Competitive Advantage In The Banking Industry

Competitive Advantage In The Banking Industry Online banking is a self service technology that is used by customers of the bank to carry out in real time activities such as, payment of bills, check account balance and transfer funds. It is worthwhile to note that online banking can be used to reduce cost for banking institution. For instance Hernandez-Murillo et al (2010) suggest that the cost of a customer doing online banking transaction, in a brick and mortar bank in the United State is about one percent of the cost of the customer using the traditional banking method. Esser (1999) reported some of the advantages of online banking to the customers. The findings were: Customers can easily manage their accounts as they can access their accounts any time of the day. The customers do not also need to visit the bank premise to request for services such checking loan rates, view their transaction history etc. Customers can set up a standing order to pay bills and can also schedule new bills or stop payment of bills, when the need arise but this is subject to availability of the internet. Specialised services such as ordering for checks, changing user profile or address can all be done through the online banking. Messages are sent to customers via encrypted email. It should however be noted that the use of internet by bank is not seen just as an innovation and a convenient way for customers to use banking services, but also as a way to make more profit and to reduce operating cost for the bank (Arnaboldi and Claeys, n.d.). Internet banking services are expanding rapidly in the developed countries mainly due to the availability of computers and easy of access to the internet. Its adoption is developing countries was at a slower pace, until recently when banks in developing countries are offering internet banking against the limitation they face (Jenkins, 2007). Another noteworthy point is that online banking can also act as a disadvantage to banks, for instance a troubled bank that has low deposits and could not for borrow from the interbank, when the news of the banks distress leaked out, most the customers withdrew their deposits through the internet without facing the issue of queuing in the banking hall and opening time (Janson, 2009). This could not have been possible without the online banking facility. Customer satisfaction is affect by several factors that can hinder or improve the adoption of online banking by the customer. One of these important factors is personalisation, which demands politeness, courtesy, and friendliness from the employees of the bank toward the customer (Simmers et al, 2008). However, the self-service technology has made a remarkable change in the way the bank interacts with its customer (Simmers et al, 2008). Most of the researches on online banking explore the factors affecting the adoption by banks. The focus of their researches were on the usage of online banking by banks as a reaction to the adoption decisions of the industrys competitors (Hernandez-Murillo et al 2010). Hernandez-Murillo et al (2010) study the factors that determine the adoption of online banking by banks in United States during the period 2003-2006. The Multimarket Contact index was used by these researchers as a substitute of the strategic force required by banks to adopt online operations as a competitive reaction to the rivals actions. The authors results suggest that strategic consideration plays an important role in the adoption of online banking by geographically localised market. Tan and Teo (2000) base their study on studying the factors namely, attitudinal, social and behaviour control, that affect customersthe adoption of online banking in Singapore. The theories of planned behaviour and diffusion of innovations were used by the authors to evaluate their hypothesis. The authors argue that the consumers attitude, his subjective norms and his perceived behavioural control, all contributes towards his adoption of online banking. Amin (2009) examines the factors affecting the acceptance of online banking by people in Malaysia through the use of a technologically accepted model called a linear regression. He propose through the study that the qualities, perceived ease of use, perceived usefulness, perceived credibility and social norm were statistically important while perceived enjoyment was not important. Another factor affecting the adoption of online banking by customers is security of the account accessed through the internet. For customers to feel secure and make use of online banking, the bank must offer online security systems that protect customers assets and information (Smith, 2006). The research to examine the intensity of the impact of online banking on the financial performance of community banks carried out by Acharya et al (2008), both sampling and statistical procedures were used to build a broad online banking index. The basis of their study was on analytical frameworks which used both the structural equation modeling (second-order factor analysis) and multiple regression analysis. Internet banking seems to represent a possible means of allowing new entrants into the banking industry (Arnaboldi and Claeys, n.d.). Smith (2008) uses Porters five force model to analyse the competition within retail banking in an increasingly financially troubled environment. In his analysis where used data from 22 banks, Smith suggests that the barriers to entry identified may not prevent considerable number of entrants into the banking industry. He also observed that the true competition amongst banks may be found in the differentiation of their internet banking products. The paper is based on an exploratory research for a sample of nine banks from each country, a web survey is conducted to collect data for each internet bank using an analytical framework based on a three dimensional model. Both the advancement in technology and change in social trends, such as the increase in customers preference to perceived convenience, have caused a high reorganisation of the financial institution. Banks have to re-examine their marketing