Essay on How to Bake Cookies and Doughnuts - 525 Words

How to Bake Cookies and Doughnuts Cookies and doughnuts are incredibly satisfying treats. They both are baked goods that make our tummies warm, and leave a dusting of sugar on our lips. Doughnuts, along with cookies, can be considered awfully sweet, yet they are completely different. They both are distinct in their individual means of ingredients, cooking and traditional settings for consumption. There are very few things you can do to ruin a simple chocolate chip cookie if you follow the recipe. The main ingredients for cookies include flour, sugar, water, eggs, and butter. These are all typically found in any kitchen. Because of this, cookies are relatively easy to prepare. Chocolate chips, nuts, and fruits are frequent†¦show more content†¦You then place the sheet into a conventional oven and bake at 375 degrees. The cookies will turn golden brown when theyre done. After being cooled for a few minutes, the cookies can be served. Unlike cookies, doughnuts usually are not made in the home, hence all of the doughnut shops: Krispy Kreme, Winchels, Daylight Doughnuts. Even though doughnuts are made with the same ingredients as cookies, they are more complicated to make. Doughnuts do contain another main ingredient, yeast. The yeast gives doughnuts a more bread-like quality and adds tiny air pockets that make the dough rise. After the dough has risen, it can be shaped into the familiar ring shape. This can be done by rolling the dough into snake-like portions. More commonly, the dough is spread thickly over a flat surface, then a device much like a multiple cookie cutter is used. The popular doughnut shop Krispy Kreme has developed a doughnut extrusion process that results in their distinctive rosette shape with curved vertical ridges on the sides. After the doughnut dough is shaped, it is cooked using hot oil or fat. This oil is at a much higher temperature than that used to bake cookies. The dough is then cooked to produce a golden-brown crust on the outside while s till maintaining a soft core. Toppings such as sugar may then be applied. This consists of little more than putting sugar and flavoring on the outside of the doughnut in the formShow MoreRelatedHow to Manage Diabetes789 Words   |  3 PagesDISCUSSION 1) How does meat affect diabetes? a) Why should diabetics watch what meat they eat? When individuals develop diabetes watching your red meat, and processed meat intake is important. Red meat, and processed meat has a large amount of saturated fat, and has been linked to lead early on set type 2 diabetes. Studies have shown that women with type 2 diabetes that consumed more processed, and red meat were at a greater risk of developing heart disease than women with diabetes that consumedRead MoreThe Art Of A Pastry Chef1534 Words   |  7 PagesChef The art of the pastry chef has been around since the eighth century BC. 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Stack remarked, ``People ask me how I keep my teeth from chattering when it’s cold.’’ Pausing, Stack matter-of-factly replied, ‘’I leave them in my locker.’’ As Nike began expanding overseas to Europe, it found that its American style ads were seen as too aggressive. The brand imageRead MoreLogical Reasoning189930 Words   |  760 Pagesrelevancy should attract readers. Stanley Baronett. Jr., University of Nevada Las Vegas Far too many authors of contemporary texts in informal logic – keeping an eye on the sorts of arguments found in books on formal logic – forget, or underplay, how much of our daily reasoning is concerned not with arguments leading to truth-valued conclusions but with making choices, assessing reasons, seeking advice, etc. Dowden gets the balance and the emphasis right. Norman Swartz, Simon Fraser University

Diversity Among Children In Language And Development .

Diversity Among Children in Language and Development Children from across the world come to America with their parents to chase the American dream. Their families leave everything behind to provide better future and opportunities for their children. Parents migrate to this country facing many difficult challenges along the way. Society today plays a huge role on how people are viewed based on its family ethnicity or its development. Children have the most tough time adapting to society norms and assimilations in this country. Next, the United states also known as America is known for the country of better future and opportunities for their families. Today the population of immigrants have greatly decreased within the past five decades†¦show more content†¦They will feel discouraged to socialize and communicate with others because they are afraid their classmates will make fun of them and exclude them from daily activities. Also, learning and adapting to its new environment and associating with society in a broad manner is a challenge they will face daily. According to research, immigration results in huge stress for their children. This stress involves transitioning from one home to another in a different country, learning and adapting to their society customs and norms. These challenges become more difficult when it comes to adapting to their unfamiliar environments, people, and norms. Due to the language barrier, children will be discriminated and bullied based on their cultural backgrounds. When children are mistreated and discriminated this can result for children to have low self-esteem and their academic progress. In the article, Emily who is seven years old attended school for the first time, her first reaction when she entered her classroom was terrified unfamiliar with all her classmates. Everywhere she turned she would hear a language she did not know, she did not understand. As she was walking around the classroom one of her classmates look ed at her and started calling her India which is Indian. Emily was dark skinned with long black hair the moment she heard her classmates discriminating her appearance she began crying, saying she wanted to go home. The teacher was bilingual which comfort her and sheShow MoreRelatedBilingual Education for Children1219 Words   |  5 Pageslearn a certain language. They stress that anybody can learn a new language at whatever age. Others do argue that using bilinguals is prepositioning the child on a wrong footing on how to learn the first language and the second language. Whether this people have a point or not is the major point of writing this paper. One thing bilingual education critics forget is that people come from different backgrounds that have differing cultures and language. 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Review of Related Literature Free Essays

