316 CASE 6 EXPATRIATE COMPENSATION AT ROBERT BOS GMBH: COPING WITH MODERN MOBILITY CHAL
316 CASE 6 EXPATRIATE COMPENSATION AT ROBERT BOS GMBH: COPING WITH MODERN MOBILITY CHAL By Ihar Sahakiants, Marion Festing, Manfred Froehlecke the report, which described the highlights of 2010 with respect to new markets, particularly noting: January 18. New presence in Southeast Asia: Bosch Communication Center opens branch in the Philippine capital Manila May 13. Bosch steps up its activities in Southeast Asia: new headquarters opened in Singapore July 5. Indian software subsidiary expands its operations: Robert Bosch Engineering and Busi- ness Solutions opens location in Vietnam ""I would rather lose money than trust."" Robert Bosch It was raining in Stuttgart. The new task which Klaus Meier, an employee of Robert Bosch GmbH's Ger- man headquarters' central International Assignments department, received last week from his direct super- visor Michael Stein was simultaneously interest- ing and extremely challenging: a new international assignment policy had to be designed for the whole Bosch Group. The importance of a new international assignment policy is hard to overestimate. First it may be useful to take a look at some statistics for 2010 from the latest annual report of the Bosch Group. The report, citing 2010 as 'a year of historic recovery' after recession on a historic scale', highlighted that Bosch Group sales had skyrocketed by about 24 per cent to 47.3 billion euros. About 41 per cent of the company's total sales were made outside Europe (see Figure 1). Out of 283,597 worldwide employees, 169,950 - or about 60 per cent of the total headcount - were located outside Germany, the home country of the corporation. Moreover, 34.18 per cent of these per- sonnel were located outside Europe (see Figure 2). Statistics on the importance of international oper ations for Robert Bosch were indeed impressive. but the figures on international mobility within the Beach Group were even more so. In 2010, there were approximately 2200 managers on international projects requiring relocation to a foreign country and lastiver two years, while the number of inpathates from Asia, the Americas, and Europe on assignments or the same two-year period reached 400 employees Fach new location and new market meant addi tinnal flow of evoatriate and inpatriate employees within the Bosch group, Klaus opened pages 12-13 of September 13. Market entry in China. Bosch delivers 40.000 start-stop systems to the auto- maker Changan October 11. Bosch builds new plant in India: Packaging Technology invests four million euros in a facility near Goa; SB LiMotive opens a new production plant in Ulsan, Korea, lithium-ion battery cells for hybrid and electric vehicles will be manufactured November 16. New proving ground in Japan: in the north of Hokkaido, an extended proving ground has been inaugurated - twice as big as the predecessor (Robert Bosch GmbH, 2011: pp. 12-13). Although a whole range of issues related to international mobility needed to be addressed in the new international assignment policy. Klaus wanted to start with the finan. cial aspects of the operation. As an international mobility professional himself, he knew only too well about the high costs of expatriation. These costs included not only expensive expatriate compensation packages but also huge administration expenses and the costs of expatriate lanure, e.g. the premature termination of an soignment. These total costs had the potential to make long-term assignments prohibitively e
CASE 6 EXPATRIATE COMPENSATION AT ROBERT BOSCH GBH 319 FIGURE 1 Bosch Group sales by region, 2010 FIGURE 2 Headcount at Bosch Group by region, as per 1 January 2011 Americas 2396 Europe 5996 Germany 113,557 Rest of Europe 73,045 Asia Pacific 18% ""Including other countries To gain an overview of the situation at Bosch, Klaus Americas planned to study the details of several actual assign- 33,689 ments in various locations. First of all, he examined the Asia Pacific/ personnel file of Hendryk van den Bosch, an old friend 63,216 or his. He took the first and the last balance sheet cal including other countries culations prepared for Hendryk's international assign Source: Robert Bosch GmbH (201120 ments: an inpatriate assignment to Germany in 1999 and an expatriate assignment to Korea in 2009. issue in many other countries, where the exchange Hendryk van den Bosch started his career at Robert rate of local currencies fluctuated significantly in rela- Bosch BV, Noofddorp (Netherlands) as a SAP projecttion to the Deutsche mark or euro. coordinator in 1994. In only two years he became The host-country component of Hendryk's not manager of the data processing department for the salary (65 per cent of the salary paid in host-country regional subsidiary in Holland. From 1997, he was currency) was adjusted for cost-of-living expenses, responsible for the whole Benelux region (Belgium, the on top of which a foreign assignment bonus was pro- Netherlands, and Luxembourg). In 1999, he accepted vided. There were no further costs related to the for the position of system planning department manager eign assignment in the host country. It was Hendryk's at the company's cou n tgart, Germany. decision to remain in the Dutch social security system The balance shell new position in accordance with Regulation (EEC) No. 1408/71. in Germany was a t or expatriate while housing expenses in Germany were covered by assignments within the so u roup (see Figure 3 the employer. As the rent costs in the home country overleaf). At that time, there was no single currency in had been previously borne by Hendryk from his net Europe. Thus, according to the company rule, expatri income, and would not be incurred during his assign- ate compensation had to be paid in the host countryment in Germany, a housing expenses 'Rent in Home although was calculated both in Holland florins (HFL) Country equivalent fi.e. an equivalent apartment rent and Deutsche marks (DEM) - the national currencies in the home country to the amount of 18,600 HFL) before the Euro. In doing so, 35 per cent of the net was deducted from the benefits component. Hend- income was guaranteed in the home-country currency ryk's rent in the host country was therefore zero because, in line with the assignments guideline, this in order to minimize any currency exchange risks for amount was paid directly by Bosch the expatriate employee. The host-country currency On 1 September 2003, Hendryk van den Bosch portion of pay was adjusted at the end of each year returned to Stuttgart, Germany as the Head of the to eliminate possible negative effects arising from Organization and Information Systems unit from his exchange rate fluctuations. Klaus knew about the most recent assignment in Brazil, in 2009, he was importance of currency adiustment for expatriates. expatriated again, this time to Korea as Regional Sales Although the exchange rate between HFL and DEM Director. had been relatively stable over the years, it was a big
CASE 8 EXPATRATE COMPENSATION AN SCH GMBH 321 The pay calculation for his assignment to Korea short-tem was more complex (see Figure 4 overleaft. At that year, frequent point, Hendryk had two children, which meant additional assignme tional expenses in the host country as well as the loss Many of these of child allowance in Germany (then 1848 euros per popular que child, per year). However, the latter was compensated nication to by Robert Bosch GmbH in accordance with internal explicit goals of th company policy, while housing expenses in the host country were again borne by the company A couple of years prior to that, several changes were to introduced in the assignment policy, triggered initially as by increasingly refined market data comparisons, Forpos Korea short-term International assignments lasting up to one At that year, frequent flyer assignments, commuter and rota additional assignments, global virtual teams, and so on well as the loss Many of these forms were becoming more and more uros per popular due to the rapid development of telecommu compensatednication technologies and transport, and they were ince with internal being used increasingly at Bosch. Moreover, one of the ng expenses in the host explicit goals of the Bosch Group was to increase the percentage of local senior executives in its foreign loca- hat, several changes were tions to at least 80 per cent. However, although it was ent policy, triggered initially a strong cost-reducing factor, this measure could not instance, a change of the cost-of-living data provider ket data comparisons, For possibly hinder the rapid increase of standard expatri- le cost-of-living data provider ate assignments given the importance of international ate assignments to make a differentiated use of indices markets. Thus, Klaus had to consider first and fore- ally sophisticated and detailed calculations, most a number of cost reduction opportunities related Although this also contributed to a reduction in assign to standard expatriate assignments: ment costs for the Bosch Group, the primary goal of Based on an analysis of multiple sources stemming Most changes in the compensation policy was to offer from the academic literature, as well as management assignment conditions in line with local market conditions, consulting and practitioner publications, Klaus made According to the new policy, the foreign assignment a list of feasible potential cost-reducing solutions. allowate was determined and frozen at the beginning in order to form an idea of the prevalence of these of signment. As such, cost-of-living calculations measures among leading international companies, he We s ed on two indices: a more generous Standard checked the latest Global Assignment Policies and He Base Index and a so- Cost Effective Home Practices' survey by KPMG."" He started his analysis BERS (CEHB) Index. The Home Base Index with the top five positions on the list: was used in the first and years of the assign Relocation allowance. A way to reduce costs ment, whereas, only start the third yer wat related to the relocation allowance is to provide ate compensation was called based on a lump-sum payments at the beginning and at Index. The decision to use the latter index was the end of an assignment. According to the the the assumption that cost of living decreases KPMG survey about 54 per cent of all compa- nies, including 47 per cent of European partic- course of an assignment. This logic was based on the ipants, implement this policy. Only 13 per cent notion that, over time, an expatriate employee would be of respondents worldwide do not provide any expected to use less expensive shopping opportunities relocation allowance at all. and to refrain from expensive imports by increasingly Efficient calculations of the cost-of-living using cheaper local products. However, calculations allowance. There is a clear trend among multi- for the first year were also based on the CEHB Index nationals to increasingly implement an efficient in order to indicate to the expatriate his future income purchaser index' in their cost-of-living calcula- and to make clear that using the Standard Home Base tions. According to the KPMG survey, 32 per Index represented more generous support at the start cent of all responding companies use this index, of an international assignment. Therefore, the differ- a 10 per cent increase since 2003 ce between CEHB-based and Standard Home Base Cap on allowances. Capping expatriate allow- adex-based income was compensated as a cost-of- ances makes it possible to reduce significantly the iving supplement. Furthermore, lump-sum payments overall costs of foreign assignments. All allowances, were used in order to facilitate cost control. including the cost-of-living, hardship, or other com- Klaus knew all too well how a group discussion on pany-specifio allowances, can be frozen for expatri- ways to reduce expatriation costs might proceed. One ates with an expatriate income exceeding a certain of the proposed solutions was to use increasingly aiter- level. The KMPG survey shows that the majority of native forms of international assignments, including companies stil do not cap the major allowances.