strategies and also prompt growth in the adoption of self-service technologies (SSTs) (Loonam and OLoughlin, 2008). Very little research has explored the role of SST in a high involvement service such as that of financial investments. Customer satisfaction with banking services was researched with respect to their interaction with human and technology. It was discovered through the use of multiple regression that consumers overall satisfaction is predicted to be influenced more by human rather than technological encounter (Haytko and Simmers, 2009). While consumers show they are displeased with failure in transaction that involve a bank employee, they tend to accept responsibility for any kind of failure they come across during or after the use of online banking and may continue its usage (Haytko and Simmers, 2009). It should however be note that the focus group used in the research by Haytko and Simmers were students who already has high affinity for the internet. Liao and Cheung (2008) employ the use of service quality (SERVQUAL), Technology Acceptance Model (TAM) and transaction cost analysis to measure customer behaviour to the use of online banking. In their empirical studies, six elements of SERVQUAL namely, usefulness (USE), ease of use (EOU), reliability (REL), security (SEC), responsiveness (RES) and continuous improvement (IMP) , were used to relate to consumer satisfaction in internet banking services (CSIBS). The study was Laukkanen et al (2008) provides more insight to barriers erected by bank customers to the adoption of online banking. The researchers split the non-adopters of online banking into three groups namely the postponers, opponents and rejectors. They suggest, through survey papers submitted by some customers of banks in Finland, that psychological barriers are higher determinant of resistance to adoption than ease of use and its value. Bauer and Hein (2006) carried out another research to gain more knowledge about the consumers point of view in the adoption of online banking. They use micro-economics theory of consumer utility maximisation to model how consumers make decisions on adopting online banking. Simmers et al (2008) relatively examine how the impact of the human services and those provided by technology affect the consumers satisfaction. The authors through two studies both use the six-item and five-point Likert scales conclude that human encounter was initially more important than technology encounter until the convenience of banking online prevailed. The first study was carried out through the survey of some undergraduate students, with most of those that responded between age 19 and 21 years. The second study was carried out with as survey of 153 bank customers at the university, with most less the 24 years of age. It could be seen from these studies that students who have higher affinity to the internet are used for the two studies. It should also be noted that the research is carried out in US, but will most bank customers in UK score convenience higher than online banking security? Joseph and Stone (2003) investigated the customer perception of the impact of technology on service delivery in the banking sector. According to the findings of this research . . . high scores on the ability to deliver service via technology appears to be correlated with high satisfaction with services deemed most important to customers Hence, availability of internet banking services appears to be very important for banks for customer satisfaction and retention. However, availability of internet banking services itself is not a sufficient factor to increase customer satisfaction. User friendliness of the internet banking services appears to be an important factor for customers to use these services Research has been carried out on performance of the internet as an alternative or complementary channel used in delivering some bank services, like current accounts. For instance Gondat-Larralde and Nier (2004, cited by Arnaboldi and Claeys, 2008) carry out a research on the competitive process in the UK market for personal current accounts between 1996 and 2001. The rate at which the market shares changed with respect to price differentials between the brick and mortar banks and the direct banks that use the internet and telephone to operate. The results of the research point to the significance of customer switching cost as a key determinant of the competitive process in banking industry. Mukherjee and Nath (2003) suggest note that the physical separation between the bank operation internet service and the customer introduce an environment of insecurity. The authors develop a structural equation model, called Lisrel, and through empirical test carried out on 510 internet users in India. Nearly all research work refer to the US banking system and research attempts on the performance of online banking are few (Arnaboldi and Claeys, n.d.). IBM (2005) identify three shortfalls of customer satisfaction researches, the first one is that enough attention is not paid to the different behavioural segment customers belong, the research usually take a general view of the customer base. The next one is that most of the researches are not analytical as they fail to show the impact the different elements of the customers experience might have on the brand support and emotional link. Lastly how customer satisfaction is measured is a poor forecaster of to future behaviour of customers. This research differ from other studies in that it will be carried on banks in UK and as there are little research done on the use of online banking as a tool competitive advantage in the banking industry. The author will survey focus groups made up of bank customers in UK will be use to analyse the reason for adoption of online banking and finally the evaluation of satisfaction derive by the bank customers. Qualitative data analysis research will be

Reflection on Critical Care of COPD Patient