Chapter2 Related Literatures Foreign Literature Eugene F. Brigman, Fundamentals of Financial Management, 5th ed. , (Hinsdale: Holt, Richard and Winston Sounders College Publishing, 2000), pp. We will write a custom essay sample on Review of Related Literature or any similar topic only for you Order Now 840-841. Companies are increasingly employing Inventory System. A computer start with an inventory counts in memory. Withdrawals are recorded by the computer as they are made, and the inventory balance is constantly revised. When the recorded point is reached, the computer automatically places an order, when this new order is received, the recorded balance is increased. Retail stores have carried this system quite far, each item has a magnetic codes, and as on item is checked out, it passes over an electronic reader, which then adjusts the computers inventory balance, at the same time the price is fed to cash register tape. When the balance drops to the recorder point, an order is place. Chapter 3 Research Design The authors aim to develop a automated inventory system which is technically, operationally, and economically feasible for PhilHealth Company, Dagupan City. The method used by the researchers to develop a automated inventory system is Descriptive Method. The researchers conduct several interviews in order to gather information about the present existing conditions of the inventory system, knowing its problems and enhancing it by developing an automated inventory system. Questionnaires were also distributed to all interviewees for additional information. Using the descriptive method, the researchers also observe the functionality of the present inventory system of the PhilHealth, which help them discover that Electronic Data Processing is Advantageous than other. REVIEW OF RELATED LITERATURE The review of the literature for this study focuses on creating computerize inventory system for Cavite State University Marketing Main Campus. In order to create we need to find some helpfull resources about the study. Related Literature Janes (2001) stated that computers are extremely reliable device and very powerful calculators with some great accessories applications like word processing problem for all of business activities, regardless of size, computers have three advantages over other type of office equipment that process information because computer are faster, more accurate more economical. Reyes (2005) task would be time consuming to accomplish manually and more practical with the aid of computers field in cabinet. Dioso (2001) stated that computer assist careful intelligent planning, organizing, actuating and controlling . This maybe observed from the past that they monitor production activities, solve scientific problem and help arrive in tentative answer to a multitude of involve conditions. Ralph M. Stair (1999) emphasized that the development of technology through the years have enabled us to do more with less effort. From the orientation of the light bulb to the industrial revolution and beyond, we have continuously tried to in a more efficient means of doing tasks. Lewis (2002) stated that the reason for using computers vary from person to person. Some of the computers in business are to perform accuracy, to be as productivity, to decrease bottle necks or hassles to alter cash flows or to simples elevate your status. Sybex Inc (1999) stated that visual basic provide a graphical environment in which the users usually designed the forms and control that become the building block of tour application . Visual Basic support many useful tools that will help the user more productivity. Gold Chager et al (2003) said that computer as a device for processing information knew computer plays a significant role†¦ [continues] Inventory Systems Summary According to the U. S. Small Business Administration, â€Å"Inventory refers to stocks of anything necessary to do business† (U. S. Small Business Administration, 2010, pp 1-2). The U. S. Small Business Administration publication describes what constitutes successful inventory management (balancing cost versus benefits of inventory), including 1) Maintaining a wide assortment without spreading the rapidly moving items too thin, 2) Increasing inventory turnover without sacrificing service, 3) Keeping stock low without sacrificing performance , 4) Obtaining lower prices by making volume purchases, 5) Maintaining an adequate inventory without an excess of obsolete items. Anyone in business must understand the business of inventory. Below is a look at six different inventory systems as well as a comparison of the advantages and disadvantages. Wal-Mart Inventory System Wal-Mart runs its stores on a perpetual inventory system. This system records the quantity of items sold as items are purchased. The computer system at Wal-Mart constantly keeps up with additions or deductions from inventory and tells management what items are on hand. The organization also conducts counts of employee manual counts of inventory periodically. When an item arrives at the Wal-Mart distribution center it is scanned into the inventory system. When the items are purchased by the consumer, the point-of-sale system reduces the inventory from that purchase. According to Wal-Mart’s Gail Lavielle, a leaner inventory will help clear out store clutter and help Wal-Mart focus on specific brands and products that consumers want (The Associated Press, 2006). Advantages and Disadvantages of the Wal-Mart Inventory System The advantages of a perpetual inventory system are that inventory is quickly updated in real-time, which gives a constant picture of the inventory status. With this data, inventory counts will be more accurate and allow one to keep up with demand†¦ continues] Anesthesia recordkeeping: Accuracy of recall with computerized and manual entry recordkeeping ProQuest Dissertations and Theses, 2011 Dissertation Author: Thomas Corey Davis Abstract: Introduction: Anesthesia information management systems are rapidly gaining widespread acceptance. Aggressively promoted as an improvement to manual-entry recordkeeping systems in the areas of accuracy, quality improvement, billing and vigilance, these systems record all patient vital signs and parameters, providing a legible hard copy and permanent electronic record. At risk is a potential loss of â€Å"connectedness† to the atient with the use of computerized recordkeeping, perhaps jeopardizing vigilance. Methods: This research analyzed differences in the accuracy of Certified Registered Nurse Anesthetists’ (CRNAs) recall of specific patient variables during the course of an actual anesthetic case. CRNAs using computerized recordkeeping systems were compared to CRNAs using manual entry recordkeeping. Accuracy of recalled values of 10 patient variables was measured – highest and lowest heart rate, systolic blood pressure, inspiratory pressure, and end-tidal carbon dioxide levels, lowest oxygen saturation and total fluid volume. In addition, a filmed educational vignette was presented to evaluate any effect on accuracy of recall following this presentation. Four tertiary care facilities participated in this research. A Solomon four-group research design was selected to control for the effect of pretesting on results of the filmed educational treatment. Results: 214 subjects participated in this study; 106 in the computerized recordkeeping group, and 108 in the manual entry recordkeeping group. Demographic covariates were analyzed to ensure homogeneity between groups and facilities. No significant statistical differences were identified between the accuracy of recall among the groups. There was no statistically significant effect of the educational film vignette on accuracy of recall. Conclusions: There was no difference in the accuracy of practitioners’ recall of patient variables when using computerized or manual entry recordkeeping systems, suggesting little impact on vigilance. The educational film presented did not have an effect on accuracy of recall following the discussion of benefits and limitations of methods of recordkeeping. ABSTRACT ANESTHESIA RECORDKEEPING: ACCURACY OF RECALL WITH COMPUTERIZED AND MANUAL ENTRY RECORDKEEPING By Thomas Corey Davis, PhD A dissertation submitted in partial fulfillment of the requirements for the degree of PhD in Health Related Sciences at Virginia Commonwealth University. Virginia Commonwealth University, 2011 Major Director: Dr. Chuck Biddle Director of Research, Department of Nurse Anesthesia And Dr. Jeffery A. Green Assistant Chief of Anesthesiology, Department of Anesthesia Introduction: Anesthesia information management systems are rapidly gaining widespread acceptance. Aggressively promoted as an improvement to manual-entry recordkeeping systems in the areas of accuracy, quality improvement, billing and vigilance, these systems record all patient vital signs and parameters, providing a legible hard copy and permanent electronic record. At risk is a potential loss of â€Å"connectedness† to the patient with the use of computerized recordkeeping, perhaps jeopardizing vigilance. Methods: This research analyzed differences in the accuracy of Certified Registered Nurse Anesthetists’ (CRNAs) recall of specific patient variables during the course of an actual xiv nesthetic case. CRNAs using computerized recordkeeping systems were compared to CRNAs using manual entry recordkeeping. Accuracy of recalled values of 10 patient variables was measured – highest and lowest heart rate, systolic blood pressure, inspiratory pressure, and end- tidal carbon dioxide levels, lowest oxygen saturation and total fluid volume. In addition, a filmed educ ational vignette was presented to evaluate any effect on accuracy of recall following this presentation. Four tertiary care facilities participated in this research. A Solomon four- group research design was selected to control for the effect of pretesting on results of the filmed educational treatment. Results: 214 subjects participated in this study; 106 in the computerized recordkeeping group, and 108 in the manual entry recordkeeping group. Demographic covariates were analyzed to ensure homogeneity between groups and facilities. No significant statistical differences were identified between the accuracy of recall among the groups. There was no statistically significant effect of the educational film vignette on accuracy of recall. Conclusions: There was no difference in the accuracy of practitioners’ recall of patient variables when using computerized or manual entry recordkeeping systems, suggesting little impact on vigilance. The educational film presented did not have an effect on accuracy of recall following the discussion of benefits and limitations of methods of recordkeeping. 15 CHAPTER ONE: INTRODUCTION In the United States, over 50 million anesthetics are delivered each year (Ishizawa, 2011). For each of these anesthetics, a detailed record is generated that includes vital signs, medications, and events of the surgery or procedure. Patients are monitored according to standards published by both the American Society of Anesthesiologists and the American Association of Nurse Anesthetists (AANA). These standards detail the vital signs and parameters that must be recorded by an anesthesia provider to document the monitoring of oxygenation, ventilation, circulation, and temperature (AANA – scope and standards for nurse anesthesia practice. 2007; ASA, 2005). The first known example of an anesthetic record can be found in the archives of the Massachusetts General Hospital, dated November 30, 1894 (Beecher, 1920). Developed by Dr. E. A. Codman, the record allowed the continuous documentation of heart rate, temperature, and respirations throughout the course of the anesthetic (Beecher, 1920). Systolic blood pressure readings were added to anesthesia records appearing after 1903 (Beecher, 1920). Both Dr. Codman and his contemporary, Dr. H. A. Cushing, indicated the merits of documentation of ether anesthetics, â€Å"It was undoubtedly a step toward improvement in what had been a very casual administration of a dangerous drug (Beecher, 1920)†. 