How can Malaysia get out of the middle income trap?

By what method would malaysia be able to escape the center pay trap? Malaysia is trapped in the center snare at the present time and getting it out is moving to be intense. With a salary that isn't excessively high and not low, Malaysian think that its difficult to arrive at a more elevated level of pay. To truly get out from the center salary trap, Malaysia needs to change what it has been doing financially for as far back as 40 years. Center salary trap idea alludes to a simple change of a low pay to a center pay economy because of its serious nature as far as modest wages and work escalated ventures. It is anything but difficult to travel from low pay to center pay however it will be difficult to travel from center pay to high salary because of a few elements. Malaysia is getting into center salary trap and is probably going to encounter a little change in factor-value proportion. This implies compensation got by both talented and incompetent work doesn't expand a ton and doesnt arrive at high pay level. In our examination paper, we will separate into the four fundamental parts. Initially, we examine the foundation of Malaysias economy and afterward the elements which lead Malaysia to fall into the center salary trap, in this part we discover that there are around six variables which lead Malaysia into the snare. From that point forward, we talk about on individuals who are influenced because of the center salary trap. Finally, ways or technique to escape from the center pay trap is likewise our primary concern. We have a few different ways to execute to cause creating countries to can graduate into turning out to be completely best in class economies. At the point when we take a gander at our financial foundation, we can obviously observe that from autonomy to the 1980s, Malaysia advanced quickly. From a farming society during the 1950s, it advanced into an Asian Tiger Economy by the 1980s, predominantly work concentrated industrialisation. Be that as it may, resulting exertion in develop our industrialisation make our monetary to stay stale while different nations keep on extending quickly. As of late, countrys execution has been disillusioning with GDP development rate declining to 5.5 percent in 2002 to 2008 from 9.1 percent in 1990-1997. In the previous 1970, about half of Malaysian live in total neediness however now reduction to under 4%. Be that as it may, Malaysian feels that they are stuck from expanding where GDP development has eased back up. Be that as it may, when we take a gander at different nations for instance Korea, they are at one time the least fortunate nation on the planet however they are becoming both financial and politic. Reason that their financial can develop is on the grounds that they have higher buying power contrasted with Malaysia. This is on the grounds that they get averagely higher pay and with higher pay they will have all the more spending power which will help their economy. Nations, for example, Cambodia and Vietnam have low wages while Malaysia traps in the center ground. Instructions to get into center pay trap One of the components Malaysia caught into the center pay is expected to over reliance on FDI and absence of doing innovative work (RD). Worldwide organizations will just give moment of capital, ability and innovation into Malaysia however they won't create or improving Malaysias item. Malaysias specialists appear to be fulfilled in making benefit by serving the MNCs and keeping up their unique, get together based plans of action. Plus, work efficiency is becoming very delayed than during the 1990s. Assembling in Malaysia has a low worth included and had spent a low RD spending. For instance, Malaysia had spent just 0.6% of GDP in RD contrasted with South Korea which is 3.5%. South Korea is likely the best case of a creating nation which movements to a development nation. Organizations in Korea like Samsung and LG rules in the market. Taiwan is likewise not a long ways behind. Chinas policymakers know that they have to suit with the adjustments in advertise if the work costs rise. With a low tech fabricating businesses and absence of gifted work contrasted with nation, for example, Singapore, the creation in Malaysia is less serious and in this way less benefit which means lower compensation paid to the laborers. Transient specialists which discourage compensation additionally one of the elements which cause Malaysia to fall into the center salary trap. It is an error in giving transient specialists to flood access Malaysia and discourages compensation. This will restrain the enhancements of the profitability. Malaysia has too colossal measure of outside specialists which is apparently has 1.9 million enlisted laborers and another 600000 unregistered ones representing about one-fifth of the working populace. These laborers are not restricted to the alleged 3D employments where the occupations are troublesome, messy and risky that local people are reluctant to do those sorts of occupations. Such a large number of incompetent work will prompt low esteem included the efficiency. Malaysian specialist are compelled to get low wages since rivalry with the vagrant laborers are sharp in light of the fact that the transient laborers are eager to acknowledge lower wages and longer long stretches of wor king. Plus, when we consider the negative externalities