Reflection on Critical Care of COPD Patient Foundations of critical care. Introduction The aim of this essay is to present a situation in describing my experiences caring for am identified female patient, and reflecting upon the issues which arose during one shift in a Critical Care unit. The reflective analysis will be carried out using Johns model of reflection (1995) which incorporates Carpers fundamental ways of knowing. This includes aesthetic, personal, ethical and empirical knowing and re flexibility. The purpose of the reflection is to understand better the ways of knowing applied to the situation, and to build upon this knowledge to improve future practice. Case Description. The chosen patient is a 59 year old female with a history of COPD and asthma. For the purposes of this essay, she will be called Jane. Jane had a severe infective exacerbation of COPD, which resulted in PEA Cardiac arrest in the admission medical unit secondary to type 2 respiratory failure, although it was a brief period of output loss only. Jane was intubated and transferred to the critical care unit, and since then she has had difficulty being ventilated due to bronchospasm/air trapping. At the time that I took over care for this patient, she had been on the critical care unit, on ventilatory support, for 12 days. Reflection (based on John’s Model and Carper’s Fundamental Ways of Knowing). AESTHETIC KNOWING: As I came on shift, the ventilation mode was on BIPAP, ASB 15, PEEP 10, I:E 1:3, FIO2 .65 via tracheostomy tube. Upon assessment at the beginning of the shift her BP 110/40, map was 60mmhg despite of noradreanline, and core temperature was 38.6 with improving markers of inflammation. The CVP had fallen to 8, but there was good urine output, 45-70 mls per hour over the previous four hours, with hourly urine measurements continuing. There was an intercostal drain in situ for a pneumothorax which developed post subclavian line insertion. Jane was sedated on midazolam and morphine sulphate infusion. She wass also paralysed with Vecuronium infusion to optimise ventilation, in the light of the previous difficulties. Jane was also on noradrenaline and actrapid insulin infusion, both of which aimed to maintain homeostasis. She was fed via nasogastric tube with Osmolite 60mls/hr with water 50 mls/hr, the latter because her sodium level had been rising when the serial U+Es were reviewed. I als o noted also her heart rate rising up to 148b/m, and was aware that she had had an episode of SVT on the previous day, with a loading dose of amiodarone having been given on that day. Having noted these findings, I reported to the Doctor that the patient may be dehydrated and need significantly increased fluids, perhaps an IV fluid challenge, as it had been noted that her CVP was declining, that she was hypotensive, and that urine output had started to tail off . This finding was supported by the fact that the patient was tachycardic. In response, the doctor prescribed 500mls of Gelofusin and an amiodarone infusion for 24 hours to be restarted. The care of this patient involved frequent, close observations, and these were what initially alerted me to the changes in the patient’s condition. The reduced central venous pressure was the first indicator, which was accompanied by consistently low blood pressure readings. This was despite the patient being medicated with noradrenaline, which should have brought about an increase in blood pressure and CVP. These, accompanied by the tachycardia, made me wonder whether the patient might be dehydrated, quite severely. The plan for the shift then became to give the patient a fluid challenge, in the form of the Gelofusin infusion, and to optimise her electrolyte levels, monitor and correct her pc02, and improve her positioning to improve V/Q mismatch. It was my responsiblity to report to the doctor or nurse co-ordinator if there were any untoward changes with the patients observations. There were a lot of issues surrounding the care of such a patient, and I believed that I was making decisions based upon previous experiences, a degree of previously developed innate knowledge, and other knowledge, including empirical knowledge. However, I also felt that it was hard to combine all the observations, results, care plans, orders and the like into an overall consciousness of the patient’s current condition. This leads into the next section of the reflection, that of personal knowing. PERSONAL KNOWING: The personal knowing relates to some innate knowledge, and this is based on experience. I have in past practice previously looked after patients who were haemodymically unstable and needed prompt intervention. In fact, I felt a degree of confidence with this kind of patient. However, this was different to having to look after a long term complicated case, a woman who had demonstrated such difficulty to ventilate (due to broncho- spasm/air trapping), was challenging. The fact that the patient was paralysed, with a vecuronium infusion was something entirely new to me, which caused concern and a little distress. However, from my previous experience I felt very strongly that thei patient might require fluid challenge due to the observations already discussed. I was concerned that day if it was left untreated for much longer, Jane patient might develop metabolic acidosis, and potentially acute renal failure due to hypoperfusion and hypovolaemic shock due to the decrease in circulating volume. I identified this as an opportunity to be proactive, and although everyone around me seemed more concerned with oxygen pressures and ventilation, I felt that it was important to consider other aspects of the patient’s condition as well. ETHICAL KNOWING Ethical knowing in this case was very acute, because of the level of dependence of the patient, who was dependent on nursing and medical staff for every one of her activities of daily living. Addressing one of these needs that I sensed other staff may have overlooked meant that I was able to be proactive. Discussing with the doctor that the patient might need a fluid challenge made me feel that I had acted as an advocate for my patient, but also that I had made good use of the knowledge I already had, even if I did not feel I had enough specialist knowledge to address some of the patient needs. The patient’s social and emotional needs were also an