- BUSCH GBH 323 Housing allowance and/or costs. There are several ways to reduce housing costs. is to select residence areas comparab e housing costs. One way areas comparable to those used by local employees in comparable posi- tions, thus avoiding expensive residence areas being used mainly by expatriate employees Another way is to follow the recommendations of housing data providers and to offer additional Incentives for finding housing less expensive than the standard cost recommendations. However, as reported by KPMG, the overwhelming majority of companies (82 per cent) still do not provide this type of incentive. Travel expenses. There is a trend to provide 'economy-class travels to expatriate employees. About 56 per cent of companies surveyed by KMPG implement such a policy, 3 per cent more The rain had passed through the city and shafts of sunlight appeared through the grey clouds, Klaus recalled the themes of 'courage, curiosity, and change at the recent corporate meeting he had attended in Berlin. The Berlin conference was one of some 850 activities staged worldwide in 2011 to mark the 125th anniversary of the Bosch company and the 150th anniversary of Robert Bosch's birth. He returned to his desk and began working to apply these themes Questions: than in 2010. Many of the above cost reduction measures were already being implemented at Bosch. Apart from the allowances, yearly economy-class Flights to the home country had become the standard option for com- pany travel. However, longer flights for business rea- sons could still be carried out using business class. The challenge, however, was to further improve exist- ing policies by comparing several cost options, data providers, and outsourcing alternatives. This would be just the first step towards cosigning an all-encompass ing assignment policy, aster steps would analyze tax-efficient ways of providi x patriate perquisites, as well as organize taxation an social security cover- age during international assignments in co-operation with a team of international legal advisors. Nevertheless, enthusiastic and confident of success as he was, Klaus knew that designing a new interna- tional assignment policy was going to be a long and drawn-out process involving multiple calculations as well as negotiations with colleagues and external mobility services providers. This was especially the case because the cost issue was only one aspect of the wider issue of the co-ordinated and strategi- cally effective use of international assignments. There were many more related concerns - such as motivat- ing potential expatriates, the impact of international assignments on professional careers, repatriation management, dual-career issues, and family income. The more Klaus thought about it, the more he saw the linkages and implications operating across multiple HR practices and multiple product and geographic units. 1 Why did Bosch state the cost-of-living allowance amount as a CEHB-based sum and a separate cost-of-living supplement in the first and the sec- ond years of the assignment in the balance sheet for Korea? 2 Which expatriate compensation elements at Bosch Group were already based on cost-reduction con siderations listed in the case study? Please suggest ways in which these could be improved further 3 What further cost-reduction measures could be implemented? 4 Do you believe it is possible to design a Bosch Group international assignment policy covering both expatriate and inpatriate employees at all international locations? 5 One of the measures used to reduce the costs of expatriation was to outsource elements of the administration function to external service provid- ers. Please discuss the advantages and disadvan- tages of such a policy. 6 Do you believe that alternative assignments can substitute for traditional expatriate assignments in the long run? Please discuss the major opportuni- ties and barriers. 7 What are the mat barriers to the localization of expatriate managers? 8 Many international companies do not provide any additional foreign assignment allowances (e.g. relocation or hardship allowance). Do you think it would have been feasible to implement this system at Bosch? What would be the related advantages and disadvantages?"
1. Why did Bosch state the cost-of-living allowance amount as a CEHB-based sum and a separate cost-of-living supplement in the first and second years of the assignment in the balance sheet for Korea can be explained as follows.
Answer:
Bosch applied CEHB (Cost Effective Home Base) Index and another COLA for the first two years of the assignment because the former allows higher initial costs to be offset and more reasonable subsequent annual changes. To balance the first loss where people may have high moving costs and other cost of establishment, CEHB Index offered more forgiving baseline. The different cost-of-living supplement was intended to compensate variable over-time cost of living differences. Such two-level hierarchy proved useful for Bosch in providing sufficient support at the stage of beginning the assignment, and at the same time, controlling expenditures as the assignment was ongoing.
2. Which of the cost reduction considerations arteady included in the case study being taken by Bosch group while designing the expatriate compensation elements? It therefore would be important to suggest how these could be made even better.
Answer:
Cost-reduction elements already implemented:
Lump-sum Payments: Bosch made cash payments for reimbursement of costs incurred during the relocation and for any assignment expenses to make the process less bureaucratic and to assess increased costs.
Standard Home Base Index: Applied at a first level of higher support and recalculated as the support progresses.
Capped Allowances: This was through freezing of allowances for housing as well as other facilities in order to cut costs.
Suggestions for further improvement:
Enhanced Data Analytics: Minimize expenses by worrying about the cost of living and provide the right allowance by using state-of-the-art analytics.
Local Market Adjustments: Time-based update of compensation policies can be done much more precisely according to the real-time data in the current market.
Incentives for Cost-Saving: Offer incentives for expatriates to look for accommodation that does not meet the standard recommendations so as to save cash.
3. Additional possible cost-saving initiatives:
Answer:
Outsourcing Administration: Outsource more in an effort to cut on overhead expenses that may be incurred in undertaking administrative operations.
Economy-Class Travel: Company policy should only allow certain planned economy air travel for expatriates with the rest being for only business essential travel.
Home Country Benefits Optimization: Negotiate how much you can offer in terms of benefits from home country to avoid hiking costs but still be able to support them.
Flexible Assignment Types: Increase usage of short term or rotor assignments in a bid to shorten duration and costs that come with them.
4. Can an effective Bosch Group international assignment policy for both expatriate and inpatriate Bosch employees in all those international Bosch affiliated locations be developed?
Answer:
Yes, it is but not easy… A comprehensive policy would need to address:A comprehensive policy would need to address:
Diverse Needs: Whereas such employees require different compensations depending on the location, the job they are assigned to do, and the length of their assignment.
Legal and Tax Compliance: Prerequisite to make sure that policies you put in place are in conformance with different local laws.
Flexibility: Have additional elements that can be used depending on the situations at work and the positions that people have.
Coordination: Good organization of various areas and subfields to formulate and execute the same tactic.
5. Among these was the outsourcing of some particular aspects of the administration function to outside service providers as a way of minimizing the costs of expatriation. Kindly expound the lone of such a policy as well as the strengths and weaknesses of the policy.
Answer:
Advantages:
Cost Efficiency: When compared to internal handling the level of bureaucracy is lowered and may end up being more cheaper.
Expertise: Uses the services of numerous specialized providers who are familiar with the current legislation and standards.
Focus: Enables internal HR department to concentrate more on strategic aspects and not on more operational issues.
Disadvantages:
Control Issues: Uncertainty of the level and time of delivery of services.
Communication Barriers: Can cause poor interaction between outside vendors and firm’s employees.
Confidentiality Risks: Outsourcing of services might lead to some forms of risks especially with regard to the confidentiality of the data of the employees.
6. Can you postulate that there are other routines that can replace the conventional expatriate assignments in the long haul? Kindly highlight the detailed opportunities and threats that are major.
Answer:
Opportunities:
Cost Savings: If long-term expatriation has certain drawbacks, there are other assignments that may be applied – reduced costs connected with virtual teams and short-term assignments.
Flexibility: It has a certain level of versatility since the business can handle tributary concerns without a permanent move.
Technology Utilization: Technology has enabled people to work together with so much ease due to the improvement in technology in the realm of communication.
Barriers:
Cultural Integration: Other assignments can be less effective than extended assignments since they cannot be cultural as much as long-term mission positions can.
Effectiveness: Virtual teams are likely to face problems of time zone including communication breakdowns.
Employee Development: Few tangible chances for prime practical exposure and nurturing of human assets of enterprise.
7. More specifically, what are the significant obstacles to the process of localisation of expatriate managers?
Answer:
Resistance to Change: Sometimes expatriates have rigid mindsets that make them do not want to move or accept local positions.
Skill Shortages: Some of the organizational Human Resource Management challenges that might cause the firm’slabour productivity to decline are: Absence of a competent pool of local talent to fill higher level jobs.
Cultural Differences: Experiences that expatriates have learnt may be detached from the local corporate culture and how to manage local employees.
Career Development: Fear from HR about expatriates’ career mobility if some localized positions are not possible.
8. Most MNEs have restricted additional foreign assignment allowances (such as relocation or hardship allowance). Lastly you may ask yourself if it would have been possible to work this system at Bosch? What might the a�iliate benefits and losses be?
Answer:
Feasibility:
Well, yes, it can be done, but there is a need for proper degree of planning and change in some or most of the existing policies.
Advantages:
Cost Reduction: To remove extra allowances and may also contribute a lot to reducing expenditures.
Simplified Administration: Simplifies the process of dealing with the benefits of the expatriates.
Disadvantages:
Employee Attraction: May reduce the ability of the organisation to attract the best candidates for international postings.
Employee Satisfaction: Might be unhelpful for expatriates’ job satisfaction and organizational commitment if they do not feel organizational support.
Competitiveness: It is also expected that Bosch might be less competitive vis-à-vis companies providing competitive allowances.
To sum up, creating the international assignment policy means having a right scale of costs while maintaining enough expatriate and inpatriate support. This involves signing firm cost, compensation market, cost cutting and a number of alternative models for assignment.
