 in search for a route to Asia which led accidentally to his discovery of new land inhabited with Indians. Christopher sailed under the Spanish monarchs, Ferdinand and Isabella for his journey to the â€Å"Indies,† whom he was loyal to by claiming everything in their name. De Vaca , followed in Christopher’s footsteps and journeyed to Hispanionola for Spain’s emperor, Charlves V, the grandson of Ferdinand and Isabella. Both, Columbus and de Vaca composed a series of letters addressing the main issue of their journey to the new land, but both were expressed in a different manner, included different material, and were motivated to write for dissimilar reasons. Columbus’ and de Vaca’s purposes to compose letters are quite divergent. Christopher Columbus’ main objective in his Letter to Ferdinand and Isabella Regarding the Fourth Voyage, was to list his unnoticed accomplishments, justly sufferings, and devotion in order for the monarchs to save him. He had his heart set on Ferdinand and Isabella’s pity to obtain their permission to go to Rome and other places of pilgrimage. In Columbus’ â€Å"Letter to Ferdinand and Isabella Regarding the Fourth Voyage,† Columbus had the intention to please his majesty by claiming his â€Å"[pure devot...

Journey To My Past: Responses to Silent Dancing Story Essay -- Silent

Journey To My Past: Responses to Silent Dancing Story 1 Journal of Reading Silent Dancing Many people say, "Do not judge a book by its cover," but the cover of this book drew me into a journey of reading. The line of the letters Silent Dancing is on top; just below that is a picture of a beautiful four-year old girl. Perhaps she lives with a wealthy family; the girl looks so cute and pretty in her dress. Like many other young girls who usually love toys, she is holding a rattlebox; however, she does not pay attention to the toy in her hands. The young girl appears sad because of wide opened eyes that seem interested of what is in front of her. The quiet lips that have no smile make her look shy and older than her time. Why does this young girl have a feature of sadness? This picture seems to suggest that after reading Silent Dancing I should have the proper answer to that question. Silent Dancing is a garden of many stories in the childhood of a Puerto Rican girl, Judith Ortiz Cofer. Some chapters in her book are very exciting because her memory sometimes stimulates mine. There are many remembrances that are evoked by the reading this book. 2 Reading "More Room" When I first read the caption "More Room," I did not guess that the main character in this chapter was an unhappy person. Soon after reading, I understood she was a sad woman because of only a reason: she could easily get pregnant (actually she had many children). That woman's situation reminds me of my mother. What are the similarities between this character and my Mom? A simple thing: they both were mothers of many children and sometimes felt full of cares when they knew they were carrying another baby. The sound is simple but the fact is not. Like many ... ... tiny paper clothes. Some characters in Cofer's childhood were exciting just like some of the people in my childhood, but the ending of her childhood and mine were very different. At the age of fifteen, Cofer had some boyfriends; they loved and admired her. She fell in love for the first time and learned a lesson about the love; she also was no longer a child at the age of fifteen. However, the ending of my childhood was caused by a war. Like the rope of a kite was broken in the raging wind, my childhood's kite disappeared into the sky. The tragedies of the war fell upon the people in my family and my country; they shattered my innocent childhood when I was only a thirteen years old girl. Although everyone has a different memory about their life, and each of us has special ending to our childhood, reading Silent Dancing gave me the urge to recall these remembrances.