important part of ethical knowing. Jane lives alone, and her sister is her next of kin. Her sister kept calling the unit for any changes, although she was already updated by the medical team every day, and talking with the sister helped to ensure that I was aware of Jane as a person, and also able to make sure that those who needed t o know were involved as much as possible in her care. EMPIRICAL KNOWING. I was aware that institution of high level of PEEP in the ventilator decreases blood return to the heart and cardiac output as the PEEP ventilation generates positive intrathoracic pressure. However, the symptoms persistently suggested hypovolaemia (Kelly, 2005). I was also aware of other issues, such as the need to increase oxygen pressure, but the ABG tests carried out every six hours demonstrated good oxygen pressures. However, I had to learn about the implications of ventilation on the cardiovascular system. â€Å"Ventilation can profoundly alter cardiovascular function via complex, conflicting, and often opposite processes. These processes reflect the interaction between myocardial reserve, ventricular pump function, circulating blood volume, blood flow distribution, autonomic tone, endocrinologic responses, lung volume, intrathoracic pressure (ITP), and the surrounding pressures for the remainder of the circulation†. (Pinsky, 2005 p 592s). One of the most significant issues surrounding empirical knowing in this case was the need to understand all the potential complications of having a patient in such a condition, paralysed and receiving the high levels of PEEP in order to maintain ventilation. The literature shows that there are a number of issues surrounding mechanical ventilation. For example, Putenson et al 2006) state that mechanical ventilation generates an increase in airway pressure and, therefore, an increase in intrathoracic pressure, which may decrease systemic and intra-abdominal organ perfusion, which may have significant effects on homeostasis an organ function. Critically ill patients can therefore develop a systemic inflammatory response that culminates in multiple-organ dysfunction syndrome and death, which suggests that the symptoms that Jane was displaying, and the findings from the electrolyte levels, could have been related to a more serious bodily response to mechanical ventilation. I did not know about this possible response to mechanical ventilation, until I carried out a literature search, and so would not have been aware that the findings were possibly linked to this kind of serious response. Kollef (2004) suggests that for all patients who are intubated/ventilated, there are a number evidence-based interventions which focus on the prevention of aerodigestive tract colonization which can result in one of the serious complications of ventilation, that of ventilator-associated pneumonia. These include avoidance of unnecessary antibiotics, stress ulcer prophylaxis, chlorhexidine oral rinse, selective digestive decontamination, short-course parenteral prophylactic antibiotics in high-risk patients, and the prevention of aspiration of contaminated secretions, with preferred oral intubation, appropriate intensive care unit staffing, avoidance of tracheal intubation with the use of mask ventilation, application of weaning protocols and optimal use of sedation to shorten the duration of mechanical ventilation, semirecumbent positioning, minimization of gastric distension, subglottic suctioning, avoidance of ventilator circuit changes/manipulation, and routine drainage of ventilat or circuit condensate (Kollef, 2004). Obviously a key element of empirical knowing for me in this situation is about the haemodynamic monitoring, which has been so important in assessing this patient (Pinsky, 2003). The literature says that ongoing and dynamic haemodynamic monitoring is important in judging the response to the treatment, including the fluid challenge (Hadian and Pinsky, 2007). Michard (2005) states that â€Å"mechanical ventilation induces cyclic changes in vena cava blood flow, pulmonary artery blood flow, and aortic blood flow. At the bedside, respiratory changes in aortic blood flow are reflected by â€Å"swings† in blood pressure whose magnitude is highly dependent on volume status.† ( p 419). Another element however that is very important is the administration of the fluid challenge. Fluid challenges are common in a range of nursing situations (Vincent and Weil, 2006). According to Michard (2005), â€Å"the expected hemodynamic response to a fluid challenge is an increase in cardiac preload and, according to the Frank-Starling mechanism, an increase in stroke volume and cardiac output† (p 423). This should be evident in a blood pressure increase and a reduced heart rate. However, there is the danger of fluid overload, and therefore administering a fluid challenge must be carried out carefully. Vincent and Weil (2006) propose that fluid challenges should follow a protocol should include four variables: the type of fluid administered; the rate of fluid administration; the critical end points; and the safety limits. The choice of fluid was gelofusine, which is a colloidal fluid useful for volume replacement because of its unique properties (Vincent and Weil, 2006), Vincent and Weil (2006) state that using a structured approach to fluid challenges would be best, in order to correct fluid deficits and minimize the risks associated with fluid overload. It is important to monitor patient response closely (Vincent and Weil, 2006). When gelofusine was given her CVP increased and blood pressure and urine output improved. Her potassium, magnesium sulphate and Phosphate were topped up during my shift, and electrolyte levels were stable. Her heart rate went down to 110bpm since amiodarone infusion was restarted. She was on a few other medications, which potentially affect the potassium levels such as hydrocortisone, insulin actrapid infusion, salbutamol nebuliser and theophyline via NGT, which in addition can also cause arrrhythmias. REFLEXIBILITY. I learned a lot about basic nursing care activities, and in particular, the importance of time management. Time management is