16 The first known example of an automated anesthesia recordkeeping device dates to 1929 (McKesson, 1934). The device recorded three variables, oxygen percentage, respiratory volumes, and pulse pressure, on a continuous paper roll delineated in graphic form (McKesson, 1934). Fluctuations in these variables, primarily that of tidal respirations, indicated variations in the depth of anesthesia delivered, and any interruptions in the spontaneous breathing of the patient (McKesson, 1934). In his concluding remarks, Dr. McKesson indicated that such records would be â€Å"valuable for statistical study,† much as modern anesthesia records are used for quality improvement (McKesson, 1934). Dr. McKesson also stated, â€Å"Automatic recording equipment is a more accurate means for the immediate determination of cause and effect during an administration. Such records stimulate closer observation and increase our knowledge of anesthesia, and should safeguard the patient (McKesson, 1934). † Despite Dr. McKesson’s praise, such means of recording data during an anesthetic did not take precedence over the manual entry chart. Only with the advent of computerized systems introduced in the 1970s is there further mention in the literature of electronic recordkeeping (Drui, Behm, Martin, 1973). With improvements in computing technology, efforts to automate medical records have attempted to ease the task of recordkeeping (Drui et al. , 1973). Applications specific to the anesthesia record have begun to proliferate throughout the United States, due to established benefits of improved billing, legibility of the record, and access to data for quality assessment and improvement programs (Spring et al. , 2007). In a recent survey of academic medical centers, 14% currently utilize an anesthesia information management system (AIMS), 17 ith an additional 29% in the planning or implementation phase (Egger Halbeis, Epstein, Macario, Pearl, Grunwald, 2008) Proposed benefits over traditional manual entry recordkeeping systems (MERS), such as a reduction in workload or increased vigilance, have not been well established (Saunders, 1990). The proposed reduction in workload intended to increase the practitioners’ time for monitoring of the surgical field or other activities of impr oved vigilance could also be spent in activities unrelated to direct patient care (Allard, Dzwonczyk, Yablok, Block, McDonald, 1995). With anesthesia reimbursement reductions and the steady advance of technology into all aspects of medical care, known benefits such as enhanced capture of billing services may result in the adoption of AIMS in many markets currently skeptical about their safety (Levitan, 2008). AIMS are cited as superior to MERS in the areas of time management (Heinrichs, Monk, Eberle, 1997), data collection for quality improvement (Vigoda, Gencorelli, Lubarsky, 2006), and the capture of billing elements (Levitan, 2008). Concerns regarding the recording of artifact data as a potential source for malpractice claims (Feldman, 2004), excessive financial investment, increasing complexity of tasks, and decreasing attentiveness to the patient and monitors, thereby decreasing vigilance, (Abenstein, DeVos, Tarhan, Tarhan, 1992) have all been cited as limitations of AIMS. Studies analyzing vigilance and workload have failed to show significant differences between the two methods (Thrush, 1992). Examining the recall accuracy of specific vital signs, parameters, and events experienced by anesthesia practitioners utilizing AIMS and 18 MER should serve as a starting point for further evaluation of the benefits and risks of recordkeeping systems. Population and Recruitment Certified registered nurse anesthetists (CRNAs) administer more than 30 million of the 50 million anesthetics delivered each year (American Association of Nurse Anesthetists, 2008). This study will draw a sample of CRNAs from a population of more than 200 CRNAs practicing at four medical centers across Virginia. CRNAs assigned to each facility on the day of evaluation will be asked to complete a simple questionnaire. A trained observer will provide each practitioner with brief relief from patient care, after constant attendance of the patient for a minimum of 30 minutes of anesthesia care during the maintenance phase of the case. The CRNA assigned to the case will be asked to turn away from the monitors and complete the questionnaire. The observer will document values directly from the trend data recorded in the patient monitor. To evaluate the accuracy of anesthesia providers’ recall when recordkeeping with AIMS or MERS, a simple instrument has been developed (See Appendix I). Following establishment of face and content validity for this instrument, the research plan will be submitted for approval by the investigational review board (IRB) for Virginia Commonwealth University (VCU). With IRB approval, this instrument will be administered to practicing anesthesia providers participating in the actual delivery of anesthesia, and will require the provider to recall various aspects from the previous 30 minutes of their assigned case. Actual patient data will be collected by the relief CRNA to compare to the practitioners’ recollections. Practitioners utilizing both AIMS and MERS will be evaluated, to allow 19 comparison of any influence of the method of recordkeeping on the accuracy of practitioners’ recall. Four centers will be included in the project, selected by similarities of number of operating rooms, case load, and number of CRNA providers. These facilities are described in Table 1. All sites have agreed to participate in this research. Table 1: Facilities Facility Number of Beds Number of Operating Rooms Number of CRNAS Method of Recordkeeping Virginia Commonwealth University Medical Center (VCUMC) 788 30 41 AIMS Inova Fairfax Hospital (IFH) 833 47 68 AIMS Bon Secours St. Mary’s Hospital 369 30 41 MERS Medicorp Mary Washington Hospital 412 26 51 MERS Research Design A Solomon four group design has been selected for this study. This design minimizes the threat of testing on the outcome through the inclusion of one site that receives neither a pre-test, nor a treatment, but only a post-test. Each of the four facilities will be assigned to one of the four groups of this design as indicated in Table 2. Two sites will receive surveys as pre-tests, two sites will receive education with a trigger film (treatment), and all sites will be surveyed following the time of this presentation and again one month following the trigger film, as a post-test. 20 Table 2: Solomon Four-Group Design Statement of Purpose The purpose of this research is to analyze the practitioner’s accuracy in recalling patient data when using each method of recordkeeping. A second purpose of this research is to assess the effectiveness of a trigger film that details the benefits and limitations of both recordkeeping methods on the subsequent recall accuracy of anesthesia providers. This project seeks to answer two research questions: †¢ Do anesthesia providers using AIMS recordkeeping demonstrate equivalent recall accuracy of specific patient variables, as compared with anesthesia providers using a MERS? †¢ Does the instruction of the benefits and limitations of recordkeeping practices by trigger film influence the recall accuracy of specific patient variables by anesthesia providers using AIMS or MERS? To answer these research questions, the following hypotheses will be analyzed: H 1 For each anesthetic case, there will be no difference in the accuracy of recall of specific patient variables recorded by an anesthesia provider using AIMS or an anesthesia provider using a MERS. H 2 For each anesthetic case, there will be no difference in the accuracy of recall of specific patient variables recorded by an anesthesia provider who Group Survey Trigger Film Survey Survey– 1 month Post – treatment St. Mary’s (MERS) O 1 X O 2 O 3 Inova Fairfax (AIMS) O 4 O 5 O 6 VCUMC (AIMS) X O 7 O 8 Mary Washington (MERS) O 9 O 10 21 has attended a trigger film presentation on the benefits and limitations of recordkeeping methods than a provider that has not received such instruction. Significance In the United States today, approximately 67% of all anesthetics delivered each year are administered by nurse anesthetists (American Association of Nurse Anesthetists, 2007). Since the initiation of anesthesia documentation, the majority of anesthesia providers have recorded this data manually on pre-printed forms. This form of MERS persists in more than 90 percent of anesthesia practices (Levitan, 2008), although the prevalence of AIMS is rapidly increasing (Egger Halbeis et al. , 2008). Improvements in the capture of billing elements, legibility of the record, and enhanced capabilities to review accurate data for quality improvement purposes have caused many experts in the field to brand the adoption of AIMS as inevitable (Levitan, 2008) (Hamilton, 1990) (Vigoda et al. , 2006). In 2001, the Anesthesia Patient Safety Foundation published an initiative to utilize AIMS to improve patient safety (Cooper, 2007). This initiative was created in response to the Institute of Medicine’s landmark report in 1999, which called for efforts to utilize developing technology to reduce the number of medical errors (Kohn, Corrigan, Donaldson, 1999). As recently as March 2008, an article in Anesthesiology News indicated that AIMS would â€Å"revolutionize anesthesia care† (Levitan, 2008). Despite these claims, the safety of AIMS recordkeeping has not been established. Early in the debate, voices called for caution in their use (T. N. Noel, 1986)(Saunders, 22 1990). Studies of vigilance that compare AIMS and MERS have been hindered by confounding variables and small sample size (Thrush, 1992). At the present time, AIMS are utilized by only five to ten percent of anesthesia providers (Levitan, 2008). This small percentage is cited to be due to the high initial cost of AIMS. With the increasing appeal for the implementation of AIMS (Levitan, 2008), there is an excellent opportunity for research into the benefits and limitations of each method of recordkeeping. Before widespread adoption of AIMS, researchers must examine differences in the â€Å"connectedness† of practitioners to the subtle trends of vital signs, parameters, and events that may influence patient safety. Researchers must also explore techniques to educate practitioners to enhance the benefits and minimize the limitations of either recordkeeping system. 23 CHAPTER TWO: REVIEW OF LITERATURE History From the time of development of the first documented use of diethyl ether by Dr. William T. G. Morton in 1842, the safety of anesthesia administration has steadily increased. Initially the task of anesthetizing a patient was relegated to medical students under tutelage of a practicing surgeon, creating an anesthesia provider with a primary focus of studying the surgical procedure being preformed rather than vigilance toward the anesthetized patient. By the turn of the 20 th century, the morbidity and mortality of anesthesia delivery had become unacceptably high, and a provider dedicated to the specialty of anesthesia was sought (Gunn, 2005). At this time, physicians who specialized in anesthesia were few, due to the culture of medicine prevalent at the time. Surgeons recognized the need for anesthetists with specialized training, particularly those who would â€Å"(1) be satisfied with the subordinate role that the work required, (2) make anesthesia their one absorbing interest, (3) not look on the situation of anesthetist as one that put them in a position to watch and learn from the surgeon’s technic {sic}, (4) accept the comparatively low pay, and (5) have the natural aptitude and intelligence to develop a high level of skill in providing the smooth anesthesia and relaxation that the surgeon demanded† (Thatcher, 1953) 24 Most often, this role fell to nurses rather than physicians (Thatcher, 1953). Many of the physicians who administered anesthesia during this time were called in to service from the ranks of medical students studying the practice of surgery, were unskilled in the delivery of anesthetic agents, and often met with tragic results. A personal report shared by Dr. Harvey Cushing from the time of his medical training of a patient’s death under anesthesia indicates not only the challenges of anesthesia delivery, but also the nonchalant attitude towards the mortality ascribed to such mortality by the surgeons at the time. Dr. Cushing was advised by the surgeon, â€Å"that sort of thing happed frequently and I had better forget about it and go on with the Medical School. † As a result of this and other such incidents, Dr. Cushing and his colleague, Dr. E. A. Codman of the Massachusetts General Hospital were encouraged to develop the first known examples of an anesthesia record. These documents recorded respirations, pulse rate, and temperature, along with narrative accounts of the events of the patients’ reactions to the anesthetic. As stated by Dr. Cushing, â€Å"It was undoubtedly a step toward improvement in what had been a very casual administration of a dangerous drug. We do so much better with ether these days, but even so there remains much to learn† (Beecher, 1920). More widespread use of handwritten accounts of anesthesia and surgery were to follow, but not for more than 20 years after these initial accounts. Even at this early date, voices of caution were raised, indicating that the manual documentation of â€Å"too elaborate a record of this kind might take the administrator’s mind from his primary job†. In defense, Dr. Cushing stated, â€Å"I feel most emphatically that it keeps his mind on his job† (Beecher, 1920). 