INTRODUCTION The commercialisation of the Internet and the subsequent evolution of electronic commerce
INTRODUCTION The commercialisation of the Internet and the subsequent evolution of electronic commerce have resulted in a dynamic business environment where transactions are able to take place without face- to-face interaction. As the popularity of electronic commerce continues to increase, numerous payment systems have been created, attempting to make the process of exchanging money over the Internet easier for consumers. Electronic payment systems (EPS) can be defined here as any payment system that facilitates secure electronic commerce transactions between organisations or individuals. These include systems such as electronic cash, electronic cheques, smart cards and micropayment solutions such as PayPal. EPS provide users with an array of functionalities including person-to-person (P2P) payments and electronic bill presentment and payment (EBPP). These new EPS are also able to facilitate financial transactions over the Internet which are significantly more efficient, faster and less Copyright 2007, Australian Computer Society Inc. General permission to republish, but not for profit, all or part of this material is granted, provided that the JRPIT copyright notice is given and that reference is made to the publication, to its date of issue, and to the fact that reprinting privileges were granted by permission of the Australian Computer Society Inc. Manuscript received: 10 January 2007 Communicating Editor: Joan Cooper Journal of Research and Practice in Information Technology, Vol. 39, No. 4. November 2007 231
Exploring the Reasons for a Failure of Electronic Payment Systems expensive than using credit cards (Abrazhevich, 2001). Yu et al (2002) argues that EPS which help avoid the use of credit cards are important to the development of electronic commerce. A significant number of EPS have failed within a relatively short period of time. These include companies such as Beenz. CyberCash, Cybercent. Digicash, Charge. First Virtual Flooz and Micromint (Hurwicz, 2001: Kniberg, 2002). In fact, the use of credit cards still remains the most widely used payment method for electronic commerce transactions despite the criticism from the literature for its lack of efficiency and security as well as high transaction fees (Simpson 2004; Shon and Swatman, 1998). The majority of research into the area of EPS has focused on successful cases such as Hong Kong's Octopus smart card system and PayPal (Liao and Wong, 2004: Schwartz, 2001). However, there have been relatively fewer studies into failed EPS (Kniberg, 2002: Truman et al, 2003). This is most likely due to the difficulty in gaining access to failure cases. In this study, we explore factors that lead to the failure of EPS. For this purpose, a single in-depth case study of a failed Australian EPS was conducted in 2005 This study is also differentiated from existing studies of EPS by its approach. Recent studies in this area can be grouped into two general streams. One stream examines adoption of an EPS from the users' perspective or user acceptance (Abrazhevich. 2001; Chu and Poon. 2003: Liao and Wong. 2004: Yu et al. 2002). The other stream of studies proposes new payment schemes from the technological perspective. They develop new payment protocols in order to address some limitations with current solutions (Camenisch et al. 1996; Dai and Grundy, 2006: Herzberg. 2003: Juang, 2006Peha and Khamitov, 2004). This study takes a system provider's perspective, through the examination of a business case. This perspective is able to provide coverage of a wider range of issues and factors surrounding EPS not only user acceptance and technology, but also collaboration and competition in industry and market, and fimm-related management issues. The findings demonstrate that cooperation with established organisations, simplicity, trust. security and mutuality of stakeholder benefits are all of importance to the adoption of EPS. These factors are consistent with the adoption factors found during our literature-based analysis. In particular, this study highlights the significance of establishing partnerships with large organisations in the adoption of EPS because they are able to provide access to a large installed base of customers. association with their brand and marketing resources in order to achieve public awareness. In the next section, a literature review on factors affecting the adoption of EPS is presented. The research method used for this study is then described. This is followed by a short description of the case. Then findings are presented and discussed. In the conclusion, we highlight contributions made in this paper and make suggestions for further research. ELECTRONIC PAYMENT SYSTEMS (EPS) ADOPTION Factors that influence the adoption of EPS are multifaceted. They include cooperation with established entities (Badderley, 2004), trust (Chau and Poon, 2003), security (Ba et al, 1999) and simplicity (Weiler. 1995). Recently, the concept of mutuality of stakeholder benefits has also been used to explain the adoption of EPS (Oh et al. 2006). These factors are discussed below. Cooperation with Existing Entities The literature related to EPS clearly identifies cooperation with well known.established institutions as a factor which influences adoption of these systems (Mann, 2003; Mc Andrews, 1997: Panurach. 1996; Rosen, 2001: Simpson, 2004). Investigating EPS from an economic standpoint, Badderley (2004) contends that in order to be successfully adopted, an electronic payment system requires 232 Journal of Research and Practice in Information Technology, Vol. 39, No. 4. November 2007
Exploring the Reasons for a failure of Electronic Payment Systems universal acceptability. This acceptability can be achieved through cooperation with institutions such as recognised businesses, governments and banks. Oh et al (2006) assert that a precondition for success in the EPS market is the involvement of a partner who is able to provide a critical mass of users. Rogers (1991) defines critical mass as the point where enough individuals have adopted an interactive innovation to cause the perceived cost- benefit of adopting the innovation to shift from negative to positive for the individuals in the system"" (p.250). Therefore, once this critical mass is provided by the partner, both the benefits of the system and consequently system use will increase. This can be seen in the case of the successful PayPal system. Rosen (2001) argues that the main contributor to the widespread acceptability of PayPal was its cooperation with large entities with an installed base of users, especially online auction site eBay. This is consistent with the principle of network extemalities which stipulates that the value of unit product/service increases as the number of sold products/services, or the number of consumers, increases (Shapiro and Varian, 1999: Hanseth. 1999). Network externality has positive feedback mechanism in itself which makes the strong stronger. Trust The literature identifies that a high level of user confidence or trust in an EPS is an important factor contributing to their successful adoption (Dekleva. 2000; Lanford and Hubscher. 2004: Panurach. 1996: Schwartz, 2001: Yeung et al. 2003). In investigating Hong Kong's successful Octopus payment system. Chau and Poon (2003) identified trust in the system and its provider as a primary contributor to its success. Liao and Wong (2004) also examined the Octopus system, surveying users and identifying factors which influence the use of the smartcard. The authors also found that users are willing to use the Octopus system because they perceive it to be trustworthy. These two investi- gations of the Octopus system are pertinent as they identify elements which lead to the successful adoption of an EPS. These findings are supported by a user survey conducted by Abrazhevich (2001) who found that users would refrain from using a system which they feel is not trustworthy. Kniberg (2002) associates the credibility of an EPS with adoption, arguing that a credible, recognised and trusted system will be more likely to be adopted by both users and merchants. Security In the context of EPS security refers to the capacity of a system to reduce fraud and protect the user from the theft of their funds and personal information (Shon and Swatman, 1998). Security has been a longstanding issue for customers, which can be traced back to the origins of electronic commerce (Ford and Baum. 1997: Garfinkel and Spafford. 1997). The literature widely recognises the security concerns of users and the effect it has on the adoption of electronic payment systems (Ba et al. 1999: Mann, 2003: Schwartz, 2001). Taking a technological view of security, Rose et al (1999) contend that inadequacies associated with security are the primary impediment to the acceptance of electronic commerce. Rose et al (1999) strongly recommend that organisations engaged in electronic transactions employ security measures such as encryption and firewalls. In the aforementioned study of the Octopus system, Liao and Wong (2004) concluded that the employment of security mechanisms by the payment provider had a positive effect on customers' willingness to use the system. Simplicity A survey undertaken by Weiler (1995) found that simplicity was one of the most pertinent aspects influencing EPS adoption. A number of payment schemes have focussed on factors such as security Journal of Research and Practice in Information Technology, Vol. 39, No. 6, November 2007 233
Exploring the Reasons for a Failure of Electronic Payment Systems and user anonymity, employing technologies and processes which are difficult for the user to understand (Kniberg, 2002). As a result, these systems have failed to achieve widespread usage. In a study of a failed smart card implementation trial in New York. Truman et al (2003) found that the complexity of using the smart card technology in particular, the process of replenishing the cards) adversely affected the acceptance of the technology. On the other hand. Schwartz (2001) found that the simplicity of the PayPal payment process was a significant contributor to its success. Yu et al (2002) clearly asserts that an EPS should be simple and easy to use. Ease of use has long been cited as a contributing factor affecting the adoption of information systems (Davis 1989: Karahanna and Straub. 1999). Davis (1989) defines ease of use as ""the degree to which a person believes that using a particular system would be free of effort"" (p.320). A number of studies have applied the construct of case of use to the context of EPS. For example. Liao and Wong (2004) found that perceived case of use had a positive effect on customers willingness to use the Octopus smartcard system Kniberg (2002) states that the case of registering with an EPS provider is also a factor which affects the adoption of an EPS Mutuality of Stakeholder Benefits The concept of stakeholder mutuality has also been applied to the adoption of EPS (Oh et al. 2006). The authors contend that mutuality of benefits and costs among stakeholders is a necessary condition for the diffusion of an EPS. In the context of EPS, the main stakeholders include consumers and merchants who want to use the system. Mutuality of stakeholder benefits stipulates that the benefits for each individual stakeholder must exceed the cost these stakeholders incur when they choose to adopt a system. When adopting an EPS, consumers incur certain costs including transaction fees, the time taken to sign up and occasionally, subscription costs. For merchants who wish to use an electronic payment system as a means for collecting money from customers (for example, through their company web page). an EPS must be integrated with organisational processes and this may also incur certain investments. Applying mutuality of stakeholder benefits to the adoption of EPS would imply that a consumer would be more likely to adopt an EPS if the aforementioned costs were outweighed by the benefits of the payment system, namely, convenience, cost advantages, rewards. etc. Similarly, merchants would be attracted to adopt an EPS if their integration costs were compensated by benefits such as increased revenue, lower fees. less paperwork, etc. The concept of mutuality of stakeholder benefits assumes stakeholder independence and rationality. In the case of EPS stakeholders are able to act independently of each other due to the absence of regulation by an overarching governance structure (Oh et al. 2006). RESEARCH METHOD For this study of a failed EPS, we conducted a case study. As EPS are influenced by multiple factors such as individual consumers, internal management, merchants and alliance partners as seen in the literature review, the case study is an appropriate approach in that it allows researchers to deal with those factors in a comprehensive manner (Lee, 1989). The case study is an appropriate approach as it allows to answer ""why"" and ""how' questions (Yin, 1994), that is, why and how the EPS under study failed to attract a sizable user base. Data were collected using semi-structured interviews and document analysis. In selecting participants within the organisation, the roles and positions of staff members were considered with the objective of attaining all appropriate perspectives of the organisation. The interview process involved three participants, cach from a different area of the organisation. These participants included the heads of the Operations department and the Research and Development team as well Joumal of Research and Practice in Information Technology, Vol. 39, No. 4, November 2007 234
The gloves of the instrument nurse were accidentally punctured by a needle while the surgery going on, does the instrument nurse can proceed to assist?