an important element of managing such a complex case, because it requires specific measurements, observations and recordings at specific times, whilst also managing emergent issues, maintaining records, and liaison with other members of the multidisciplinary team. Good patient assessment also emerged as a key learning point, and promoting a safe working environment, particularly in relation to all the aspects of care that posed challenges, such as managing drains, lines, infusion machines, monitoring morphine as a controlled substance, and also keeping contemporaneous records. These were all very challenging and made me feel under pressure to somehow keep juggling all the different tasks and demands, and still have time to reflect and think about the overall picture. Record keeping helped with this, but it seemed that critical care of such a patient requires t he development of specific capabilities, which must mean that such multi-tasking and multi-awareness gets easier over time. The level of vigilance required in order to anticipate and be ready for any emergent changes in Jane’s condition was significant, and required a great deal of concentration and focus. I also learned that it was important to work with confidence and collaborate with the multidisciplinary team. However, maintaining communication with the team was very difficult given all the demands on my time. One of the issues here was also whether or not Jane still needed mechanical ventilation, and during this shift, there was no discussion of when or whether she would be weaned off the ventilator. As she was paralysed, there was no indication of whether or not she would be trying to breathe with the ventilator, and how good her respiratory function might be. 12 days on the ventilator is a significant amount of time, and some literature suggests that earlier weaning from ventilator support may be possible in a lot of cases (Dasta et al, 2005). However, there was no indication of this, but similarly, there was no indication that this was a palliative care case (Mularski et al, 2006). If I had had more knowledge and understanding of this kind of nursing, and in particular, of the details and implications of Jane’s condition, I might have considered whether or not, as her advocate, I should be asking about the continued need for ventilation, particularly in the light of other possible approaches, such as non-invasive ventilation (Don et al, 2007). My discussions with other, more experienced members of staff, however, showed that the kinds of knowledge that most informed their care in this situation were experiential knowledge developed over a significant period of time. Therefore, it seemed to me that the empirical knowledge discusses above needed to be tempered with experience, which includes the experiences that come from working with more experienced and knowledgeable colleagues. Another issue which arose was about learning how much of my nursing practice is based upon good communication skills and developing a relationship with the patient, neither of which were useful or appropriate in this case. Although communication with ventilated patients is a focus of critical care nursing (Bergbom-Engberg, and Haljam, 1993), in this case I found it strange to work without including the patient in my care, whilst I also realised that the patient needed my advocacy more than any other, because they could not be involved or speak for themselves. However, the role of the critical care nurse in managing mechanical ventilation is something which became very apparent during this experience. The literature shows that critical care nurses have high levels of autonomy and responsibility in relation to mechanical ventilation, and that â€Å"critical care nurses were responsible for the majority of the decision episodes that resulted in a change to ventilator settings, ranging in complexity from the simple titration of FIO2 to a decision to commence weaning† (Rose et al, 2007 p 440). CONCLUSION This reflection has looked at the care of a client in the critical care nursing sector, who, after an infective exacerbation of COPD had to have a tracheostomy and be ventilated. I identified potential markers of dehydratrion, and presented these conclusions to the doctor in charge, who prescribed regulatory medication and a fluid challenge with Gelofusine. I administered the fluid challenge, infusing at the prescribed rate of 500 mls over 2 hours, and noted an improvement in central venous pressure, blood pressure and mean arterial pressure. An improvement in hourly urine output was also noted. It was also important to monitor electrolyte balance, and arterial blood gases, all of which improved with therapeutic intervention. The care of the client highlighted a number of issues for me as a nurse. The first is the value of this kind of reflection in highlighting my knowledge and my learning processes. Gustafson and Fagerberg (2004) highlight how important structured reflection is to professional development, and in this case, using a structured process of reflection has highlighted my knowledge base, learning needs, learning process, and the application of nursing knowledge which is more than empirical knowledge, to a specific clinical scenario. Jones (1995) suggests that reflection is a part of the development of true nursing expertise. This has proved to be correct in relation to the learning that has occurred during this reflection. It has shown that understanding the effects of mechanical ventilation required more than simply monitoring observations and test values, but understanding that ventilation can affect cardiovascular function, and that this can be affected by haemodynamic status. Although pre vious knowledge and experience indicated that the patient’s condition was likely due to hypovolaemia (potentially secondary to dehydration), there were a number of other mechanisms that might have affected this. It also became apparent that the role of the nurse in this situation is more than to simply monitor vital signs and infusions, ventilator functions, urine output and general wellbeing, attending to the activities of daily living. When