25 Perhaps as a result of similar concerns of distraction and reduced vigilance, in 1929, Dr. E. I. McKesson (1934) developed a device to record respiratory volumes, oxygen percentage, and pulse pressure, from which both the systolic and diastolic blood pressures were derived. Dr. McKesson (1934) advised, â€Å"It is very difficult for one person to count the pulse and respiration, measure the blood pressure and the volume of breathing, to determine the volume of rebreathing or the quantity of carbon dioxid {sic} used (the anesthetic), to note the dosage and a few other factors in their proper sequence and with sufficient frequency to aid in the administration†. Dr. McKesson (1934) also indicates that these same limitations were raised as cause not to keep such a record of anesthesia, to better maintain vigilance focused toward the patient. Through examples of anesthetic records generated by his device, Dr. McKesson (1934) also indicates the first recorded incidence of â€Å"artifact† or erroneous data. Listed in Chart 2 a â€Å"notch† is indicated in the graphic display of respirations. Such a â€Å"notch† indicates a reduction in tidal volume of respirations, as with â€Å"deep narcosis (McKesson, 1934). In this example, this data is indicated to reflect a failure of the anesthetist to maintain an adequate mask seal to the patient’s face, and this is indicated by a handwritten notation on the record. Dr. McKesson (1934) indicated that such records could be applied toward the ongoing research of anesthetic delivery techniques. He also indicated that such automatic recordkeeping had a higher degree of accuracy than handwritten records, many of which may be generated after the completion of the anesthetic rather than at the time of the event. Finally, the value of automatic records could be shown through improved 26 nowledge of anesthesia by the practitioners, resulting in improved patient safety (McKesson, 1934). While prophetic, Dr. McKesson’s opinions and apparatus would not gain widespread use, and the handwritten record persisted with few changes into the distant future. Not until 1973 was there further mention of the benefits to accuracy in anesthesia recordkeeping t hat an electronic system could provide (Drui et al. , 1973). Early Development and Implementation With the introduction in 1972 of a compact computerized calculator, the HP-35, the faithful slide-rule became instantly obsolete (Computer history museum – timeline of computer history. 009). At this time of rapidly developing computing technology, Drui et al (1973) examined anesthesia practice with the intent of improving efficiency and, ultimately, patient care. The authors utilized â€Å"memomotion,† a video imaging system that recorded data slower than actual time, to document the tasks of anesthesiologists. In addition, a trained observer with a stopwatch documented a series of twenty-four tasks, including periods of inactivity. Tasks were then rated according to the percentage of time devoted to the task, and the required knowledge, skill, and importance of each activity. The task of recordkeeping, while occupying a large proportion of the anesthesiologists’ time, was determined to have very low requirements of knowledge, skill, and importance. The authors determined that such an activity of low importance, requiring a minimum of skill and knowledge to perform should be automated (Drui et al. , 1973). Five years later, computing technology had advanced to the point that such automation had become possible, with Zollinger et al (1977) providing a comparison 27 between handwritten anesthesia records and those generated by â€Å"a computerized surveillance system†(Zollinger, Kreul, Schneider, 1977). Over this study of 100 patients, computer generated records were found to produce â€Å"acceptable blood pressure measurements 78 percent of the time,† at a rate of one reading every 2. 5 minutes. The resident anesthesiologists produced handwritten records that documented 94 percent of blood pressure measurements, at an interval of once every five minutes. Discrepancies between the two forms of recordkeeping occurred in 43% of the records, most of which occurred during times of high workload for the provider, such as during induction, or periods of time when the providers’ attention was focused on other tasks. Some of the discrepancies were indicated, â€Å"†¦when the vital signs recorded by the anesthesiologist tended to make the record look smooth† (Zollinger et al. , 1977). Zollinger et al (1977) concluded that the records produced were similar in accuracy, and advocated that computerization of the record could collect data at times when the provider was â€Å"otherwise occupied,† and would eliminate data that was â€Å"underestimated by humans who tended to smooth out a record. Even at this early stage, voices of caution were raised, as the article included comments by a guest editor, calling into question the accuracy of the recording devices employed in the study, and cautioned against â€Å"a ‘hands off’ policy† (Zollinger et al. , 1977). A year later, Shaffer et al (1978) examined the prevalence of handwritten records and the potential use of these documents to improve the quality of anesthesia delivery. The authors cited a survey of 46 hospi tals that revealed that as many as 8 percent did not maintain any form of anesthesia record, and that 17 percent did not record drug 28 dministration or dosages. This finding was supported by a similar study from Great Britain, finding that â€Å"25. 9 percent of the anesthesia records were comprised of a single written entry, 45 percent of the anesthesiologists never analyzed their records, and 51. 6 percent analyzed them only sporadically† (Shaffer, Kaiser, Klingenmaier, Gordon, 1978). Further analysis of the methods of recordkeeping indicated that many limitations of production of these documents existed. These limitations included the difficulties with production of copies, limited space available for documentation, incorrect or omission of entries, and illegibility of handwriting. These limitations indicated a need for greater automation of the anesthetic record, to improve the current deficiencies and reduce the anesthetist’s time spent on the task of recordkeeping. Shaffer et al (1978) surveyed anesthesiologists at their facility to devise a list of attributes for an ideal automated recordkeeping system. Shaffer et al (1978) summarized the survey into four main attributes deemed necessary by over 90 % of respondents: 1. Automatic capture of information with the ability to edit inaccurate or erroneous data. 2. Ability to enter data manually through a keyboard, light pen, or graphic display. 3. Reliability of function 4. Ease of electronic storage and retrieval of information Shaffer et al (1978) concluded that a â€Å"semiautomated† system would be the solution to the limitations of the system and account for the suggested improvements. Such a system would maintain many aspects of the handwritten record, to allow for manual entry and 29 error correction, while providing automated capture of vital signs, allowing for a savings of 33 to 50% of the time spent producing a record by hand. At this time in history, standardization of anesthetic equipment was in its infancy. The Pin-Index system, a method to prevent errors of connecting incorrect gas cylinders to an anesthesia machine, had only recently been introduced (Thompson, 1978). The automated non-invasive blood pressure device manufactured by Applied Medical Research, Tampa Florida, had just been introduced to the field, and was beginning to appear in clinical anesthetizing locations. This device, the Dinamap, provided an automated blood pressure reading with reliability, but provided only a visual display, and not an automated record of readings (Lindop, 1981). Against this background of developing technology, Apple et al (1982) offered a proposal for the development of a semiautomatic recordkeeping system similar to that called for by Shaffer et al in 1978. Apple et al (1982) provides details of the Abbograph, from Abbot Labs in Houston, Texas. The Abbograph provided only vital signs on a graphic plotting device, and had no capability for manual entry, an attribute deemed essential by both research studies. The authors offered a system of their own design, capable of both automatic capture of vital signs, as well as manual entry through a keypad of seven categories of data, including â€Å"anesthetic gases, intravenous fluids, body fluid losses, blood pressure data, ventilator settings, general patient record information and general events. Entry of data into this system could be made at the time of the event, at a later time, or â€Å"time independent,† for patient information that is not time sensitive. To evaluate the device, the authors compared 20 handwritten records and 20 keypad records. Of the entries made by hand, Full document contains 256 pages Abstract: Introduction: Anesthesia information management systems are rapi dly gaining widespread acceptance. Aggressively promoted as an improvement to manual-entry recordkeeping systems in the areas of accuracy, quality improvement, billing and vigilance, these systems record all patient vital signs and parameters, providing a legible hard copy and permanent electronic record. At risk is a potential loss of â€Å"connectedness† to the patient with the use of computerized recordkeeping, perhaps jeopardizing vigilance. Methods: This research analyzed differences in the accuracy of Certified Registered Nurse Anesthetists’ (CRNAs) recall of specific patient variables during the course of an actual anesthetic case. CRNAs using computerized recordkeeping systems were compared to CRNAs using manual entry recordkeeping. Accuracy of recalled values of 10 patient variables was measured – highest and lowest heart rate, systolic blood pressure, inspiratory pressure, and end-tidal carbon dioxide levels, lowest oxygen saturation and total fluid volume. In addition, a filmed educational vignette was presented to evaluate any effect on accuracy of recall following this presentation. Four tertiary care facilities participated in this research. A Solomon four-group research design was selected to control for the effect of pretesting on results of the filmed educational treatment. Results: 214 subjects participated in this study; 106 in the computerized recordkeeping group, and 108 in the manual entry recordkeeping group. Demographic covariates were analyzed to ensure homogeneity between groups and facilities. No significant statistical differences were identified between the accuracy of recall among the groups. There was no statistically significant effect of the educational film vignette on accuracy of recall. Conclusions: There was no difference in the accuracy of practitioners’ recall of patient variables when using computerized or manual entry recordkeeping systems, suggesting little impact on vigilance. The educational film presented did not have an effect on accuracy of recall following the discussion of benefits and limitations of methods of recordkeeping. Paper-Based Versus Electronic Medical Record Keeping For many years, physicians’ offices documented all data in paper-based medical charts. Now, the physician or clinician records the medical data into a computer. Information stored in this manner is known as an electronic-based medical record or EMR. By definition, an EMR is a computerized record of the important health information regarding a patient including the care of that individual and the progress of that patient’s condition (Bonewit-West, Hunt, Applegate, 2009). The use of computers in physicians’ offices is not new. For decades, physicians have used computers and practice management software primarily to schedule appointments and for billing. The government has offered physicians incentives designed to encourage the adoption of electronic medical records to promote medical information accessibility, better patient care, greater efficiency, and financial savings (Hamilton, 2010). In the face of advancing technology, small medical offices must compare the cost, ease of use, and maintenance of electronic medical record systems versus paper-based record keeping. The cost of keeping paper-based and electronic medical records is not just about the actual price tag of the record-keeping systems. The cost of keeping an electronic medical record system (EMR) begins with the initial purchase and implementation of the hardware and EMR software. There are also ongoing maintenance expenses, loss of revenue associated with temporary loss of productivity due to converting paper charts to electronic ones, and the training of the staff (Menachemi Collum, 2011). The way these record systems are stored is very different and can greatly affect the cost as well. EMR records are stored on a server, digitally, in a secure computer database within the office practice (Hamilton, 2010). How to cite Review of Related Literature, Essay examples