Sales Report Example

Table of Contents Executive Summary3 Part 1: GSM Personnel Specification4 1. Experience4 2. Qualifications4 3. Required skills5 Part 2: Key issues and Recommendations6 1. Introduction6 2. Key issues6 2. 1 Motivation and job satisfaction6 2. 2 Recruitment and selection7 2. 3 Training and development7 2. 4 Key account management8 2. 5 Sales team structure8 3. Conclusion9 4. Recommendations10 4. 1 Change the reward system10 4. 2 Set up the formal recruitment and selection process11 4. 3 Set up a standardized training11 4. 4 Restructure the sales team with the new role of KAM13 . 5 Action Plan15 4. 6 Expected Outcomes16 5. Limitations17 6. Bibliography18 7. Appendices19 7. 1 The recruitment process19 7. 2 Sales people calculation19 Executive Summary The report is divided in two parts. The first part ‘Personnel Specification’ is aimed to identify the required main skills areas of the new GSM. Those are: * Five to eight years sales experience and management; * University degre e of business or marketing management; * Excellent and proven communication skills and interpersonal skills; * Ability to reate a work environment and culture to stimulate individual’s development and motivation; * Ability to negotiate and high levels in numeracy and literacy skills; * Personal traits: high motivation, ambition in sales, enthusiasm, full commitment, and ability to work under high pressure. The second part, which is the most important part of this report, consists two main sections: key issues and recommendations. The key issues have been identified through analyzing our current company’s situations and related theories.Those key issues are: * Low motivation and decreasing job satisfaction; * The lack of formal recruitment and selection process; * The lack of quantity and quality in training and development; * The missing role of Key Account Management in the sales operation; * The inappropriate sales team structure. Based on the analysis of key issues, the fully detailed recommendations are provided in the end of this report, following with an Action Plan and expected outcomes. Part 1: GSM Personnel SpecificationAccuClean is in crucial need of a new General Sales Manager, who will be in charge of the sales team in all regions and report directly to the Managing Director, Peter Ward. Our company is facing several leadership problems and lack of focus in sales team. The new GSM is expected to bring the new fresh leadership style and able to manage the sales team in all regions to achieve the highest performance and long-term development. The personnel specification of GSM will be illustrated in details. Experience The new GSM is expected to have at least 7 to 8 years sales experience, preferably in B2B market (CPSA, 2012; Myjobs, 2012; Reed, 2012).The experience in B2B sales market is very important for our company since our customers are ranging from small to large sized companies, and many of them are with us more than ten years. He/she has a minimum of 5 years experience in business management, marketing and sales strategies and planning, and financial oversight (Inc, 2012; Myjobs, 2012). With these experiences, the new GSM is able to diagnose the management problems within our sales operation, and bring in his/ her new approach in leadership style, in order to improve sales team’s performance as well as increase the motivation and satisfaction of sales people.However, we should be very flexible in selecting candidates based on experience. If a candidate had excellent qualifications regarding his/ her education and 2-3 years experienced, we should not exclude him/ her from our shortlist. The requirement of sales experience is likely to cause a problem of excluding potential candidates (Jobber and Lancaster, 2006). Qualifications The candidate needs to have Bachelor degree of Business or Marketing Management (CPSA, 2012). The university degree is necessary since the good educational background will h elp the new GSM a lot in management.Besides, the combination of education and experience for the GSM position is ideal for long-term development of our sales force. Required skills The new GSM is required to have excellent and proven oral communication skills (Inc, 2012). In addition, the candidate needs to prove his/ her skills in exceptional customer facing and interpersonal skills to enable difficult situations to be overcome successfully (JCT600, 2012). Communication skills are the most crucial qualities of sales people, especially sales manager (Jobber and Lancaster, 2006).Furthermore, the new GSM should be able to create a workplace environment and culture that allows all the sales people in the team to develop and excel their jobs (JCT600, 2012). This requirement is essential since the current leadership style in our sales operation does not seem to work very well and need a crucial change and improvement. The potential candidate is able to negotiate effectively and at the hi ghest level together with excellent numeracy skills and literacy skills (JCT 600, 2012). For both short-term and long-term development of our sales force, these skills are necessary.Besides, the most two important basic qualities that a good sales person must have are empathy and ego drive (based on the study of Mayer and Greenberg, 1964, cited in Donaldson, 2007). Empathy is defined as â€Å"the important central ability to feel as the other fellow does in order to be able to sell a product or service† (Donaldson, 2007, p. 60). Ego drive is a desire to want and need to make a sale (Donaldson, 2007). Both of these basic qualities are a must for our potential GSM since in order to be a good sales manager, he/ she should be a good sales person.Last but not least, we are looking for a new GSM with high motivation, ambition in sales, enthusiasm, full commitment, and ability to work under high pressure (Mathews and Redman, 2001, cited in Jobber and Lancaster, 2006). Part 2: Key is sues and Recommendations 1. Introduction Part 2 is aimed to illustrate the key issues regarding our sales operation in AccuClean. The analysis based on our current situation and theory is presented for every issue. Recommendations are coming in the end of this report, followed by the Action Plan and expected outcomes.All the key issues and recommendations are ordered according to its priority of taking urgent actions. Key issues 1. 