a patient is paralysed and ventilated, unconscious due to sedation, the role of the nurse is to act in their stead, in their best interests, to be their advocate and to ensure plans of care are implemented which not only meet patient needs but anticipate them. Rolfe (2005) describes reflective practice as a deconstructive process, which allows nurses to question practice and ways of working. This process has identified a range of nursing issues related to this case, and shown that nothing is a simple matter of managing one condition in critical care nursing, it is part of an overall focus on patient-centred care. References Bergbom-Engberg, I. and Haljam, H. (1993) The communication process with ventilator patients in the ICU as perceived by the nursing staff. Intensive and Critical Care Nursing 9 (1) 40-59. Bridges, E.J. (2008) Arterial Pressure-Based Stroke Volume and Functional Hemodynamic Monitoring. Journal of Cardiovascular Nursing. 23(2):105-112. This article is not included in your organizations subscription. However, you may be able to access this article under your organizations agreement with Elsevier. Dasta, J.F., McLaughlin, T.P., Mody, S.H. and Piech, C.T. (2005) Daily cost of an intensive care unit day: The contribution of mechanical ventilation. Critical Care Medicine. 33(6):1266-1271. Don, D.S., Wong, E., Mayers, I. et al (2007) Effects of nocturnal non-invasive mechanical ventilation on heart rate variability of patients with advanced COPD. Chest 131 156-163. Gustafsson, C. and Fagerberg, I. (2004) Reflection: the way to professional development? Journal of Clinical Nursing 13 271-280. Hadian, M. and Pinksy, M.R. (2007) Functional hemodynamic monitoring. Current Opinion in Critical Care. 13(3):318-323. Jones, P.R. (1995) Hindsight bias in reflective practice: an empirical investigation. Journal of Advanced Nursing 21 (4) 783–788. Kelley, D. (205) Hypovolemic Shock: An Overview. Critical Care Nursing Quarterly. 28(1):2-19. Kollef, M.H. (2004) Prevention of hospital-associated pneumonia and ventilator-associated pneumonia. Critical Care Medicine. 32(6):1396-1405. Michard, F. (2005) Changes in arterial pressure during mechanical ventilation. Anesthesiology 103 419-428. Mularski, R.A., Curtis, J.R., Billings, J.A. et al (2006) Proposed quality measures for palliative care in the critically ill: A consensus from the Robert Wood Johnson Foundation Critical Care Workgroup. Critical Care Medicine. Improving the Quality of End-of-Life Care in the ICU. 34(11) Suppl:S404-S411. Pinsky, M.R. (2005) Cardiovascular Issues in Respiratory Care. Chest 2005;128 592-597. Pinsky, M.R. (2003) Hemodynamic monitoring in the intensive care unit Clinics in Chest Medicine 24 (4) Pages 549-560 Polanco, P.M. and Pinsky, M.R. (2006) Practical Issues of Hemodynamic Monitoring at the Bedside Surgical Clinics of North America 86 (6) 1431-1456 This article is not included in your organizations subscription. However, you may be able to access this article under your organizations agreement with Elsevier. Putensen, C., Wrigge, H. and Herin, R. (2006) The effects of mechanical ventilation on the gut and abdomen. Current Opinion in Critical Care. 12(2):160-165. Rolfe, G. (2005) The deconstructing angel: nursing, reflection and evidence-based practice Nursing Inquiry 12 (2), 78–86. Rose, L, Nelson, S., Johnston, L. and Presneill, J.J. (2007) Decisions made by critical care nurses during mechanical ventilation andweaning in an australian intensive care unit. American Journal Of Critical Care, 16 (5) 43-54. Vincent, J-L. and Weil, M.H. (2006) Fluid challenge revisited. Critical Care Medicine. 34(5):1333-1337.

Shakespeares Othello - There Would be No Othello Without Iago Essay

There would be No Othello without Iago Though the name of the play written by William Shakespeare is called "Othello," the character Othello is not the main character, but rather Iago is. Iago is the character who drives the play, he is the one who makes things happen. Without his greed and hated, there would be no play at all. The whole play is centered around Iago's revenge and in doing so, he is willing to make other people's lives miserable. Through "Othello," Iago uses the other characters to avenge the wrong doings which Othello has inflicted upon him, and will go to any means to do so. The play starts out with Iago not attaining the position he wanted from Othello, but rather the position was given to Cassio, who in Iago's mind is unqualified for the job. This is where Iago starts to spin his web of destruction. Iago hates Othello with a passion, and in his heart he truly believes that Othello has slept with his wife Emilia. "I hate the Moor, and it is abroad that 'twixt my sheets 'has done my office" Othello. Act I. iii. 429-431. Being placed aside for the lieutenant position made him even more mad. He then decided on a plan and took full action upon it "to abuse Othello's ear that he (Cassio) is too familiar with his (Othello's) wife" Othello. Act I. iii. 438-439. Roderigo was Iago's puppet. He believed everything that Iago told him and always did as he said, which in the end got him killed. Through the play one wonders often why Roderigo keeps following Iago's demands, and it was because he truly loved Desdemona. He was willing to kill himself if he couldn't have her "i... ...sp; Every person that came in contact with Iago ended up dead or wounded in some way. Iago manipulated everyone he knew for his own means. In the end he got everything he wanted. He got revenge on Othello and ended up killing three people and seriously wounding one person in the process. One of the people who died was his own wife, but he could have cared less about that as long as he succeeded. If Iago was not around and did not carry with him the animosity, hatred, greed, and selfishness, none of those inimical things would have happened, but then, there wouldn't be a play either. Bad characters are needed in plays and in life. If we always got what we wanted and bad things never happened, then life would be very boring. Iago tormented and played around with Othello's mind, and he enjoyed this immensely, it was his goal and he achieved it.