The circulating nurse keep 1 foot distance from the mayo table while offering the additional sterile instruments with the picking forcep, does the nurse maintain the sterility within the OR field?
When the surgeon announces for closure of the operative site, the needle slip on the hand of the instrument nurse and it fell down, is that sharp object can still be used?
The circulating nurse already setting up the sterile field and lay out sterile instruments. She remains in the room while waiting for the other surgical team members. Is the action ideal?
Circulating nurse opened the sterile pack with his bare hand and placed it on the mayo table, does the nurse able to maintain the sterile field free from any contamination?"
1. It is also known as puncture gloves of the instrument nurse or the Instrument Nurse Puncture.
Scenario: While on the surgery the instrument nursejongled the needle and accidently pierced his/her hand with it.
Action: Cleared punctured gloves are a no-no, the instrument nurse should refrain from helping that way. In the event that gloves are breached they turn into a way of contaminating the sterile space around the operation region. The problem should be raised to the surgical team and the affected gloves discarded, and the nurse puts on a new sterile gloves to continue the process.
2. Circulating Nurse and Sterility
Scenario: The circulating nurse position herself one feet from the mayo table as will offer additional sterile instruments with the helping of the picking forceps.
Action: Yes the nurse can maintain sterility in this depending with the need for the surgical aseptic measure. Since the circulating nurse does not come in close contact with the operating room field while assigning sterile instruments with forceps she does not compromise on the sterility of the OR field.
3. Dropped Needle
Scenario: This moves on stage with the needle dropping on the theatre floor immediately after the surgeon announces the sterillization and closure of the wound.
Action: No, the needle should not be again used because it spreads the infections from one patient to another, this can be done by the bacteria. Any object that has a sharp edge that is dropped on to the floor is believed to have landed on several different stains and therefore cannot be rolled on an area that is regarded as being sterile. It should be disposed off, and a new needle should be gotten for the process.
4. Present Practice Pertaining to the Circulating Nurse Preparing the Sterile Field
Scenario: The circulating nurse locates the uncontaminated zone and positions the instruments/tools and the circulating nurse remains in the operating room awaiting the other surgical members to come.
Action: However, the performance of this action, is not preferred. The circulating nurse should ensure that the supplies in the sterile manner and then leave the field so that they do not compromise the tissue. The circulating nurse should attempt not to repeatedly go through the steri field again, if possible should use a belt and braces approach to barrier precautions.
5. Some examples are; It is unlawful when handling or opening sterile pack the practitioner touch it with bare hands.
Scenario: Ambulatory nurse using front hand they ask for sterile pack then connect the sterile pack used front hand and put it over mayo table.
Action: However, doing so is unbeneficial as such an action undermines the intactness of the pack’s hygiene. The packs should be opened in as sterile manner as possible to ensure that the pack is not contaminated with bacteria; this could be achieved by wearing aseptic gloves or in opening the pack in a manner that will not bring into contact with the contents of the pack. Though, it may not be appreciated fully, the nurse should not touch the area singled out for the sterile surgery known as the sterile filed.
Summary
Punctured gloves: As simple as touching an object, do not continue to wear gloves; switch gloves if possible.
Distance from mayo table: ,but safe if forceps are used with a correct aseptic method.
Dropped needle: Garbage; the material that it is made from cannot be recycled; the garment is unwelcome.
Circulating nurse waiting: After setup is complete, should leave the sterile field or only minimal necessary motion should be done around surgical area.
Opening sterile pack: MUST be done aseptically; handling with hands is forbidden.
Technique of sterile measures and requirements is most useful to health facility particularly throughout operations with a purpose of minimizing infection
Topic: Multiple Sclerosis Answer the following questions
Topic: Multiple Sclerosis Answer the following questions: 1. Describes how physical, emotional, spiritual, cognitive aspects of the person affects in person with Multiple Sclerosis. 2. Prognosis(best case scenario and worst- case scenario.) 3. Identify support groups and resources. 4. Describes how this illness impacts in family relationships. Please put the references."
1. Multiple Sclerosis’ effect on physical, psychological, spiritual and cerebral layers
Physical:
Symptoms: MS impacts the Central Nervous System, which explains the plethora of physical symptoms observed, which include; muscle weakness, spasticity, tremor, fatigue, and problems in coordination and balance. People may develop various disabilities and need walking aids such as; wheelchairs, canes, and crutches.
Management: Medication, physical therapy, and changes in diet and other aspects of day-to-day life are typically required for symptoms and effective functioning.
Emotional:
Challenges: Patients with MS are likely to be depressed, anxious, and have emotional fluctuations resulting from the randomness of the disease and the effects it has on the patient’s life.
Management: Family and doctor’s help, counseling, and group support can in turn help maintain the emotional state.
Spiritual:
Impact: MS can force changes in attitudes and specific views on the world and the Universe. While some people try to find the sense of purpose or comfort in religion or spirituality, there are cases of spiritual suffering or doubt.
Support: It is possible to receive support from a spiritual counselor, participation in religious or spiritual organizations, and self- reflexion.
Cognitive:
Symptoms: Neuropsychological alterations in MS include impairments in memory and learning, attention and executive abilities and functioning. They may relate to common living experience and problem solving in day to day activities.
Management: These problems can be solved with the help of cognitive rehabilitation, methods of managing cognitive disorders, as well as receiving support from neuropsychologists.
2. Prognosis
Best Case Scenario:
Stable or Mild Disease Progression: There are some patients with MS who have a very progressive, but a relatively benign disease with relatively brief episodes of relatively mild symptoms and relatively minor deficits over the years. They can socially rein-tegrate with proper medication and self-care, as well as live full and independent lives.
Worst Case Scenario:
Severe Disability: : Thus, in the worst MS can cause severe disability of virtually any aspect of a person’s life with almost permanent consequences: loss of mobility, severe cognitive impairment and changes of nearly all aspects of the daily life. They may have to be taken care of full time and basic activities may have to be done for them.
3. Support Groups and Resources
Support Groups:
National Multiple Sclerosis Society (NMSS): Offers service and information for people with MS and for the families. Provides affiliated local chapters and online self-help groups. Website
Multiple Sclerosis Foundation (MSF): This has assistance services, education, and connection to other people facing similar issues. Website
MS Society (UK): Offers forums and other means of support as well as initiating organizations for those suffering from MS. Website
Resources:
MSAA (Multiple Sclerosis Association of America): Provides information on MS, treatments, and where to find financial support. Website
Centers for Disease Control and Prevention (CDC): Blanket of information on multiple sclerosis and other related issues of health interest. Website
4. Impact on Family Relationships
Challenges:
Caregiving Burden: People from the family may end up being the caregivers and this is equal to being a health assistant and can be tiresome. It may cause stress, burnout and possibly changes in family relations as a result of constant care giving responsibilities.
Emotional Strain: Because of this unpredictable disease and its symptoms an individual experiences emotional stress in as much as it affects the family. Some of the common emotions that the members of the family may have are hopelessness or anger.
Financial Impact: The impacts of such an illness arising from managing MS comprise financial implications such as medical bills and loss of income in case of disability, all of which exert further pressure on family resources.
Promoters:
Increased Support: The concept of reunion is prevalent so that families stand by one another, and the relations between the different members tighten. It is found that social support, which may be constructed in terms of functional adaptation, plays a mediating role in the relationship between multiple sclerosis (MS) and the family members’ experiences.
Support Networks: Close relatives particularly those in a position of offering care to ailing relatives should consider joining caregivers support groups in as much as they offer techniques on how to handle the responsibilities and also take care of their health.
References
Multiple Sclerosis Society. (2024). Overview of Multiple Sclerosis. Website
National Multiple Sclerosis Society. (2024). Understanding Multiple Sclerosis. Website
Multiple Sclerosis Association of America. (2024). Living with Multiple Sclerosis; Useful Links. Website
Centers for Disease Control and Prevention . (2024). Multiple Sclerosis. Website
For this Assignment, you will work with a pediatric patient with gastrointestinal or genitourinary condition
For this Assignment, you will work with a pediatric patient with gastrointestinal or genitourinary condition that you examined during the last 3 weeks, and complete a Focused SOAP Note Template in which you will gather patient information, relevant diagnostic examination."
The structure for admiral of a Focused SOAP Note for a Pediatric patient with a G/I or GU diagnosis is as follows: The following template shall help you in capturing different patient details as well as the necessary diagnostic tests. Always should consider the individuality of the particular client and the diagnosis he/she was given.
Focused SOAP Note Template
S: Subjective
Chief Complaint:
The purpose of the patient visit (for example, pain in the stomach, discomfort with the urine, and the like).
History of Present Illness (HPI):History of Present Illness (HPI):
Additional information on the symptomatology as regards: onset, duration, site, severity and nature of the complaints.
Any other complaint (e. g. , vomiting, dysuria, fever, etc),
A treatment or medication that was given before the current episode of treatment.
Whether there are any recent changes in the diet, lifestyle or any habits regarding the patient.
Past Medical History (PMH):
Related G/ GU disorders ( e. g. , chronic constipation, recurrent UTI).
Previous surgeries or hospitalizations.
Medication History:
Prescriptions and non-prescriptions drugs, and natural products that are taken at the present.
If there was any shift in the patient’s medication dosage in the last two months.
Allergies:
Prior medical history including allergic reactions such as to drugs or food products.
Family History:
A requirement of family medical history with special focus to any gastrointestinal or genitourinary abnormalities.
Social History:
Diet and fluid intake, bowel and bladder control, suicidal ideation, and other factors that may affect present health.