1 2. 1 Motivation and job satisfaction Motivation is â€Å"the amount of effort that a salesperson expends on each activity or task associated with the job† (Donaldson, 2007, p. 230). Many factors are believed to cause positive motivation, such as monetary reward, workload, promotion, degree of recognition, supervisory behaviour, targets, and tasks (based on Adams’s inequity theory, Jobber and Lancaster, 2006).In AccuClean, the first factor that causes the low motivation in the sales team is bonus system, which is perceived by many staffs as unfair. The bonus system in AccuClean is set based on achieving a sales figure above the individual sales target, starting from 5% above target sales with a bonus of 5% basic salary. Last year, only nine sales people out of 71 have been able to achieve the bonus, which gives the evidence about the inappropriate bonus system. In addition, the salary is based on individual negotiations when they joined the company, which might lead to unfairness between individual sales people in the team.According to Vroom’s expectancy theory, it is assumed that â€Å"people’s motivation to exert effort is dependent upon their expectations for success† (Jobber and Lancaster, 2006). It means to what extent AccuClean sales people believe by working harder (increase effort), they will achieve 5% above target sales (high expectancy), and that higher sales will lead to higher salary – bonus of 5% of basic salary (high instrumentality), and higher salary is very important for t hem (high valence).Moreover, during the merger, there were several sales staffs left to join competitors, which may result from the lack of motivations. According to Herzberg’s motivation- hygiene theory, working conditions and company policies are two of the hygiene factors, which cause dissatisfaction, thus, lead to low motivation (Donaldson, 2007). Bonus as money is the only type of rewards that is used in AccuClean, nevertheless, there are many more types of rewards that could also be applied, in order to motivate various types of sales people.The suggested bonus system will be illustrated in the recommendation part in the end of this report. 2. 2 Recruitment and selection Bob Carter is in charge of the selection process for new sales people. However, he has no formal system for recruitment and selection as well as no job description. Formal selection process is crucially important to ensure the quality of sales persons, which can have a substantial effect on sales turnov er (Jobber and Lancaster, 2006). Furthermore, hiring a sales person is very costly, much more than the basic salary.Therefore, selecting the right person for the right position is essential, and can be achieved through setting up a formal selection procedure. Another problem is Carter’s way of selection – ‘he knows a good sales person as soon as he sees one’. This bias can harm the screening process, which is part of the recruitment process (see Appendix 5. 1). Either selecting the wrong person or dropping good persons is costly (Donaldson, 2007). Donaldson defines job description as the roles and duties attached to a specific position in the organization (2007).It is necessary for AccuClean to prepare job descriptions for any new positions in the sales team, to ensure the responsibility of each team members, thus, no role ambiguity can occur. 2. 3 Training and development Training is one way for sales managers to improve the performance of the sales peopl e under their controls, broadly to meet the company objectives (Donaldson, 2007). Training and development for sales people in AccuClean are lacked due to several reasons. Any trainings or development relies on the management style and differs in every ASM.There is no formal training process since Carter believes that sales people learn best ‘on the job’. Indeed, there are many kinds of training, which includes individual on-the-job training as Carter’s opinion (Donaldson, 2007). However, good trainings can also be achieved through company-specific programs that are organized in a standardized and professional manner. The irregular and occasional training sessions, usually occur when introducing new products (currently in AccuClean), might lead to the lack of knowledge about products and new skill practices.As the merger of one cleaning chemicals and the other in cleaning machinery, training should have been taken at the early stage of the merger, in order to sup port sales people in both companies about the company objectives and targets, the knowledge of different and new products, competitors and their products, selling procedure and techniques (Jobber and Lancaster, 2006). 2. 4 Key account management Area sales teams are responsible for all accounts regardless their size and importance.The treatment for key accounts, medium-size accounts or small accounts is much dependent on each ASM’s view, its current mix of accounts in the area and experience. There are in fact 21 customers; each has accounts worth over ? 