Alcohol Fetish Essay -- Alcohol

As humans, we all yearn to be free, yet we are trapped by expectations, responsibilities and standards placed upon us by the modern world. Alcohol creates freedom and vulnerability for individuals oppressed by the dynamics and speed of everyday life especially in very developed ‘high class’ nations. Alcohol particularly creates this freedom for individuals in disenfranchised populations, where expectations from a foreign â€Å"sophisticated† ideology overwhelm the people of the once free nations. And because alcohol creates a free and youthful state of mind, it becomes fetishized. In order for one to defetishize alcohol, and drinking to escape from reality, one must look at their reality and question what reality they are escaping in the first place. In the paper, I first examine the history of alcohol in different cultures and societies. I then talk about how the type of culture a person lives in, whether it is sophisticated or more ‘third world’, re flects one’s relationship with alcohol. Sex and vulnerability also plays an important role in the fetishizing of alcohol in most communities; I observe this next and how it relates to individual’s overall creation of freedom. Lastly, I look at how individuals are better able to have fun, at all ages, when drinking. All in all proving that drinking alcohol creates a state of freedom for people who lack freedom because of their realities. The history of alcohol, unlike many other commodities on the market dates back very far into history. Each and every part of the world seems to have their own personal relationships with the popular beverage. Brewing of alcohol dates back to the beginning of written civilization, and possibly before. Ancient Babylonians, as well as the Ancient Egyptians ... ... Brave Heart, M., Chase, J., Elkins, J., & Altschul, D. B. (2011). Historical Trauma Among Indigenous Peoples of the Americas: Concepts, Research, and Clinical Considerations. Journal Of Psychoactive Drugs, 43(4), 282-290. doi:10.1080/02791072.2011.628913 Hanson, David J. Preventing Alcohol Abuse: Alcohol, Culture and Control. Wesport, CT: Praeger, 1995 Mohindra, K. S., Narayana, D. D., Anushreedha, S. S., & Haddad, S. (2011). Alcohol use and its consequences in South India: Views from a marginalized tribal population. Drug & Alcohol Dependence, 117(1), 70-73. doi:10.1016/j.drugalcdep.2010.12.021 Yuan, N. P., Eaves, E. R., Koss, M. P., Polacca, M., Bletzer, K., & Goldman, D. (2010). â€Å"Alcohol is Something That Been With Us Like a Common Cold†: Community Perceptions of American Indian Drinking. Substance Use & Misuse, 45(12), 1909-1929. doi:10.3109/10826081003682115

The Pancreas :: essays research papers fc

The pancreas is located in the middle of the abdomen. It’s surrounded by the stomach, small intestine, liver and spleen. It’s about six inches long and shaped like a thin pear, wide at one end. It has three sections: wider right end is the head, the middle is the body and the left end is the tail.   Ã‚  Ã‚  Ã‚  Ã‚  The pancreas has two functions; to make enzymes that help digest fats and proteins and the other, to produce insulin that controls the blood sugar level called glucose. It consists of Islet cells (1 of 3 types), which are endocrine glands. This means the Islet cells secret the insulin directly into the blood stream. The pancreas contains many more of these Islet cells than the body needs to maintain a normal insulin level. Even when half of the pancreas is removed, the blood sugar level can still remain normal. The pancreas is also made up of exocrine glands, which produce enzymes for digestion.   Ã‚  Ã‚  Ã‚  Ã‚  When the blood sugar levels aren’t normal, it’s a disease called diabetes. Diabetes (diabetes mellitus) is a deficiency of the hormone insulin or the inhibition of its action with the cells. The insulin acts like a bridge between the glucose and the cells. In the US there are about 16 million people who suffer from diabetes. It is the seventh most common cause of all deaths. Diabetes is most common in Native American females over 45 years of age.   Ã‚  Ã‚  Ã‚  Ã‚  There are two main types of diabetes. The firsts is insulin-dependent diabetes mellitus (IDDM). In IDDM the body either doesn’t produce diabetes or produces very small amounts. The symptoms usually occur in teenagers under 20, usually around puberty. Untreated IDDM affects the metabolism of fat. Since the body can’t convert glucose into energy, it is broken down into fat and stored for energy. This also increases the amounts of ketone bodies in the blood, which interfere with respiration. The second type is called is non-insulin-dependent diabetes mellitus (NIDDM). This is when the body doesn’t make enough insulin or is unable to use it. NIDDM is the most common of all diabetes; it makes up 90 to 95 percent of all cases. Scientists believe that in some people weight gain or obesity is what triggers their diabetes because 80 percent of people with diabetes are over weight.   Ã‚  Ã‚  Ã‚  Ã‚  Another problem people have with the pancreas is pancreatic cancer. Each year about 29,000 Americans and 3,000 Canadians are diagnosed with it.