Review of Systems (ROS):
Other systems found in other studies that were reviewed (e. g. , changes in weight, alteration in bowel habits, changes in the frequency of urination, or pain).
O: Objective
Vital Signs:
This includes temperature, pulse, rate of respiratory movements, blood pressure, and end morning weight.
Physical Examination:
General Appearance: Well-being of a patient in general (e. g. , well-nourished, upset).
Abdominal Exam: Inspection, palpation, percussion and auscultation. Signs and symptoms that should be reported include: Tenderness, distention, visible masses and gastric sounds.
Genitourinary Exam: Examination for any irregularities or symptoms of infection (for instance inflammation, redness, pus).
Diagnostic Tests:
Laboratory Tests: Tests done on blood samples; complete blood count, comprehensive metabolic panel, urinalysis or other tests which may be stool based.
Imaging Studies: Any relevant investigations carried out as part of clinical history (e. g. abdominal ultrasound, X – ray).
Other Diagnostic Exams: Other investigations done in the course of assessment prior to diagnosis, for instance endoscopy or urodynamics.
A: Assessment
Diagnosis:
Debugging and differential diagnostic approach which may be based on subjective and objective data.
Differential diagnoses if applicable.
Clinical Impression:
Conclusions that have been made together with their relation to the diagnosis.
P: Plan
Treatment Plan:
Medications: Certain medications, their quantities and timings.
Non-Pharmacological Treatments: A treatment for change in diet, alteration in lifestyle or physiotherapy.
Follow-Up: Possible procedures that the patient should follow up, further appointments and any referrals to other specialists.
Patient Education:
Teaching given to the patient and or the family (e. g. , how to take the medications, when and what to eat).
Further details concerning the symptoms and signs to look for.
Additional Testing:
Whether there is a need for any other test in diagnosing or managing the condition.
Preventive Measures:
Prevention advice for recurrence or complications.
Example of a Focused SOAP Note for a Child with Gastrointestinal Problem
S: Subjective
Chief Complaint: Pain in the stomach and tendency to loose bowel movements.
HPI: It began two days ago: the patient complains of abdominal pain accompanied by frequent, watery diarrhoea. The pain is cramp-like and in particular in the lower abdomen. Does not present with fever or vomiting. The patient has not been on any change of diet but the patient has recently joined school.
PMH: None of the patient’s past medical history that may have any bearing on the case presented herein is documented.
Medication History: None of the present regular medications.
Allergies: No known allergies.
Family History: It is also important you know that mother has had Irritable Bowel Syndrome IBS in the past.
Social History: No fever, no diarrhea, traveling not more than two weeks’ ago, and no contact with sick people.
ROS: Negates weight loss, altered eating, or defecation containing blood.
O: Objective
Vital Signs: Temperature 98. Temperature = 6 ℃, pulse = 88 per min, respiratory rate = 18 per min, systolic blood pressure = 105 mm Hg, diastolic blood pressure = 65 mm Hg, weight = 30 kg.
Physical Examination:
General Appearance: Well-nourished, alert.
Abdominal Exam: In the lower abdomen, there is a mild to moderate degree of palpatory tympany; there is no (positive) peritoneal sign, no (positive) hepatic dullness, and normoauscultation is noted for the bowel sounds.
Genitourinary Exam: No deviations from a normal condition; al! is well.
Diagnostic Tests:
Laboratory Tests: CBC reveals raised RMNS and mild anemia, the stool test for rotavirus is positive.
Imaging Studies: None was done at this time.
A: Assessment
Diagnosis: Severe diarrhoea due to rotavirus.
Clinical Impression: Lab findings: Symptoms and presence of virus in the stools are in favor of viral cause.
P: Plan
Treatment Plan:
Medications: Rehydration solutions as fluids for issuance to patients.
Non-Pharmacological Treatments: Make the client to drink a lot of liquid as well as ensure that he/she rests well.
Follow-Up: More… If not getting better or worsen after 3-5 days reconsider.
Patient Education: Quizzed parents on likely symptoms of dehydration and the need to hydrate their children. Told on measures to be taken to avoid contracting the diseases particularly on matters concerning hygiene.
Additional Testing: At this time there are no further tests required.
Preventive Measures: Suggest rotavirus vaccination especially in children in order to avoid future cases of the same.
1- State a policy question
1- State a policy question 2- how would you measure the outcomes of your policy 3. challenges and promoters of your policy. please help with some examples . what's the difference between a policy question and a PICOT question. 4. Thank you very much
1. State a Policy Question
A policy question usually concerns itself with broad influences of applying or altering a regime. It concerns issues relating to policy in as much as policy making, implementation and consequences in a specific context.
Example Policy Question:
“What degree is promoting compulsory vaccinations useful in avoiding occurrences of preventable diseases in children in public school?”
2. By your own estimation, by how would inculcate measure the impact of your specific policy?
In this case, information should be gathered which in one way or another gives information on whether the policy is meeting the target set or not. Here are steps and examples for measuring policy outcomes:Here are descriptions of the steps and example for measuring policy outcomes;
Steps:
Define Objectives: Find for what purpose is a specific policy intended for.
Example: To cut down by at least half the mortality arising from fatal diseases which are in fact preventable within the next 2 years.
Select Key Performance Indicators (KPIs): Therefore, it is advisable to choose indicators that would show policy effectiveness.
Examples: Proportionalities of vaccination, proportionalities of incidence of diseases which in reality are preventable, number of school children who fail to attend classes due to illnesses.
Data Collection: Acquire data pertaining to the situation during the time of implementing some polices and the final position after the implementation.
Examples: Passports to health, immunisation records, health records of school.
Analyze Data: As it will be evident on this paper, this will make it easy to compare the data with an aim of establishing whether or not the established objectives have been met.
Example: This is in a sex way by comparing the disease incidents that occurred before policy implementation with that of after policy implementation.
Review and Adjust: Based on such results produce a recommendation that calls for change or more often a lack of change in the policies.
Example: If the policy did not contribute to the achievement of the envisaged reduction, it should be reconsidered including such factors as availability of vaccines and compliance.
3. Challenges and Support to Your Policy
Challenges:
Public Resistance: Citizens of a country failing to take a mandatory vaccination due to one or the other belief or misleading information that they come across.
Example: Some of the negative consequences that may arise include: Reduced confidence in vaccines by the targeted groups of the people.
Resource Allocation: That physical resource including financial resources used in supporting the vaccination and other related programs.
Example: Lack of a wide immunization coverage to the general population and especially to the hard to reach population.
Data Management: Examples when it comes to the tracking of the rates of vaccination as well as incidence of a given disease.
Example: Inadequate or out-of-date medical records, both general and / or in specific specialties.
Promoters:
Educational Campaigns: The required message that such kind of advertising reiterates, is that of vaccination, and the benefits and safety implied in them for human beings.
Example: Informants in schools and through the social marketing communication channels such as ordinary conversation, radio, TV and newspaper adverting.
Incentives: Encouraging suggestion for instance giving free vaccine or gifts for people who have received vaccine.
Example: Free vaccination in school and contemplates in other areas of the communities such as the community center.
Policy Support: One of the largest benefits of the technical analysis approach is the great backing of health related organizations and governments.
Example: Recommendations based on the WHO and county and city health department recommendations.
4. The difference between a Policy Question and a PICOT Question is that:The difference between a Policy Question and a PICOT Question is that:
Policy Question:
Focus: Broad and associated with the effectiveness and outcome of some of the policies or treatment.
Example: Target clients’ questions: ‘’To what extent is the compliance with the vaccinations effective in the exclusion of communicable diseases among children attending public schools? ’’
PICOT Question:
Focus: Selective and systematic Which are employed mostly in activities under EBP to develop questions for research.
Components:
P (Population): The focus, which are the people that will be the objects of research.
I (Intervention): The object treated in the intervent or exposed in the intervent or exposure being tested.
C (Comparison): The finally determined group of children that did not get the type of intervention they preferred or the group with whom the kind of intervent ion under research was compared.
O (Outcome): The dependent variable as the reference to measure and known as the variable that interests the change.
T (Time): The time within which the impact of a project is considered; this has to do with the time frame that is taken to consider the impact of the project in question.
Example PICOT Question:
‘What is the number of children of 5-10 years, who had influenza (O) out of those who received the flu vaccine (I) versus children in the same age bracket who did not receive flu vaccine (C) in one given flu season (T)?’
Therefore, the policy implications policy questions are somewhat related to general questions related to the policy while the questions under the PICOT questions are related to more specific questions of the study in terms of interventions and the results that are expected to be achieved.
List the steps for palpating the thyroid gland using the posterior approach.
A. briefly discuss some of the percussion notes in the thorax, include its description and cause/s.
crackles
coarse crackles"
Five Process of Palpation of Thyroid Gland by Posterior Technique
Position the Patient:
Ask the patient to sit comfortably with their neck slightly aligned at a several factors basic position. Thus, the position of the patient should be as calm and comfortable as possible: the shoulders should be down and, ideally, aligned with the rest of the body, turned forward.
Stand Behind the Patient:
Stand beside the patient, and in this way, ensure that you are comfortable to use both of your hands.
Locate the Thyroid Gland:
Put your four fingers across the patient’s neck and your thumb on the other side of the trachea. It is situated in front of the cervical vertebrae from the C5 to C7 and lies just below the larynx (voice box) and above the .
Palpate the Lobes:
With the tips of the fingers of both the right and the left hand feel with the thyroid lobes using a circular motion. The thumb of one hand ought to be resting at the patient’s trachea, while the fingers of the other hand feel for the lobes of the thyroid gland. Palpate for any increase in size or nodularity.
Ask the Patient to Swallow:Ask the Patient to Swallow:
On swallowing, the thyroid gland should shift dorsalwards beneath your fingers. This kind of movement is useful to evaluate the dimensions and homogeneity of the gland.