Kairos free essay sample

In fact, Kairos is an opportunity for men to have agency in a world usually dictated by fate. In this way, Kairos restores freedom to human lives that would otherwise be predetermined. Finally, it is interesting to notice that there does not exist a modern English translation for Kairos, which seems to suggest that it is a concept that does not have a place in modern society and thus in our modern understanding of time. Chronos and Kairos oppose each other in many ways.. Whereas Chronos refers to sequential time, measurable and regular, Kairos denotes qualitative time, or a favorable moment. Moreover, unlike Chronos, Kairos is unpredictable and can only be ‘revealed’ thanks to the correct interpretation of external signs, hence the impression that it is situated outside of Chronos. The â€Å"opportune moments† Kairos provides are neither measurable nor predictable, and cannot be located on a clock or on any similar device. Thus, to a certain extent, Kairos seems to be a â€Å"timeless† time. The Hippocratic Corpus, a group of texts said to be written by Hippocrates, exemplifies the importance of Kairos to the ancient Greeks in everyday life. The author writes that the success of the medicine a doctor administers to a patient depends greatly on the time or moment that the medicine is given. While the success of the remedy used is also dependent on different characteristics of the patient’s body, it is the moment that the remedy is used that is the most important. Indeed, Kairos cannot be placed in a larger temporal framework because it does not relate to the notions of past and future. For this reason, Kairos can only exist in the present. This is why a physician does not try to redict how a disease will evolve, but instead attempts to predict in which Kairos, or â€Å"critical phase† he is in at the moment of his medical examination. For example, in the case of â€Å"an overpowering heaviness of the head†, â€Å"water, or at most [†¦] a pale-yellow wine† should be administered. While this quote may seem to describe the way doctors apply medicine today, it is in fact a description of a ver y different system. Rather than seeking a connection between the symptom and the medicine, ancient doctors felt there was a connection between the symptom and the moment of Kairos it exists in. Different symptoms indicated different moments of Kairos which then dictated how the patient ought to be treated. Furthermore, these moments of interpretation are deeply anchored in the present, as it is the only â€Å"time† (as opposed to past and future) in which action can be taken. This is to say that Kairos is the moment in which a man can escape his fate, which otherwise rules his life. Fate is always associated with Chronos time, which can be predicted and unavoidably evolves from past to future according to a predetermined development. In contrast, Kairos time allows for spontaneous action based on temporal opportunities. Since in Chronos time, the present is already determined by the past, there is never a true moment of freedom. Sophocles’ play Oedipus at Colonus presents an illustration of this predestination: â€Å"Thy tale of cruel suffering For which no cure was found, The fate that held thee bound. † Here the Chorus addresses Oedipus, clearly expressing the idea that his life, just as that of anybody else, is constrained by fate, which he cannot escape. Chronos is the father of all the Olympian Gods, represented as a wise old man, and known as â€Å"Father Time. † In contrast to this image of Chronos, Kairos is represented dancing, holding the scales of fate in his left hand; with his right hand, he is tipping the scale in one direction or the other. This clearly shows his ability to liberate moments from fate and his detachment from Chronos. Because of this, the moment of the action is often emphasized more than the action itself. This is evident in the Hippocratic Medical Corpus: â€Å"This is the time for administrating gruel that must be most carefully observed† – â€Å"Consider this time of great importance in all diseases† From this quote, it is clear that the most important factor in the administration of medicine is not the disease the patient has, but the moment the remedy will be given. This moment must occur at the right time, during the right phase of the illness, in order for the remedy to be successful. The same can be said about Pindar’s Pythian 4, an ode to the victor of the Pythian games. In Pythian 4, Pindar spends more time describing the process that led the heroes to go on an expedition in search for the golden fleece at the moment they did than he does describing their exploits, which are only summarized. This example is particularly interesting in that through those feats, Jason, the hero of the myth, and his companions will achieve kleos, and will thus transcend Chronos time. However, it is the fact that the expedition left at the right moment that seems important to Pindar, or at least more important than the exploits. In an example such as this one, Kairos does seem to be treated as the agent of the action, or at any rate, as responsible for its success. This gives Kairos an extremely important role, in rehabilitating man’s freedom. Indeed, without the existence of Kairos, human beings would be trapped in their fate without any power over their destiny. Kairos is an opportunity and a â€Å"critical moment†, but it is also the â€Å"due measure† that allow humans to influence on the course of their own existences. However, Kairos only allows men to take action; it does not take action for them. This is evident in the medical corpus: â€Å"[Physicians] generally make the change from fasting to gruel exactly at those times at which often it is profitable to exchange gruel for what is virtually fasting. † One can imagine that relying on such a method could have led to serious mistakes. The nature of Kairos is such that these mistake could easily have disastrous consequences, for which the physician, and not Kairos, would be responsible. Indeed, Kairos alone is not sufficient for a patient to heal, or for an action to be carried out with success. In order for an action to succeed the individual must act in the right moment but must also act correctly. In the medical corpus example, giving gruel could probably have been beneficial, but was not because it was given to the patient at the wrong phase of time. This also is why the medical corpus says medications listed can only be efficient in â€Å"the proper time of their use†. In this way, Kairos is a necessary condition, but is in no way sufficient on its own. The positive outcome of an action therefore does not only depend on Kairos, but on the correct interpretation of Kairos. Thus, a good physician is not one who knows all the different names of every disease, a good physician is one who above all else can read a patient’s body in order to recognize the phase of time the disease is in, and thus determine what should be done. This is why, according to a passage of the Hippocratic Corpus, every physician should learn â€Å"the changes of the seasons and the risings and settings of the phenomena† in order to â€Å"learn the times beforehand†, which will allow him to â€Å"succeed best in securing health, and will achieve the greatest triumphs in the practice of his art† Our modern concept of time leaves no place for Kairos. The word cannot be translated into modern English, and even the concept requires a fair amount of explanation, since it falls so outside of the realm of our understanding of both time and fate. The closest word to Kairos in the English language would most likely be the word, â€Å"opportunity† While â€Å"opportunity† conveys the way moments in Kairos function with humans agency, it does not fully convey the temporal dimension of Kairos. In modern day society, opportunities are not necessarily always dependent on small windows of time and are often not spontaneous. In this sense, it appears that we can only talk of an opportunity, but not of the moment in which that opportunity takes place. This is to say that the same way Kairos seems detached from Chronos, our opportunity is detached from time altogether. However, even today, moments of Kairos, though not intentionally, are often taken into consideration when a decision is being made about an action. For example, politicians often â€Å"read the signs† of the political environment or social atmosphere before making a speech on a particular topic.

7 pieces of tough but loving career advice

7 pieces of tough but loving career advice There’s an awful lot of career advice out there. Some of it is great; some of it is not so great. What most of it has in common is a general tone of optimism- †Reach for the stars! You can do anything you set your mind to!† While it never hurt to think positively, we know it also can’t hurt to hear advice that’s a little more of the tough love variety. Here are a few career advice gems that will guide you to take a more careful look at yourself and your choices, while not painting the path ahead in a completely rosy hue. Keep these in mind as you begin (or continue) your career, and you should be prepared for whatever comes your way.1. You aren’t going to be great at everything right away.Every time you start a new job or attempt to acquire a new skill, you’re likely going to be terrible at it- at least at first. And that’s fine! You cannot be perfect (at anything!) right out of the gate. Don’t despair, and don’t com pare yourself to other people. Just keep plugging away and you’ll improve.2. Not everyone is going to love you.Some people just plain aren’t going to like you. There’s almost nothing you can do about this- many times, it has very little to do with you and everything to do with them and their issues. If you don’t expect a 100% positive consensus about you in any situation, you won’t be disappointed.3. Chill out- the day to day doesn’t matter that much.Learn to find the more sustainable, moderate ground between â€Å"Everything is terrible† and â€Å"I am the most awesome worker ever† and shoot for sticking in that middle territory on average. Work hard, but don’t take things (work or home) too seriously or personally. If you don’t let things get under your skin, you’ll stay in better control of yourself- and make a better impression on those around you.4. You don’t get brownie points for overworking y ourself.There’s no trophy for the most stressed out person. Your career isn’t a death sprint to some finish line where success is waiting just on the other side. It’s a long slog, but one that will hopefully be a labor of love. It will take endurance, patience, and positivity. Work on cultivating those rather than running yourself into the ground. Don’t take on more than you can reasonably handle.5. Going the extra mile can be tough.Don’t just be a team player on paper or for show. Demonstrate to people that you have made them a priority. Seek out tasks that aren’t on your docket or directly assigned. Figure out what’s stressing your boss out the most and find a solution to that problem. Go out of your way to be helpful to others or to streamline your (or everyone else’s) workflow. Being thorough and extra attentive in these areas will make you better at your job and a better person. It takes a lot of focus and purpose, but you ’ll see results in the long run.6. Vulnerability = successThe most successful people, in work and in life, are willing to humble themselves enough to understand their own weaknesses and learn from those around them. Don’t get so caught up in getting ahead that you forget the world is made of other people too (there is no â€Å"I† in â€Å"teamwork†). Admit your mistakes and ask for help.7. Making friends is an important part of work life.Sorry introverts- you might have to channel a hidden social butterfly within. Whenever you start a new job, always say yes to coffee invitations, to that first happy hour, to the company picnic. Make friends. Be a person too, not just some shark trying to swim straight to the top.Workplace success comes when you find that ideal balance of the personal and professional. Work hard, but don’t overwork yourself. Be respectful and businesslike, but kind. Finding that ideal footing isn’t easy, so don’t be h ard on yourself. Even just striving for it puts you on the correct path for a healthy and fruitful career.

Canadian Dollar Fluctuations essays

Canadian Dollar Fluctuations essays The Canadian dollar has declined by over thirty percent versus the United States dollar, since it was at its highest in 1970. The reason for this is mainly the following factors: the Quebec factor, the inflation factor, the productivity factor, the growth in government and taxes factor, and the commodity price factor. These all come together to bring us to what the Canadian dollar is worth compared to the U.S. dollar today. The Quebec factor is partly responsible for the decline. It is no coincidence that the Canadian dollar began its descent to 69 cents in November 1976. ¹ That was the month in which the Parti Quebecois shocked political observers by winning the Quebec provincial election. It was the first, and still only, party explicitly committed to separation to assume the reins of power in Quebec City. While it is generally agreed that there is a risk premium built into the Canadian dollar because of the threat of separation, no one believes that threat is responsible for the whole, or even the bulk, of the currency's decline. ² The Canadian dollar is much lower because of separation because of what happened during the 1980 Quebec referendum. At the beginning of the campaign, in March 1980, polls showed the Yes side leading. In response, the Canadian dollar very quickly dropped from 87 cents to 83 cents. But in May, when the No side won a resounding 60-40 per cent victory over the separatists, the Canadian dollar leaped back up. It was at 87 cents again in June. The currency's movement in that period suggests a minimum 4 cent risk premium because of This is roughly consistent with what happened in the subsequent October 1995 referendum. On the night of the referendum, the television networks were showing the Yes side with a substantial lead. The Canadian dollar immediately dropped a cent. Then, however, the votes from Montreal were counted and t...