4 million. Those customers are important to our business and need to be prioritized as key accounts since the loss of even one of them would significantly cause a radical drop in sales and profits (Jobber and Lancaster, 2006). Key account management seems currently necessary, in order to serve our key customers with special treatment in all areas of marketing, administration, and service (Jobber and Lancaster, 2006).In additi on, key account management will help to develop a close relationship between our company as supplier and our customers, in order to enhance the communication and co-ordination between us, thus, create more in-depth penetration of DMU, which includes push and pull opportunities for buying decisions (Jobber and Lancaster, 2006). 2. 5 Sales team structure The sales territories of AccuClean, which are merely geographic based, have not been changed since the merger. Geographic structure is traditional and the most widely used type of sales organization in the UK.It has several advantages such as simplicity, shorter journey times, low travel costs, and less potential for conflicts over responsibility (Donaldson, 2007). However, geographic structure has some drawbacks, which might influence to the effectiveness of the sales team and its management. Examples of disadvantages are the need to sell full range, broad expertise needed, and overhead costs for more layers of management evolved (Do naldson, 2007). In order for the sales team to work more productively and better management, it is necessary to make some changes concerning our sales team structure (see Recommendations, section 4).The number of sales people in AccuClean is currently more than necessary, compared to the number of customers. Figure 1 illustrates the current sales people in each ASM as well as the actual needed sales people based on the number of customers in each area. Territory| Number of customers| Current number of sales people| Actual number of sales people| Spare sales people| Midlands| 1973| 26| 18| 8| South| 1545| 22| 14| 8| North| 1196| 16| 11| 5| Scotland/ North Ireland| 499| 7| 5| 2| UK total| 5264| 71| 47*| 24*|Figure 1: Number of Sales people (* approximate number) 1 2 Conclusion Five key issues that have been listed and analyzed above are low motivation and decreasing job satisfaction, informal recruitment and selection process, unstandardized and the lack of regular training, the lack of key account management, and the ineffective sales team structure. Those issues are the most urgent in AccuClean that need to be solved as soon as possible, in order to improve the sales team to work more effectively. Recommendations 4. 1 Change the reward systemBonus (monetary reward), which is the only form of reward using in AccuClean, shows its limitation, therefore, improving the bonus system is crucial. The starting point of 5% should be set lower and dependent on different products and accounts. There should also be other chances to get commission, which can be based on the annual sales revenue and profits. In addition to the monetary reward, AccuClean can apply many other types of rewards such as promotion or workload (based on Adam’s inequity theory, Jobber and Lancaster, 2006).Not all sales people highly value money; some of them might place higher value on promotion, responsibility or recognition. Thus, the variable of rewards will motivate different type of sale s people, in order to maximize the expectancy and value of reward (Vroom’s expectancy theory, Jobber and Lancaster, 2006). A study of sales force practices by Chartered Institute of Marketing showed that sales people are mostly motivated by individual meetings with supervisor to discuss career, job problems, etc. The second ranked motivating factors is ‘regular accompaniment in the field by the sales manager’ (Jobber and Lancaster, 2006).These methods of improving leadership style should be aware by ASMs and higher management. 4. 2 Set up the formal recruitment and selection process The formal recruitment process is proposed as below (according to Jobber and Lancaster, 2006, p. 384). Bias in selecting applicants should be minimized by carefully preparing job description and personal specification. Of course, the experience of employer should be used during the selection process. However, those five steps above should be strictly followed to avoid any mistakes dur ing recruitment. 4. Set up a standardized training Good training programs will help to equip our sales people with sufficient knowledge and skills. Besides, it plays as a motivation factor for sales people and positively influences the job satisfaction. 4. 3. 1 When should our company train our sales employees? According to Donaldson (2007, p. 208), the training should be held properly when: * New sales person is recruited * A sales person takes on a new territory * New products * New business, new market segments * Company new policies or procedure * Selling habits are poor or inappropriate An individual is being considered for promotion The sales techniques are very important to train all sales people in the organization (69% of North European firms providing sales techniques training). The market and customer knowledge is also essential in training (42% of firms providing this, based on Roman and Ruiz, 2003, cited in Donaldson, 2007). 4. 3. 2 Who should do the training? Sales tra iner can be senior managers (i. e. ASMs, GSM), technical specialists (from Production department), external specialists, or inside experienced sales people (i. e. from other ASMs).In many cases, training is more likely to be provided by inside company specialists, who not only have the best understanding about the organization and individual needs, but also can tailor training programs to suit both internal and on-the-job requirements (Donaldson, 2007). 4. 3. 3 Where should training be done? The training can be organized in internal single location (different ASMs), a centralized external location or a decentralized location (on the job). It depends on the purpose of training and variable factors to decide where to hold the training.Below is the nine possible options that are proposed by Donaldson (2007, p. 210). 