Voices of Thunder in the Chest
1. Dullness:
Description: A particular sound that is relatively brief and carries low frequency.
Causes: Can suggest the presence of free fluid within the pleural cavity (e. g. , pleural effusion), lung consolidation (e. g. , pneumonia), or a mass within the lung.
2. Hyperresonance:
Description: A tone that is extremely bass and can be sustained for quite some time.
Causes: Traditionally linked with diseases, which lead to excessive intra-thoracic pressure, for instance pneumothorax or emphysema.
3. Resonance:
Description: Medium pitched with clear ringing that will give an empty sound like that of striking a metal pipe.
Causes: Usually audible over the parenchyma and heard in patients with healthy lungs.
4. Tympany:
Description: It is a shrill, rhythmic tone that is often like drubbing.
Causes: Seen in the thorax only very occasionally but may develop if there is relatively more air in the lung, as in a giant pneumothorax.
Crackles and Coarse Crackles
Crackles:
Description: Temporary, hissed or crackling noises, which are most frequently produced during the inspiratory phase of respiration.
Cause: Outcome from initial inflation of small airways and alveoli which were previously closed or filled with secretion. Frequently present in cases of pneumonia, congestive heart failure, or bronchitis.
Coarse Crackles:
Description: Loud crackles that are lower pitched and may be appreciated during both the inspiratory and expiratory phase.
Cause: Linked with broad airways which have secretions or even fluid to the interior parts. It can frequently represent chronic bronchitis or severe pulmonary edema as the side of the lesion.
CHAPTERCASE Ethics of Offshoring
Novo Nordisk and Clinical Trials in Emerging Economies Institute for Entrepreneurship Bached ivary School of Business Ivey The essas developing countries under allegedly unethical condi- tions. Also, the Danish National Committee on Biomed- Professor Klaus Meyer wrote this case solely to ical Research Ethics has expressed concerns because provide material for class discussion. The author. Thus, she wants to discuss The author may have disguised certain names Novo Nordisk's position on these issues. and other identifying information to protect Dejgaard reflects on how to react. Several articles confidentiality on ethical aspects related to medical research in the Ivey Management Services prohibits any form Third World had appeared in the Danish press in recent months, creating an atmosphere of suspicion of reproduction, storage, or transmittal without toward the industry.' Should he meet with the journal- its written permission. Reproduction of this ist and if so, what should he tell her? Or should he material is not covered under authorization by rather focus on his forthcoming business trip to new any reproduction rights organization. To order production facilities and send Novo Nordisk's press copies or request permission to reproduce mate- officer to meet the journalist? In his mind flashes the rials, contact Ivey Publishing, Ivey Management possibility of derogatory headlines in the tabloid press. Services, do Richard Ivey School of Business, As a company emphasizing corporate responsibility, The University of Western Ontario, London, the interaction with the media presents both opportu- Ontario, Canada, N6A 3K7; phone (519) nities and risks to Novo Nordisk 661-3208; fax (519) 661-3882;y.uwo.ca Novo Nordisk Copyright 2008, Ivey Management Services Novo Nordisk AS had been created in 1989 through Version: (A) 2009-01-09 a merger between two Danish companies, Novo Industri A/S and Nordisk Gentofte A/S. Both had n a warm day in early spring 2008, the tele- been established in the 1920s as manufacturers of phone is ringing in the office of Anders insulin, a crucial medication for diabetes. Over dec- Dejgaard, chief medical officer of Novo ades of fierce competition, they had become leading Nordisk, a leading developer and manufac- providers of insulin and related pharmaceutical prod- turer of insulin and related products. A business jour- ucts. Novo Industri had been pursuing an internation- nalist of the Danish national newspaper Berlingske ally oriented strategy from the outset, and by 1936 Tidende is on the line and asking for an interview. was supplying insulin to 40 countries. A significant Dejgaard knows her from several conversations relating step in the internationalization of the company was a to business practices in the pharmaceutical industry. major push into the U.S. market in 1979. At the time, The journalist is investigating the offshoring of clini- Food and Drug Administration (FDA) regulations cal trials by Danish companies. A report recently pub- required Novo Industri to replicate its clinical studies lished in the Netherlands alleges that multinational in the United States to obtain the approval of the mar- pharmaceutical companies routinely conduct trials in keting of their new products. In 1989, the two O
158 Part 1 Foundations of Multinational Management companies merged and in 2000 the merged company In 2008, Novo Nordisk holds market shares for insulin spun off the enzyme business ""Novozymes."" of about 56 percent in Europe, 41 percent in In 2008, Novo Nordisk presents itself as a focused North America and 73 percent in Japan and employs company within the healthcare industry and a world about 26,000 people, of whom 12,689 are located in leader in diabetes care. It claims the broadest and most Denmark, 3.41 1 in the rest of Europe, 3,940 in North innovative diabetes product portfolio in the industry, America, and the remainder in Asia Pacific and the rest including the most advanced insulin delivery systems. In of the world. Production facilities are located in six addition, Novo Nordisk holds leading positions in areas countries and products are marketed in 179 countries. such as haemostasis management, growth hormone The shares of Novo Industri were first listed on the therapy, and hormone replacement therapy. Sales Copenhagen Stock Exchange in 1974 and on the London reached DKr 41.8 billion (about US$8 bilion) in 2007, of Stock Exchange in 1981 as the first Scandinavian com- which Dkr 30.5 billion were in diabetes care and pany to be listed in London. In 2008, Novo Nordisk's B DKr 11.4 billion were in biopharmaceuticals. shares are listed on the stock exchanges in both Copen- Innovation is considered pivotal to the success of hagen and London, while its American depositary receipts Novo Nordisk, as it was to its predecessor companies. (ADRS) are listed on the New York Stock Exchange. Continuous innovations allow the development of Novo Nordisk emphasizes corporate social respon- more refined, and thus more effective, insulin prepara- sibility as part of its image, pursuing a triple bottom line tions, and new delivery systems, such as Novopen, approach: environmental and social responsibility that facilitate the administration of the treatment, along with economic viability. This commitment is including self-administration by patients. In 2008, demonstrated through its values and its environmental about 18 percent of employees are working within and social responsibility policies that are reported on research and development. its website (see Appendix 1). Appendix 1 Corporate Sustainability at Novo Nordisk (Extracts) At Novo Nordisk, we refer to corporate sustainability as companies' ability to sustain and develop their busi- ness in the long-term perspective, in harmony with society. This implies a more inclusive view of business and its role: one in which engagements with stakeholders are not just used to legitimize corporate decisions, but rather the foundation for how a company conducts and grows its business. It is about innovation, oppor- tunity and planning for the long term. The Triple Bottom is the principle behind our way of doing business. The company's Articles of Association state that it strives to conduct its activities in a financially, environmentally and socially responsible way."" This is a commitment to sustainable development and balanced growth, and it has been built into corporate gover- nance structures, management tools and methods of assessing and rewarding individuals' performance.... The stakeholder dimension: Novo Nordisk needs to stay attuned to emerging trends and hot issues' on the global agenda in order to respond and to contribute to the debate. Stakeholder engagement is an inte- grated part of our business philosophy. We have long-standing engagements with stakeholders that are vital for building trust and understanding of a variety of issues. By involving stakeholders in the decision-making processes, decisions are better founded and solutions more likely to succeed. Stakeholders are defined as any individual or group that may affect or be affected by a company's activities. Translating commitment to action: Corporate sustainability has made a meaningful difference to our business, and we believe it is a driver of our business success. This is best illustrated in three examples: Business ethics: Surveys indicate that ethical behavior in business is today the number one driver of reputation for pharmaceutical companies. Any company that is not perceived by the public as behaving in an ethical manner is likely to lose business, and it takes a long time to regain trust. While the Novo Nordisk Way of Management is a strong guide to our behavior, we decided we needed more detailed guidance in the area of business ethics. In 2005 we therefore framed a new business ethics policy, in line with universally accepted high standards, backed by a set of procedures. Since then we have trained managers and employ- ees, held workshops, and offered e-learing on the new policy. continued
Chapter 4 Managing Multinational Ethics 159 Appendix 1 Continued Climate change: We need to act to put a brake to human-induced climate change. While the implications of climate change pose major business risks, there are also opportunities. We have partnered with the WWF [World Wildlife Fund) in the Climate Savers program and set an ambitious target to achieve a 10% reduction in our company's CO2 emissions by 2014, compared with 2004 emission levels. This will occur through opti- mized production, energy savings, and greater use of renewable energy supplies. The diabetes pandemic: Today, diabetes is recognized as a pandemic. Novo Nordisk responds to this major soci- etal challenge by working in partnerships with many others to rally the attention of policy-makers and influencers to change diabetes. We have made a promise of Changing Diabetes and have framed a strategy for inclusive access to diabetes care. We established the World Diabetes Foundation, and have made several initia- tives to advocate for change and build evidence of diabetes developments. The National Changing Diabetes program and DAWN are examples of education and awareness programs implemented by Novo Nordisk affiliates in their respective countries. Our Changing Diabetes Bus that promotes Novo Nordisk's global Changing Diabetes activities had reached 86,000 people by the end of 2007 during its world tour. Its primary goal is to support the UN Resolution on diabetes, which was passed in December 2006. Source: www.novonordisk.com, accessed November 2008 Critical milestones in Novo Nordisk's ambition to be their safety. Efficacy refers to scientific evidence that recognized as a leader of corporate sustainability include the drug improves patients' conditions as claimed by the publication in 1994 of its Environmental Report. It the manufacturer. Safety refers to the absence of sub- was the first company in Denmark and one of the first stantive negative side-effects. Thus, to obtain approval, in the world to do so. This was followed in 1999 by the pharmaceutical companies have to provide scientific first annual Social Report. In 2001, Novo Nordisk estab evidence that the drug improves the conditions of lished the World Diabetes Foundation, a charity aiming patients and is free of disproportional side-effects. to improve diabetes care in developing countries, where This evidence has to be based on, among other diabetes is becoming an epidemic as it had in Europe data, clinical trials in which the drug has been tested and North America a few decades earlier. on actual patients. The clinical trials are normally con- In recognition of its sustainability engagement, Novo ducted in four stages. Phase 1 involves a small number Nordisk had been included in the Dow Jones Global of healthy volunteers and serves to assess the kinetic Sustainability Indices, where it was ranked as ""best in properties and tolerability of the drug. Phase 2 is per- class"" in the healthcare category in 2007. At home, formed on larger groups of patients to assess how well Novo Nordisk is frequently ranked as having the most the drug works and to establish the doses that give the highly regarded corporate image by Danish magazines desired effect and to continue its safety assessment. Berlingske Nyhedmagasin, B�rsen, and Ingeni�ren Phase 3 trials often involve thousands of patients and aims to provide a definitive assessment of how effective New Medications: Development and safe the drug is. All data generated in the three and Approval phases form an essential part of submissions to the regulatory authorities (FDA, EMEA, and their counter- Novo Nordisk, like other pharmaceutical and medical parts in other countries) for drug approval. With this companies, heavily invests in the development of new approval, the drug can then be marketed for the medications offering more effective, safe, and user- approved indications. Further trials, in phase 4, may friendly treatments. New product development involves be required to obtain permission to extend the labeling the creation of new drugs or modifications in their use, of a drug to new indications (e.g. a different disease) or for instance their dosage and the form of administration specific groups, such as children or pregnant women. To bring new drugs or medical devices to market, they Phase 3 and 4 trials require a large number of patients must be approved by the relevant authorities�the FDA with the specific disease that the drug is to improve. A in the United States and European Medicines Agency typical approval process conducted by Novo Nordisk (EMEA) in the European Union. The approval of drugs might require six to eight different phase 3 trials with dif- and medical devices requires proof of their efficacy and ferent patient groups or combinations of the drug