Clean Edge Case Questions Essay Example | Topics and Well Written Essays - 250 words

Clean Edge Case Questions - Essay Example This functions to maintain sales and productivity for the old products while establishing a niche in the market for the new products. The idea is to avoid the new product from cannibalizing the old products while simultaneously maintaining a competitive edge for an organization’s entire product range. The customer’s sense of utility for both products should remain high for both products. There is a real threat of the new product over-shadowing the old product; therefore, it is paramount for the marketing team to have ample preparation for such an eventuality. Defects in the new product released warrants management to either recall the released products. This is a weakness, which the organization should strive to eradicate (Beckham & Quelch). Non-disposable razor use is categorized into two general types. The first is the everyday shaver, which seeks to create an ultimate shaving experience for consumers. The product’s affordability ranges from high to low-end. Conversely, the second category is the general shaver, which is available for all consumers depending on their financial capabilities. The R&D department at Clean Edge seeks to find out consumers’ frequency of use, their budget and their expectations of the product; for example, a consumer’s lifestyle determines the type of razor they require. I would recommend Clean Edge being sold as a niche positioned product, which offers the ultimate shaving experience for men who shave routinely and who seek a superior razor and performance razor. This will appeal to the functionality appeal of the consumer for a non-disposable, high quality razor. This will maintain the competitive edge that Clean Edge has and set it apart as a high quality product- a must have which appeals to the masculine in the male consumer. I would not recommend the mainstream positioning of the Clean Edge, as it would face harsh competition form the already flooded market. It could also spell the decline in

CAN COMPASSION BE TAUGHT An exploration of the concept of teaching Literature review

CAN COMPASSION BE TAUGHT An exploration of the concept of teaching compassion to nursing staff within the field of dementia - Literature review Example In this regard, a framework was developed using the guide for critiquing quantitative research suggested by Coughlan, Cronin and Ryan (2007) and the guide for critiquing qualitative research suggested by Ryan, Coughlan and Cronin (2007). Ten journal articles were selected using an exclusion and inclusion criteria based on relevance, appropriateness and the most recent research on the subject under investigation. A Fishbone analysis was conducted to determine the challenges for implementing and using compassion in the delivery of care to patients with dementia for determining the extent to which compassion can be taught as revealed in the literature. Results: The results of the study indicate that nursing staff delivering care to dementia patients and dealing with families and carers are at an increased risk of compassion fatigue. The results indicate that compassion can be taught directly and indirectly provided the welfare and wellbeing of nurses are safeguarded and promoted. Discus sion: Implications for practice and directions for further research are discussed. The limitations and strengths of the research are also discussed. Conclusion: It is concluded that in order to successfully teach and maintain compassion in the context of nursing staff in the field of dementia, three approaches have to be taken. ... dementia are at an increased risk of suffering compassion fatigue, efforts must be made to safeguard the welfare and well-being of nursing staff to ensure that they are retained and nurses do not become over-burdened with an imbalance in demand and supply. Table of Contents Abstract 2 Chapter One: Introduction and Background 4 1.1.Introduction 4 1.2.Background 5 1.3.Aim of the Study 7 1.3.1.Objectives of the Study 7 1.3. Research Methods 8 Chapter Two: A Critical Review of Literature 11 2.1. Compassion: Definition and Concepts 12 2.2. The Role of Compassion in the Care of Dementia Patients 15 2.3. Teaching Compassion to Nursing Staff in the Field of Dementia 20 Chapter Three: Findings and Conclusion 28 3.1. Findings and Conclusion 29 3.2. Implications for Practice 34 3.3. Suggestions for Further Research 36 3.4. Limitations of the Study 36 3.5. Strengths of the Study 37 Bibliography 37 Chapter One: Introduction and Background 1.1. Introduction Compassion is described as a significant quality in nursing that has an impact on the care delivered to patients (Kret, 2011). With respect to patients suffering from dementia, care science theorises that core competence and skills among nursing staff includes patience, consideration and compassion (Rundqvist & Severinsson, 1999). However, studies have shown that caregivers administering care to patients suffering from dementia are at a heightened risk of suffering from ‘compassion fatigue† (Day & Anderson, 2011, p. 2). Compassion fatigue is associated with a lack of nursing staff juxtaposed against increasing patient demands and the physical and mental burdens nursing staff confront in meeting increased patient care demands (Bush, 2009). Effective nursing care for patients with dementia is accomplished by the ability to look

The Development of Investment Banking in Hong Kong Research Paper

The Development of Investment Banking in Hong Kong - Research Paper Example This research will begin with the statement that investment banking is a type of financial service dealings with the creation of capital for other companies and co-operation. Investment banks underwrite new debts and equity securities for corporations.   They also offer guidance to issuers of security and placement of stock. In addition, they foresee sales of securities in some cases. Investment banks also take part in the mergers, acquisitions, reorganization and broker trades for firms and private investors.   A distinction feature between investment banking and commercial banking is that investment banks do not deal in cash deposits. Corporate finance is the fundamental aspect of investment banking; it also entails helping customers raise funds in capital markets. The banks also provide their customers with supplementary services such as market making, trading of derivatives, commodities as well as fixed income instruments. However, there are some instances where the bank exis ts as a part of a commercial bank but as a chief commercial banker. There are two categories or classes of investment banks based on their mode of operation. This is more relevantly defined as branches of operation in investment banking. The first is simply referred to as the ‘Sell Side’; it carries out functions such as trading securities for an exchange of cash or other securities. Under this section, the bank facilitates transactions and promotes securities and market making services. The other category is the â€Å"Buy Side†. It is concerned with the provision of guidance and advice. It deals with purchasing of investment services. Some of the organizations that deal with this category include unit trusts, insurance companies, private equity funds and mutual funds. The banking system can also be split into private and public functions. This comes to play when there is information barrier which makes the two sections separate since there is no information cros sing to either side of the system. The private section deals with private insider information; under no circumstance should this kind of information be disclosed to the public. The public section, on the other hand, deals with public information such as analysis of the stock, which is suitable for public consumption. The origin of investment banks in Hong Kong can be traced back to 1865 when major financial activities were carried out by HSBC. This was a name derived from Hong Kong and Shanghai Banking Corporation, who were the founding members of the modern group. The bank was owned by business communities of China cost in 1869. During this period financial trade in the region was not yet developed and most banking activities were still handled by Europeans or Hongs, instead of professional bankers. However, people began to venture in entrepreneurship raising the demand of larger and more sophisticated banking facilities and services. The citizens in Hong  Kong particularly neede d a specialized banking system, which was preferably owned and managed locally. After being colonized the British the colony has rapidly become a regional hub for trade in South Asia. Also due to its strategic location in a gateway of China Hong Kong has become the most important financial center in the world and attracting a huge number of investors from all over the world in its investment banking system. The industry has been modernized and conditions set that would see investment banking flourishing. This is due to the low tax rates and also considerable economic rise are key factors that have to lead to the modernization of investment banking in Hong Kong. Hong Kong harbors the best investment banks in the region which have developed over the historic period of banking evolution. It provides regional leaders, with dedicated teams of professionals serving a wide range of clients.