4. 3. 4 What methods of training should be used? Lectures, films, role playing, case studies, or in-the-field training are options of training methods (Jobber and Lancaster , 2006). Each has its advantages and limitations. The point is how to use them properly for different training purposes, in order to achieve the best results and highest satisfaction of participants. 4. 4 Restructure the sales team with the new role of KAM New proposed sales team structure is presented in Figure 2 with two radical changes. ASM North and ASM Scotland will be combined into Regional Sales Manager of North and Scotland * Key Account Manager is added to our sales team structure as one independent function Figure 2: Sales Team Structure (proposed) The Regional Sales Managers are formed to ensure the number of sales people is interrelated to the number of customers in each region. The number of customers in the North and Scotland, which is 1196 and 499 respectively, is much fewer than the number of customers in Midlands and South (1973 and 1545 respectively).Therefore, it is appropriate to merge two ASMs North and Scotland together, in order to enhance the performance in t he broader area, and increase the influence on organization’s decision-making of sales people in the North and Scotland area. The Key Account Manager is added to be in charge of all key accounts in the whole UK. KAM’s responsibility is to manage all sales people, who are managing those key accounts in different regions. Moreover, KAM is also responsible for potential key accounts and complex DMUs. The communication and leadership style are crucially important to be successful in managing sales people in different areas.Monthly meeting can be organized and the advanced record system (computer based) should be built up to develop the whole sales team’s communication flows in long-term. This proposed sales team structure is based on all forms of selling simultaneously: KAM for very big accounts, general territory representatives (Regional Sales Managers) for the medium and small- sized accounts (Jobber and Lancaster, 2006). The number of sales people in AccuClean i s currently more than necessary, as calculation based on the current number of customers. In fact, it is difficult to get rid of 24 sales people at once, and should not be done in that way.AccuClean can evaluate sales people in the whole company by their performance, motivation and achievement in past years. In a period of 12 months, it is expected to dismiss six sales people. After two years, 12 sales people in total will be fired. AccuClean may attract more customers in the future and need more sales people; therefore, it is dependent on the situation at the time to decide how many more sales people have to leave. 4. 5 Action Plan 4. 6 Expected Outcomes Limitations The merger of two ASMs North and Scotland into one Regional Sales might cause problem in the span of control.The new RSM will manage 20-23 sales people, which might lead to the role ambiguity and lack of coaching and supervision. The Action Plan illustrates many tasks that need to complete in the first year, thus, it mi ght be very challenging in the first year for the new GSM. It is a tough decision to fire some sales people in the next two years. It might cause several problems within the sales team concerning rumours or miscommunication. Therefore, it is necessary to have a serious evaluation based on a formal checklist and consultancy from different people in the team.Furthermore, the training needs to be held at the beginning of the year, to inform the sales team about new changes, thus, reduce miscommunication. Bibliography CPSA (2012) Sales Manager Job description [Online]. Available from :< http://www. cpsa. com/pdf/src/tools/Sample%20Sales%20Manager%20Job%20Description. pdf> [Assessed 16 December 2012]. Donaldson, B. (2007) Sales Management. 3rd ed. NewYork: Palgrave MacMillan. Inc (2012) General Manager Job description [Online]. Available from :< http://www. inc. com/tools/general-manager-job-description. html> [Assessed 16 December 2012].JCT 600 (2012) General Sales Manager Job descripti on [Online]. Available from :< http://www. jct600. co. uk/data/cm/careers/1028. pdf> [Assessed 16 December 2012]. Jobber, D. And Lancaster, G. (2006) Selling and Sales Management. 7th ed. England: Pearson Education Limited. Myjobs (2012) Senior Sales Manager (Oil Machinery) [Online]. Available from :< http://myjobs. classifiedpost. com/index. php/Job-Search/ENGINEERING-GENERAL-BUSINESS-DEVELOPMENT-ACCOUNT-MANAGEMENT-Job-Description/SENIOR-SALES-MANAGER-OIL-MACHINERY/597925> [Assessed 16 December 2012]. Reed (2012) General Manager – Milton Keynes [Online].Available from :< http://www. reed. co. uk/jobs/general-manager-milton-keynes/22306659#/jobs/general-sales-manager-in-milton-keynes> [Assessed 16 December 2012]. Appendices 3 4 7. 1 The recruitment process 7. 2 Sales people calculation The Figure 1 calculation will be illustrated in details as below. Based on: Number of sales people = (Number of customers x Number of call pa) / (number of calls per day x Number of working day s per year) Suppose there are 225 work days per year, 12 times calling per customer per year (once a month) Each sales person supposes to make 40 calls per week, 10 of those are to be made to prospects.Therefore, each sales person has to make: (40-10)/5 = 6 calls per day. * Number of sales people in Midlands = (1973 x 12) / (6 x 225) = 18 * Number of sales people in South = (1545 x 12) / (6 x 225) = 14 * Number of sales people in North = (1196 x 12) / (6 x 225) = 11 * Number of sales people in Scotland/ North Ireland = (499 x 12) / (6 x 225) = 5