160 Part 1 Foundations of Multinational Management component, each involving about 400 to 800 patients companies have to operate with limited financial Such trials are often conducted as multinational studies resources and to satisfy shareholders and thus cannot involving up to 15 countries. With increasing require- spend more resources than expected future revenues ments for patient exposure for approval and increasing would justify. Accordingly, the industry has been accused numbers of drugs being tested, the recruitment of of performing trials in developing countries with lower patients is often a major challenge. Typically, trials are con- attention to ethical principles-ethical bribing,"" with ducted at multiple hospitals that all must follow the same patients acting as guinea pigs that do not understand trial protocol to ensure the consistency of data and com- and/or care about the risk involved but just want to get pliance with existing ""good clinical practice (GCP) free medication and with investigators not meeting the guidelines. Multi-site trials also facilitate the recruitment competence requirements, etc. Allegedly, all this just of patients with diverse backgrounds, for instance differ- serves to generate documentation for compounds that ent ethnicities and diets, while helping to demonstrate are to be sold only in developed countries. their universal properties. Doctors and nurses but not Medical (Hippocratic) ethics concern primarily patients are normally paid for this work and hospitals the individual patients that are participating in any experi- often find it attractive to participate in trials that allow ment. The relationship between the doctor and the sub- access to new medications and front line research. Clini- ject participating in a trial is thus governed by the cal trials, especially phase 3, are a major cost factor in the doctor's responsibility to care for his or her patient. development of new medications and they often take Past incidences where this principle had been violated many years to conduct (on average eight years). continue to affect popular perceptions of medical In the early 2000s, major pharmaceutical industries research. Most infamously, the Tuskegee syphilis study increasingly moved parts of their trials, especially phases left 400 impoverished and unwitting African-American 3 and 4, to countries outside their traditional areas of men in Macon County, Alabama, untreated to study operations, especially to Eastern Europe, South America, how they developed the disease an experiment initiated India, and China. Hospitals in these areas provide in 1932 and terminated only in the 1970s. access to qualified medical staff and larger numbers of To prevent such scandals, professional medical patients with the specific conditions, while potentially organizations have developed guidelines and princi- being able to administer a trial at lower costs. Moreover, ples of ethics to guide their research, notably the the efficacy of drugs may also vary across contexts, for Helsinki Declaration of the World Medical Association instance due to genetic, dietary, climatic, or other envi- (see Appendix 2). These widely accepted ethical princi- ronmental conditions. In such cases, multi-site trials help ples aim to protect subjects, e.g. , patients, participating to establish the efficacy of medications across contexts. in such research. These include: Some countries, such as Japan, India, and China, in fact require that trials are at least in part conducted locally to � Voluntary informed consent: Each patient has approve a new medication in the respective countries. to agree voluntarily to participate in the research However, the conduct of clinical trials in these areas based on being fully informed about the purposes of the study and potential risks for the individual. also raises a range of ethical issues. Sponsors and local site investigators thus normally Ethical Issues in Medical Research ite an informed consent"" document that informs potential subjects of the true risks and potential Ethical issues in the pharmaceutical industry have received considerable media attention over several dec- benefits, which is signed by each patient or their legal guardian before any trial procedure. ades, as the industry has failed to live up to the expecta- tions of some interest groups. In particular, clinical trials � Respect of patients: The privacy of the subject raise a number of widely recognized issues. Medical pro- should be protected and they should be free to fessionals, and with them many NGOs and media, focus withdraw from the experiment at any time without on the medical ethics grounded in the Hippocratic oath reasoning. The doctor's professional responsibility that commits doctors to treat each patient to the best of to the patient should take precedence over any their abilities, never to cause intentional harm, and to other considerations maintain patient confidentiality. Scientists and approval � Independent review: Any medical and pharma- authorities have been concerned about the scientific cological research has to be assessed on its scien- rigor of the tests to provide solid evidence of the effects tific merits and ethicality by an independent review of a new drug, and thus to protect potential future users board (IRB) that is independent from those of the drug. At the same time, pharmaceutical involved in or sponsoring the research.
Chapter 4 Managing Multinational Ethics 161 Appendix 2 Helsinki Declaration of the World Medical Association (Excerpts) 10. It is the duty of the physician in medical research to protect the life, health, privacy, and dignity of the human subject 13. The design and performance of each experimental procedure involving human subjects should be clearly formulated in an experimental protocol This protocol should be submitted for consideration, comment, guidance, and where appropriate, approval to a specially appointed ethical review committee, which must be independent of the investigator, the sponsor any other kind of undue influence. This independent committee should be in conformity with the laws and regulations of the country in which the research experiment is performed. The committee has the night to monitor ongoing trials. The researcher has the obligation to provide monitoring information to the committee, especially any serious adverse events. The researcher should also submit to the committee, for review, information regarding funding, sponsors, insti- tutional affiliations, other potential conflicts of interest and incentives for subjects. 14. The research protocol should always contain a statement of the ethical considerations involved and should indicate that there is compliance with the principles enunciated in this Declaration. 15. Medical research involving human subjects should be conducted only by scientifically qualified persons and under the supervision of a clinically competent medical person. The responsibility for the human subject must always rest with a medically qualified person and never rest on the subject of the research, even though the subject has given consent 16. Every medical research project involving human subjects should be preceded by careful assessment of predictable risks and burdens in comparison with foreseeable benefits to the subject or to others. This does not preclude the participation of healthy volunteers in medical research. The design of all studies should be publicly available 17. Physicians should abstain from engaging in research projects involving human subjects unless they are confident that the risks involved have been adequately assessed and can be satisfactorily managed. Physicians should cease any investigation if the risks are found to outweigh the potential benefits or if there is conclusive proof of positive and beneficial results. 18. Medical research involving human subjects should only be conducted if the importance of the objective outweighs the inherent risks and burdens to the subject. This is especially important when the human subjects are healthy volunteers. 19. Medical research is only justified if there is a reasonable likelihood that the populations in which the research is carried out stand to benefit from the results of the research. 20. The subjects must be volunteers and informed participants in the research project 21. The night of research subjects to safeguard their integrity must always be respected Every precaution should be taken to respect the privacy of the subject, the confidentiality of the patient's information and to minimize the impact of the study on the subject's physical and mental integrity and on the personality of the subject 22. In any research on human beings, each potential subject must be adequately informed of the aims, meth- ods, sources of funding, any possible conflicts of interest institutional affiliations of the researcher, the anticipated benefits and potential risks of the study and the discomfort it may entail. The subject should be informed of the right to abstain from participation in the study or to withdraw consent to participate at any time without reprisal After ensuring that the subject has understood the information, the physician should then obtain the subject's freely given informed consent, preferably in writing.. 23. When obtaining informed consent for the research project the physician should be particularly cautious if the subject is in a dependent relationship with the physician or may consent under duress. In that case the informed consent should be obtained by a well-informed physician who is not engaged in the investigation and who is completely independent of this relationship. continued.
What can you say about the paper ?
What might affect the performance ?"
This paper will therefore look at the ethical issues and the corporate responsibilities regarding the clinical trials undertaken by Novo Nordisk mostly from the emerging markets. Here’s a summary and analysis of key points:The following is a discussion of important points and their implications:
Summary of the Paper
1. Ethical Concerns in Clinical Trials:Innovations in Interdisciplinary Clinical Research:
Offshoring of Clinical Trials: The following are some of the questions that have been raised concerning some of the ethical issues of conducting clinical trials in developing countries that shall be addressed in this paper. Of the reservations that have been made on the process some of them include that of that it could be conducted in substandard facilities and that participants could be supplied or manipulated.
Informed Consent: Another minimally required input is to ensure the provided participants have a perfect understanding of the risks and benefits of bearing of clinical trials. It turns to being unethical when participant information is not shared with them to the necessary extent or when they are compelled to take part.
Respect for Participants: The rights of the participants are; privacy; The participants have a right to withdraw from the research at anytime without any reason.
Independent Review: It also stated that trials should be assessed by an independent committee in order to determine that it includes ethical and scientific values and methods.