Literature Review On Organisational Change Management Essay

Literature Review On Organisational Change Management Essay Part A Organisational Change: Organisational Change is the process by which organizations move from their present state to some desired future state to increase their effectiveness. Characteristically Change is vital if a company wants to avoid stagnation fast and is likely to increase further in the present competitive business Change is understood as doing things differently in order to cope up with emerging changes in the organisation environment. Change in any part of the organisation may affect the whole organisation. Change could be proactive or reactive. A proactive change has necessarily to be planned to attempt to prepare for anticipated future challenges. Generally it is initiated by management. A reactive Change may be an automatic response to a change taking place in the environment (John Lacovini, The human side of Organisation Change, January 1993, Page 35.) Change Management is a structured approach to transitioning individuals, teams and organisations form a current state to a desired future state. Its major objective is to maximize the collective benefits for all people involved in the change and minimise the risk of failure to change. The major obstacle to change management is Resistance to Change. (K.Aswathappa, Organisational Behaviour, 8th revised Edition, Chapter 20, Page No.520) T John Lacovini says, The secret to real success of any organisation is effective management of the emotional vulnerability that accompanies organisational change. Types of Change: Different types of changes require different types of strategies to be implemented for effective functionality. The three types of change that occur most frequently in organisations are Developmental Change Transitional Change Transformational Change Developmental Change: Developmental Change occurs when a company makes an improvement to their current business. If a company decided to improve their processes, methods or performance standards that should be considered as developmental change. Companies are continually processing developmental changes to some degree in order to stay competitive. This type of change should cause little stress to current employees as long as the rationale for the new process is clearly conveyed and the employees are educated to new techniques. When major change such as decision to close a division, streamline the business and organisation downsizing, make developmental changes unacceptable to the employees. The employees could see that the company attempted different strategies before determining that closing the division is the only option. Transitional Change: Transitional Change is more intrusive than developmental change as it replaces existing processes or procedures with something that is completely new to the company. The period when an old process is being dismantled and the new process is being implemented is called transitional phase. A corporate reorganisation, merger, acquisition, creating new products or services and new technologies are examples of Transitional Change. It may not require a significant shift in culture or behaviour but it is more challenging to implementing than a developmental change. The future of the organisation is unknown when the transformation begins which can add a level of discomfort to the employees. (Bernald M. Bass, From Transactional to Transformation Leadership, Training and Development, May 1991 Pages 87-92) The outcome of transitional Change is unknown so employees Amy feel that their job is unstable and their own personal insecurities may increase. Education and orientation at every stage of new process implementation should be commenced in order to employees insecurity. This will make the employees feel comfortable. They will feel engaged and actively involved in change. As the employees level of engagement in new process increase, their resistance to change may decrease. Management should be a cognizant of the impact and stress these changes will have on their employees. The company should continue to inform the employees of their status offer support in helping them deal with the personal adjustments they will be forced to make. Transformational Change: Transformational Change occurs after the transition period. Transformational change may evolve both developmental and transitional change. It is common for transitional and transformational change to occur in tandem. When companies are faced with the emergence of radically different technologies, significant changes in supply and demand, unexpected competition, lack of revenue or other major shifts in how they do business, developmental or transitional change may not offer the company the solution they need to stay competitive. Instead of methodically implementing new processes, the company may be forced to drastically transform itself. (K.Aswathappa, Organisational Behaviour,8th revised Edition, Chapter 20, Page No.525) Part B Resistance to Change: The goal of any planned organisation change is to find a new and improved way of optimal utilisation of resources and capabilities in order to increase an organisations ability to create value and improve returns to its stake holders. Yet employees do not always welcome changes as expected by the organisation. As per the 2007 survey conducted by the Society for Human Resource Management (SHRM), organisational changes fail majorly due to employee resistance and inadaptability to change. Figure   Reactions to change may take various forms. Active resistance  is the most dangerous factor in change management. Employees with Active Resistance may go against the change effort and object the change in several manners. Boycotting the organisation, tending to disrupting habits and raising slogans against the organisation are some examples for high negative resistance. In the opposite nature,  passive resistance  is calm and doesnt include violence in any aspect. Passive resisters are insecure about their position after change. Instead of clearing their insecurities with the management, they tend to look for a new job and leave the organisation. Compliance, is coping up with the proposed changes with little enthusiasm. Finally, those who show  enthusiastic support  are supporters of change, who understand the value of change and contribute to the effective implementation of change. They are the defenders to organisational resistance and propagate the new way to actually encourage others around them to give support and contribute to the overall change effort. The best example of resistance of employees to change is computerisation. Change requires readjustment. Man always fears the unknown and a change represents the unknown(P Subba Rao, Essentials of Human Resources Management and Industrial Relations, Chapter 12, page 353) Factors causing resistance to change: Fear of Unknown: Such fear is due to uncertainty about the nature of change, feelings that one doesnt know what is going on and what the future holds. Loss of Control: Feeling that the change is being done to the person, worry that one has no say in the situation and events that are taking place. Loss of face: Feeling of embarrassment as a result of change and discerning it in such a way that the things one has done in the past are wrong. Need for Security: Worry about ones potential role after change and fear of losing job after change. Fear of Demotion: Employees may fear that they may be demoted if they do not possess the skills required to do their jobs, after change. Hence they prefer status quo. Loss of Power: Employees in superior cadre may assume that change may eventually result in the loss of their superior power. They give more prominence to maintaining prestige and status in the organisation, even if the change is for overall betterment of the organization. Fear of workload: Change in work technology and methods may lead to increasing workloads there by no proportional increase in salaries and benefits. This feeling creates resistance to change. Need for Training: Not all employees are interested in continuous learning and if the change necessitates relearning and continuous training, employees may resist to boredom to learn. Need for new social adjust: Any organisational change involves new social adjustment with various groups and sub groups.Some people refuse transfers and promotions, as they may need to need to break their current social comfort zone? Perceiving change as imposed from outside: Some employees may consider that change is enforced only for the development of organisation, not for their development. They perceive change as something imposed from outside on them. (Bernald M. Bass, From Transactional to Transformation Leadership, Training and Development, May 1991 Pages 93-95) Forces of Change: An organisation is affected by various forces to change. Internal forces: The forces inside the organisation which affect the change are as follows: Need to develop new products and new technologies in order to with stand in the ever changing competitive world. Focus on business diversification. Urge to implement bench marking standards in the organisation Business Process Re-engineering and Total Quality Management process implementation Cost Cutting strategies to with stand in recession times Company going for Public Issue External Forces :The forces outside the organisation which affect the change are as follows: Change in the employment and industrial laws of the country. Booming economy or recession situation. Business trends such as globalisation which helps to spread the commercial activity all over the world. Increasing competition makes companies concentrate more on customer satisfaction and customer excellence. Social, economic and political changes like terrorist attacks, political conflicts with other countries, UNO Regulations and World Bank policies. Demographic shifts like shrinking labour, droughts and drains, rising health care costs, rise in the number of foreign born workers force companies to concentrate more on matters of discrimination and civil rights. Part C: Approaches to Organisational Change Change Management Models: Management is said to be a change agent as its role is to initiate the change. It has to overcome the resistance in the organisation and make the change as a successful venture. Management must realise that resistance to change is basically a human problem and hence it must be tackled in a social and human manner. Several behavioural scientists and psychologies have studied group dynamics and organisation development and hence have proposed various theories and models to change management. They are described below. Levins Force Field Theory of Change(1936): Kurt Zadek Lewin (September 9, 1890 February 12, 1947) is a renowned psychologist and is recognized as the founder of social psychology. To his credit he was one of the first to study group dynamics and organizational development. Lewin proposed force field theory of change, which explains about various forces affecting the change and organizational equilibrium. Taken from www.change-management-coach.com An organisation at any time is a dynamic balance of forces supporting and restarting any practice. The forces supporting the practice are Driving Forces and the forces objecting the practice are restraining forces. When the forces are evenly balanced, the organisation is in a state of inertia and doesnt change. To stimulate an Organisational change managers must find ways to increase the Driving Forces and decrease the Restraining Forces. With these strategies an organisation overcomes inertia and implements change process. (John W. Newstrom and Keith Davis, Organisational Behaviour,8th revised Edition, Chapter 15, Page No.410,411) Change is introduced within a company by a variety of methods. The idea is to help change to be accepted and integrated into new practices: Adding new driving forces Removing restraining forces Increasing the strength of the supporting force Decreasing the strength of the restraining force Converting a restraining force into a supportive force A good example for this strategy is an urge for increased quality of products in an organisation is supported by forces like higher-quality work, increased company reputation and better customer satisfaction.Restrining forces being employees feeling irresponsible for the quality of product they produce. This can be overcome by implementing programs to increase employees pride, performance based hikes, providing better machines and training, quality of work life etc. Three Stages in Change: Behavioural awareness in managing change is aided by viewing change as a three step process: Unfreezing Changing Refreezing Stage 1: Unfreezing Unfreezing means that old ideas and practices need to be cast aside, so that new ideas can be learned. It basically means to have an open mind and flexibility to accept new changes. Its getting rid of old practices and accepting new challenges. Its basically breaking the current comfort zone and getting ready for change. So a manager must help employees clear their minds of old roles and old procedures. Only then they will be able to embrace new ideas. The Unfreezing stage is probably one of the more important stages to understand in the world of change we live in today. Stage 2: Change or Transition Changing is a step in which new ideas and practices are learnt.This process involves helping an employee think reason and perform in a variety of new ways. It can be a time of confusion, disorientation, overload and despair. Patience is very important in this point. There should be hope, discovery and excitement to overcome to overcome all chaos and enter a new mode of development. Stage 3: Refreezing Refreezing means that what has been learned is integrated into actual practice. The new practices become emotionally embraced and incorporated into the employees routine behaviour. Successful on -the-job practice, then must be the ultimate goal of the refreezing step. In this step emphasis is on stabilising the work process after rapid change transition. (Lewin K. Force Field Analysis and Diagram. Online. www.valuebasedmanagement.net/methods_ lewin_force_field_analysis.html.) Even though the world has changed ever since Kurt Lewin has published the model in 1947, it is still extremely relevant and the foundation of several other new models.