How Did the Europeans Affect the Native Americans? Essay

Anne Bradstreet Jonathan Edwards and Anne Bradstreet were both famous Puritan writers of their time. Each of their works, â€Å"Sinners in the Hands of an Angry God† and † Upon the Burning of Our House† convey to their audiences the strong religious beliefs prevalent during that time period. Edwards writes to persuade his audience. On the other hand, Bradstreet writes to inform her audience. Edwards mainly talks about hell and damnation in his writings, however Bradstreet talks about heaven and hope. Although both Edwards and Bradstreet have similar outlooks and understandings of religious beliefs and attitudes and beliefs about human life, there are also distinctions that allow the reader to better understand each author’s purpose. Bradstreet believes that one should look to God and pray during times of hardship. On the other hand Edwards believes that one should always look God, but not in times of hardship, he thinks people must let God come to them. Bradstreet expresses her needing of help from God after her house burns down when she said, â€Å"Raise up thy thoughts above the sky†(Bradstreet41). Referring to this quote Bradstreet looks up to God for help while she is in the middle of a crisis or hardship. Edwards suggests that people should let God come to them when he said, â€Å"And now you have an extraordinary opportunity, a day where in Christ has thrown the door of mercy wide Motahari 2 open, and stands in the door calling and crying with a loud voice to poor sinners†(Edwards129). According to this quote Edwards is saying that God has finally come to the sinners in their time of need. Not only are Bradstreet’s and Edwards’s religious beliefs different, but they also have different attitudes and beliefs. Bradstreet is a positive woman who believes that everyone is going to heaven, on the other hand Edwards is a negative man who believes that everyone is going to hell. Bradstreet expresses her positivity and belief for heaven after her house burns down while saying, â€Å"The world no longer let me love, my hope and treasure lies above†(Bradstreet119). This reveals that that she will always believe something good will happen. Even though her house and all of her things burned to ash, she still is happy that she has another home that lies above [heaven]. Edwards show his negativity towards people when he said, â€Å"In short, they have no refuge, nothing to take hold of†(Edwards126). Referring to this quote Edwards is trying to say that people do not have any escape from hell and damnation, also that there is nothing worth living for. Bradstreet and Edwards do not have the same views in the categories of religious beliefs and attitudes and beliefs of human life. Through her writings, Bradstreet explains that God is a kind loving person who is always there for us. However Edwards portrays God as a mean and angry person through his writings. I think that Bradstreet has a better view of God.

Internet Traps and False Information Essay

Internet very popular important with everybody. Nowadays, everybody also use internet. It connect people on the world. Traditional class and internet class very diffenrent Internet is the traditional system, it will help our have more knowledge, good information, good news†¦ In the past, people used internet is the search system. It have a lot of good thing in the internet. It help we have friends , forum , search everything we want. We can know more knowledge But everything will be have negative and positive. We just know a good thing in the internet , we do not need to know a lot of bad thing on the internet . Social also have two face and internet too . It has troubles , traps †¦ we need to be thought wise, we certainly know right from wrong. Therefore , we should fully exploit the advantages of the internet, that advantage should not do bad things or negative. Internet always contains interesting things. Internet is one of the greatest inventions of human history. When old does not have internet, humans can be difficult to share the necessary information useful life, thanks to the internet, today we know a lot of things good. We need to know to take advantage of the internet to be useful, or exploitation of useful things in this life. It will help you feel better love life, more interesting things. But sometimes we take advantage of it in a bad job, bad purposes will cause the opposite effect. It makes us inadvertently lead us to wrong path that they want and go against positive thinking. If we take advantage of the bad things on the internet, it will lose the good thing is its capital. Because the internet sometimes contain false information about the problem, negative nature, does not serve the purpose well. Traditional classroom is the class just come to class and do homework, construct and develop courses. Traditional classes can help students become more active in this life. Students can hardly develop the capabilities as well as their knowledge. Traditional classroom is very limited and restrictive. It is difficult to create a sense of comfort and good environment for students to learn. It gives the students a feeling extremely uncomfortable, passive. The school on the internet is extremely beneficial, it helps us to easily absorb everything without hard working. Classroo m based courses offer more focus than online courses. In a classroom, students are forced to be quiet and listen to the teacher or their peers. They can even switch to a different tab with their favorite social network instead of what they’re supposed to be learning. the Internet  classroom is convenient for professors, too! They can give us a quiz without any paper, which can reduce the consumption of trees. At the same time, it may be easier for some teachers to make corrections or comments on student’s work on the computer. In this way, the professors can concentrate more on teaching. They don’t need to care about students’ behavior like eating, talking on the cell phone, or going to the toilet. Traditonal class makes sense to attend classes in person if you decide to live in the dorms or are an incoming freshmen who wants the real college experience. There are certainly more opportunities to join clubs, associations, or fraternities/sororities while taking classes on campus.