2. Novo Nordisk’s Position and Actions: Novo Nordisk’s Position and Actions:
Corporate Responsibility: It maintains the concern of corporate social responsibility and ethical business requirement like sustainability and management of sustainability, and managing and relating with stakeholders.
Challenges and Risks: This means that the company has a number of issues for consideration in the area in question, as for instance the manner in which the clinical trials cost would be met without compromising the ethic of the business. Ethical issues are disastrous to the business if they are not well managed, hence resulting in negative publicity.
Factors Affecting Performance
1. Ethical Management:
Compliance with Ethical Standards: In this case the ethical practices describe how well Novo Nordisk conducts its clinical trials, the kind of reputation the company gets in the society. It is easy to come across a number of best practices for participants; such as getting informed consent or answering participant’s rights.
Transparency: Mainly in trial processes and result, improve trust among the employees and the public as well. This is because the various corporate activities may be concealed and lead to charges of wrong doing and erode the corporate image.
2. Regulatory and Public Scrutiny:
Regulatory Compliance: This paper also constitutes compliance with the local and international regulations as a factor towards efficiency as well as acceptability of clinical trials. The trials are supervised and scrutinised in terms of ethic issues in conducting the trials and also from the scientific perspective by some authorities.
Media and Public Perception: This is so because the media links the actual image with the perceived image of the company; it is for this reason that the image or perception forming the public<|reserved_special_token_265|> of a firm will dictate the health of the financial status of the firm. In this case therefore, how the company Novo Nordisk addresses ethical issues and leads the public and stakeholders through the media, will either inspire confidence or otherwise in the organization.
3. Operational Challenges:
Trial Design and Execution: Contrary to what one would expect based on the geographical locations, multi-site trials pose their nature and logistical characteristics no matter where they are conducted to introduce a change to the quality of data. Trial management and supervision continue to be important factors on how to ensure that all trials afford only ethical and scientifically valid data.
Resource Allocation: The main challenge is in how to attempt to serve the economic needs while still serving the ethical needs. Trials are going to be carried out by Novo Nordisk in large scale, and for this reason there is need to professionally coordinate its resources in such a manner that trials are going to be conducted in the right ethical practices all the time being conscious of the costs implications.
4. Stakeholder Engagement:
Engagement with Stakeholders: Patients, regulating bodies and the general public should be incorporated in to the organization, for better credibility. It is therefore the recommendation of this paper that Novo Nordisk should do well to take time and respond to such issues thereby portraying good ethical practice and corporate social responsibility.
Conclusion
Running through the paper is the idea of the need to maintain ethical practice in trials especially when taking business to emerging markets. Hence, ethical questionable issues, the regulatory frame work, transparency, and responsibility towards the shareholders impact performance of Novo Nordisk. Co-ordination of such factors will help in mitigation of risks as well as the reputation as well as operation success of the business will also be enhanced.
Using the antipsychotic medication Lurasidone (Trade Name: Latuda), please provide the following
1. Description of the properties
2. Mechanism of action
3. Desired effects and undesired effects
4. 2 Nursing interventions of the medication.
5. Discussion of side effects,
6. Adverse effects usual
7. Dosage, route, frequency and costs
8. Any dietary and drug restrictions
9. Cautions about the use of herbal supplements contraindications.
10. Include developmental considerations (i.e. pediatric, geriatric)
11. Describe the clinical assessments/monitoring required for this medication (list labs, psychosocial, physical).
12. Include a teaching plan for the client taking the assigned medication.
13. Include professional websites that offer guidance on the medication"
1. Description of Properties
Lurasidone is an atypical antipsychotic that is mainly utilised in tackling schizophrenia and bipolar disorder. It is considered to be less hazardous in terms of metabolic side effects in comparison with other atypical antipsychotic agents.
2. Mechanism of Action
Lurasidone acts on neurotransmitter systems in the brain. It first and foremost exhibits negative allosteric modulation at serotonin (5-HT2A) and dopamine (D2) receptors. It also possesses partial agonist properties at serotonin 5-HT1A receptors. This combination aids in regulating the levels of neurotransmitters, and the condition of psychosis as well as mood disorders.
3. Benefits and Risk and Failure
Desired Effects: In schizophrenia, it helps in reductive measures of the symptoms such as hallucinations, delusions; in bipolar disorder, mood stabilisation.
Undesired Effects: Some side effects may include; Weigh gain, metabolic syndrome, sedation, extrapyramidal symptoms such as tremors, rigidity and gastrointestinal disorders.
4. Nursing Interventions
Monitor Weight and Metabolic Status: Worth assessing the patient’s weight at least once a week, blood glucose levels, and lipid profiles to evaluate the presence of the metabolic syndrome or weight gain.
Assess for Extrapyramidal Symptoms: In patients with Parkinson’s, one needs to watch for other symptoms including tremors, rigidity, and slowness of movement or bradykinesia and need to seek medical attention if these worsen or are more severe.
5. Discussion of Side Effects
Common side effects include:
Weight Gain: This agent may also be associated with some side effects, which in contrast to some other drugs from this class, are not very serious.
Sedation: May cause drowsiness, especially when the initial doses of the drug are taken.
Gastrointestinal Issues: Nausea, vomiting or constipation, moreover, may be instigated depending on the kind of medication and its utilisation quazepam prescription. </p>
Extrapyramidal Symptoms: Less prevalent but may be presented by any of the following symptoms; There may be tremors, rigidity, or abnormal movements.
6. Adverse Effects
Severe Neurological Reactions: As in neuroleptic malignant syndrome (NMS) or tardive dyskinesia although these are rare.
Metabolic Issues: That obesity, type II diabetes, and dyslipidemia can be considered to be related to weight gain or stabilization at higher body weight.
7. The Dosage, Route, Frequency, and Costs of the most informatively utilized remedies.
Dosage: Usually is in the range of 40 mg to 160 mg per day.
Route: Oral.
Frequency: They should be taken once a day, with food.
Costs: It changes with the location but is on average between $800 and $1,000 per month for insurance and pharmacy.
8. Dietary and Drug Restrictions
Dietary: Ah should be taken together with some form of food this would increase the rate at which it is absorbed into the body.
Drug Restrictions: Drugs that affect CYP3A4 enzymes should be taken with some sort of caution since Lurasidone is metabolized by CYP3A4. It is advised not to used with potent CYP3A4 inhibitors or inducers.
9. Warnings on the use of Herbal Supplements and Side Effects
Herbal Supplements: Do not use with St. John’s Wort as this will lower the concentration of Lurasidone in bloodstream.
Contraindications: Known hypersensitivity to Lurasidone or any of the ingredients of the formulation. Precautions to be taken in patients with severe hepatic dysfunction.
10. Developmental Considerations
Pediatric: There are no risk and benefit assessments of this medicine in children under 13 years of age.
Geriatric: It should be used cautiously especially in elderly patients, patients with dementia act related psychosis since this product is associated with increased mortality.
11. Clinical Assessments/Monitoring
Labs: Taking their weight, blood glucose levels, as well as lipid profiles checked periodically.
Psychosocial: Keep an eye on any changes in the severity of the patient’s psychiatric symptoms and any onset of side effects.
Physical: Examine for extrapyramidal symptoms, level of sedation and physical status.
12. Hence, the following teaching plan will be conducted on the client:
Medication Adherence: Stress the fact of the necessity to take the medication according to the doctor’s recommendations.
Side Effects: Inform them possible adverse effects and when they should go to a doctor.
Diet and Lifestyle: Maintaining a good diet as well as getting some forms of exercise as a way of controlling your weight.
Follow-Up: Emphasize the importance of follow up visits for patients on the product.
13. Professional Websites for Guidance
Drugs. com: Latuda (Lurasidone) Overview
MedlinePlus: Lurasidone
Mayo Clinic: Lurasidone (Latuda): Uses, Side Effects, Interactions, Pictures, Warnings & Dosing
specify criteria used to evaluate the outcomes of nursing care for the CVA patient 2) Identify resources for the CVA patient and family."
Criteria to Evaluate the Outcomes of Nursing Care for a CVA Patient:Criteria to Evaluate the Outcomes of Nursing Care for a CVA Patient:
Neurological Status: Worsening, resolution, or reduction of neurological symptoms including motor, sensory, speech, and cognitive purchases.
Functional Independence: Depending on the level of disability, it focuses on the patient’s capacity to accomplish the Activities of Daily Living (ADL’s) by himself or herself or with little assistance.
Pain and Comfort: Information on pain assessment and comfort, pain and other related symptoms managing.
Safety: A reduced risk in falling or other injuries, and successful interventions for other risks such as aspiration or skin injury.
Quality of Life: Aim – Evaluations made by the patient and the family in regard to QOL: emotional and social functioning.
Rehabilitation Progress: Functional activity milestones, therapy modalities in terms of physical therapy, the degree of mobility accomplished as well as utilisation of adaptive strategies.
Medication Management: Compliance to horns and dosages, and handling of side effects as well as contradictions.
Patient and Family Education: Knowledge of stroke prevention, kind of management and self-care instruction given to the patient/family.
Resources for CVA Patients and Families:Resources for CVA Patients and Families:
Rehabilitation Services: Opportunity to receive physical therapy, occupational therapy, speech therapy in order to facilitate functional rehabilitation.
Support Groups: Special groups for social support among various sufferers of stroke or their beloved ones.
Educational Materials: This fact sheet provides the patient and family with materials which cover knowledge of stroke, its prevention, and management together with stroke recovery information.
Case Management: Services to help with finding services, coordinating, and leaning on to connect with community services.
Home Health Care: Continuing car and support, nursing and therapy services that are offered at home.
Community Services: County-based organizations and agencies offering other supplies like care in relieves, transportation, or funds for the affected.
Financial Assistance Programs: Information for assisting with medical expenses, insurance, and posibilitys of possible compensations due to disability, medical condition, or other reasons