(John W. Newstrom and Keith Davis, Organisational Behaviour, 8th revised Edition, Chapter 15, Page No.409) Kotters Eight Step Model (1995): John P Kotter (1995) has designed an extremely helpful model to understand and manage change. Each step in the model is characterised by key principle, in which people see, feel and then change. Kotler explained them as principles of response and approach to change. These are explained descriptively in his highly appreciated book Leading Change (1995). The eight step process is described as follows: Kotters Eight Step Change model is considered as one of the worlds best change management models. It has simplified the change process immensely and concluded that every successful change effort is messy and full of surprises. Managers have to view change process in a see-feel view where major problems in the process are highlighted and there by easily solved. Pendlebury, Grouard and Meston -Ten Keys Model(1998): These Scientists have presented Ten Key Factors which can be adapted to any particular change situation. All these keys may be needed to be implemented either simultaneously of separately based on the change process. The ten keys are as follows: Define the Vision Mobilise Catalyse Steer Deliver Obtain Participation Handle Emotions Handle Power Train and Coach Actively Communicate (K.Aswathappa, Organisational Behaviour, 8th revised Edition, Chapter 20, Page No.520) Nandler -12 Action Steps: Nandler, has developed a management frame work of twelve action steps which is helpful for Managers and Executives to apply at every level of hierarchy during the change process.This is immensely helpful for leading and managing change at every corner of the organisation. The twelve action steps are as follows: Get support of key power groups Get leaders to model change behaviour Use symbols and language Define areas of stability Surface dissatisfaction with the present conditions Promote participation in change Reward behaviours that supports change Disengage from the old Develop and clearly communicate image of the future Use multiple leverage points Develop transition management arrangements Create feedback Kanter, Stein and Jick Ten Commandments(1992): Kanter, Stein and Jick have done a wonderful research on organisation change and proposed Ten Commandments on how to plan a change process. Analyse the need for change Create a shared vision Separate from past Create a sense of urgency Support a strong leader role Line up political sponsorship Craft an implementation plan Develop enabling structures Communicate and involve people Reinforce and institutionalize change Ghoshal and Barletts Model(1997) : Ghoshal and Barlett argue for the importance of sequencing and implementation of activities in a change process. The interrelated change phases are: Rationalization : Streamlining company operations Revitalisation: Leveraging reqources and linking opportunities across the whole organisation Regeneration: Managing business unit operations and tensions, while at the same time collaborating elsewhere in the organisation to achieve performance. They claim that while change is often presented as difficult and messy, there is nothing mystical about the process of achieving change with effective strategies following the rationalization, revitalization and regeneration sequential process. (K.Aswathappa, Organisational Behaviour,8th revised Edition, Chapter 20, Page No.540) Dumpy and Stance Contingency Model of Change(1993): Dumpy and Doug Stance developed the best change contingency approach. They argue that the style of change and the scale of change have to be matched to the needs of the organisation. Scale of Change Style of Change Management Fine Tuning International Adjustments Modular Transformation Corporate Transformation Collaborative Consultative Lowers Performance (Avoiding Change) Developmental transitions (Constant Change) Charismatic Transformation (Inspirational Change) Directive Task Focussed Transistors (Constant Change) Turnarounds (Frame-Breaking Change) Coercive They identify five change approaches: Development Transitions: They refer to situations in which there is constant change as a result of the organisation adapting itself to external and environmental changes. The primary style of leadership is consultative, where the leader acts in the capacity of a coach aiming to gain voluntary, shared commitment from organisational members to the need for continual improvement. Task Focused Transitions: In this, the change management style is directive with the change leader acting as a captain seeking the compliance of organisational members to redefine how the organisation operates in specific areas. Directive leadership means that the overall change is driven from the top; this may translate into a more consultative approach by managers operating lower down in the organisation who are required to implement the changes. Charismatic Transformation: With this model, people accept that the organisation is out of step with its environment and that there is a need for radical, revolutionary change. Helping to create a new identity and a paradigm shift in the way in which the organisation conducts its operations, the charismatic leader is able to operate symbolically to gain emotional commitment of staff to new directions. Turnarounds : This is aimed at frame breaking changes. Turn around change leaders as commanders utilizing their positions of power to force required changes through the organisation. Taylorism: It is associated with the fine-tuning, paternalistic approaches to managing change. Dumphy and Stance their model indicates that medium to high performance organisations are likely to be using consultative and directive change management. (K.Aswathappa, Organisational Behaviour,8th revised Edition, Chapter 20, Page No.530) Huys Work on Change Management(2007) : Huy categorizes change into for ideal types: Commanding : Commanding change intervention is one where the time period is short term, abrupt and rapid. Change is usually implemented by Senior Managers who demand compliance from organisational members. Changes may well include downsizing, outsourcing and divestments. Engineering: This model is oriented toward a medium -term, relatively fast change perspective and often assisted by work design analysts who assists in changing work and operational systems. The change agent act as an catalyst in this process Teaching : This model takes a more gradual, long term organisational change perspective. Assisted by outside process consultants, staffs and taught how to probe their work practices and behaviours to reveal new ways of working. Socializing : This intervention is also gradual and long term. It sees change as developing through participative experimental learning based on self-monitored democratic organisational processes. Each ideal type has its limitations. The commanding approach may lead to resentment and rarely produces lasting behavioural change. The teaching approach is very individualistic and may not be aligned to corporate strategic objectives. The engineering approach may not encourage collaboration and spread of change across business units and socializing approach may lead to over focusing on individual work groups rather than on how they may operate as part of larger, corporate collective. (K.Aswathappa, Organisational Behaviour,8th revised Edition, Chapter 20, Page No.550) Part D Implementing Change: Implementation is the institutionalisation and internalisation of a change after it has been accepted by an organisation and a decision has been taken to accept and make it part of the on-going activity. Implementation is a multidimensional process whose end is stabilisation and institutionalisation of change. Support Training Resources Commitment Linkages Planning the implementation process: The objective of planning is to have an overall understanding of the nature of implementation. Planning process determines the entire process of implementation of change phasing. Phasing may be either temporal (in terms of time) or spatial (in terms of various units or the locations of the organisation) Processes: All processes involved in the implementation should be pre-determined. Various stages of the process include initiation, motivation, diagnosis, information, collection, deliberation, action proposal, implementation and stabilisation. Strategies: Management should formulate various strategies to implement processes. These strategies should focus on taking outsiders help, change agent, designing permanent organisational structures, unit/location of the organisation to be selected for initial process, openness with the environment etc.( P Subba Rao, Essentials of Human Resources Management and Industrial Relations, Chapter 12, page 358) Monitoring : It is the process of routine periodic measurement of programme inputs, activities and outputs undertaken during programme implementation. Monitoring is normally concerned with the procurement, delivery and utilisation of programme resources, adherence to work schedules to progress made in the production of outputs Implementation team : A broad based task group of implementation should be set up to look after the implementation of change programme and monitor it continoulsy.HRD department of the organisation may be asked to take up this responsibility.es and Minimum control: As monitoring is a delicate issue, control should be minimum in order to make the monitoring effective. Control attempts to develop new norms of creativity, diversity and experimentation. Feedback and communication: Implementation requires reviewing various processes and provides feedback. It involves getting data information and experiences and providing feedback to the people on how they are implementing compared to the design and plans. Action : Action covers all the minute details of what is implemented at different stages. This process involves various phases and steps for people and various group tasks in relation to change programme. Adaptation : Adaptation is the combination of two main criteria of effectiveness and implementation. It may be general or specific or both. Support : Various types of support from all concerned will be required for the implementation of change. The HRD department, Operations and management committee are some of main agencies which render major support. Institutionalisation: Institutionalisation is making change permanent part of the organisation and internalisation is stabilisation of change. (P Subba Rao, Essentials of Human Resources Management and Industrial Relations, Chapter 12, page 340) Part E: Evaluating Organisational Change The Balanced Score Card Approach: Since centuries Top Management has been depending only on financial measures to evaluate the performance after the organisation change. But this approach was not enough to provide information about overall effectiveness of the organisation.in 1992 Robert Kaplan and David Norton have published Balanced Scorecard in Harvard business review as a management tool for organisational development. Managers can get a comprehensive picture of the financial and operational measures using this framework. HR Consultants and OD strategists all over the world opine that Balanced Score Card is the best tool to enforce organizational change management and organizational development in todays technology driven world. They emphasize the principle that Businesses must develop in a multidimensional way viz., providing best value to its stake holders, achieving ultimate customer satisfaction, implementing bench marked business standards and developing a learning culture in the organisation. The scorecard facilitates managers to view critical performance factors and understand their interrelationships evaluating current performance and targeting performance to be achieved. Emphasis is on the organizational vision and long-term success. (Robert Kaplan and David P. Norton, The Balanced ScorecardMeasures that Drive Performance, Harvard Business Review, January and February, 1992.)   Performance levers in a Balanced Score Card : The Balance Score Card acts as a catalyst for driving organisational change within the organisation. It is dependent on four perspectives which are considered as performance levers for any organisation. The four perspectives of a Balance Score Card are as follows: 1. Financial Perspective How do we perform according to our shareholders? 2. Customer Perspective How do our customers see us? 3. Internal Organisation Perspective What should we excel in? 4. Innovation and Learning Perspective Can we keep on improving and adding value? Hence, the rationale of Balance Score Card is to give uniform importance to non-financial factors of business performance and balancing them with the financial factor. Therefore it is termed as a complete comprehensive framework which tries to bring a balance and linkage between the (a) Financial and the Non-Financial indicators, (b) Tangible and the Intangible measures, (c) Internal and the External aspects and (d) Leading and the Lagging indicators. (Robert S. Kaplan and David P. Norton, Linking the Balanced Scorecard to Strategy, California Management Review, Vol. 39, No.21, 22 1996.) All the four perspectives of a Balance Score Card are explained briefly as follows: The Innovation and Learning Perspective This perspective emphasizes on developing a learning culture in the organisation.The key goals in this perspective are Employee training and self-improvement Grooming and communication Increasing quality of work life Developing skill and knowledge management The Internal Organization Perspective This perspective emphasizes on developing internal business processes in the organization. The key goals in this perspective are Value creating internal operations Innovative supply chain management Total Quality Management. Team building The Customer Perspective This perspective emphasizes on achieving customer delight. The key goals in this perspective are Reducing customer response time Timely updated information Taking regular customer feedback Achieving best vendor award from customer The Financial Perspective This perspective emphasizes on developing financial systems in the organization. The key goals in this perspective are Centralized and automated financial information system Developing financial corporate database Providing more value to stake holders Risk assessment and cost-benefit analysis. Increased working capital and current assets. (Robert S. Kaplan and David P. Norton, Linking the Balanced Scorecard to Strategy, California Management Review, Vol. 39, No.21,22 1996.) Based on the above discussion, organsiations must develop scorecards fitting their current and future needs. Transformational leadership and strong commitment are required to initiate a change process, using Balance Score Card. Some of the worlds best Balance Score Card practises are as follows: GEs HR Score Card design and implementation HR Score card of Washington state HR Score Card of U.S. Department of Transportation Balance Score of Texas State Auditors Office (McKenzie Shilling, Avoiding Performance Measurement Traps: Ensuring Effective, Incentive Design and Implementation, American Management Association, July/Aug., 1998.)   All metrics to organisational performance