which partners with the extreme nearness of vagrant laborers, we found that transient specialist is a weight to Malaysias economy as the vagrant workforce ends up being an exorbitant undertaking. There are situations where the transient specialists cause social issue in Malaysia and there were likewise situations where the vagrant laborers are mishandled by their manager. They are additionally compelled to get low wages since there is no law to secure their privileges. It isn't denied that Malaysia needs the administrations of remote specialists, both talented and untalented however government need to guarantee that they are all around rewarded and wages ought to be expanded adjust to the neighborhood compensation so Malaysian wages can be raised higher. On account of Malaysia, high compensation need not mean high work costs if an expansion of wages are sponsored by an increment in efficiency. In different words, low wages does n't mean lower work costs if the efficiency decreases. Aside from that, over sponsorships of the financed thing prompts center salary trap. Appropriation was actualized in 1961 under the Influence Act 1961 and sponsored things incorporate petroleum, sugar, gas, rice, salt and other fundamental things. Sponsorship of these things has made the Government spending to increment and it is unreasonably overwhelming for government to keep on bearing the expense. For instance, the oil cost in 1970s was under US$12 per barrel. Notwithstanding, it increments to nearly US$75 per barrel which causes a cost that is agonizing to the administration. In addition, over appropriations in neighborhood businesses for instance proton is a weight to the administration spending. Whenever contrasted with South Korea, such industry had do something very similar before all else however they were weaned off from the administration sponsorship a lot prior and where Proton is still presently financed. The significant expense of appropriations limits the administrati on capacity to update foundations and include in more innovative work which increment the profitability and seriousness so as to turn into a high salary nation. Value control has been one of the significant reasons for falling into center pay trap. The approach where government authorized value control in Malaya to keep away from difficulties after World war2 holds until today. Value control things incorporate essential necessities, for example, rice, flour, sugar, milk and even taxi passages. Cost of products in Malaysia is a lot less expensive in view of the controls contrasted with different nations. The issue with the value control is that laborers yearly salary increases are connected to the countries CPI which is shopper cost file. This imply with a low CPI, the pay got by the specialist stay low and a move to a higher salary will be hard. Since 1980s, Malaysian wages have fallen behind wages of the remainder of the world. For a model, an alumni police officer win at RM 2300 every month contrasted with RM4400 in Singapore. Aside from controlling Malaysian wages, value controls likewise harshly twist local monetary factor extents which cause numerous industrial facilities winding up in wasteful financial creation forms. At the point when we thought about through GDP, South Korea has a GDP for every capita of US$16450, Singapore US$34,346, while Malaysia despite everything stay at US$7469. The table underneath shows that the breakdown weightage distributed for the various classes of things expended every day. For instance, Food and non-mixed drinks and Housing, water, power, gas and energizes make up over 52.8% of the weightage. We can see that the vast majority of the things are vigorously sponsored or cost controlled. Aside from the crude materials, esteem included things such prepared food and drinks are constantly collected at the market cost yet not caught in the CPI. Furthermore, transport which contribute 15.9% of the weightage does exclude employ buy for vehicles and bike or the expense of imported extra part for fixing. Some development materials such concrete and clinker perhaps cost controlled yet at cer tain cost of rental are resolved at showcase rate. http://greglopez.files.wordpress.com/2010/06/n5-1.jpg?w=300 Low swelling rate makes compensation be falsely smothered and it makes a wide hole between Malaysian working locally and those laborers who work abroad. With low wages, we will be not able to draw in ability from different nations despite the fact that our item and administrations are generally less expensive. Additionally, low or center pay makes an innovation hole making Malaysia to be uncompetitive. Innovation merchandise and enterprises have gotten progressively costly for Malaysian to buy including things, for example, Iphone, PC which it is regular these days. With a modest money, we think that its hard to buy the most trend setting innovation to improve efficiency. Malaysia was stressing on agribusiness segment in the mid 1950s however when Malaysias financial had move from farming segment to assembling division, horticulture area had turned into a drag to the economy. The predominance of oil palm and elastic in the agribusiness division is lamentably a critical drag and had made the countries quit moving to a high salary economy. Th

Administer Medication to Individuals, and Monitor the Effects Essay

The Medicines Act 1968 This demonstration is an Act of Parliament of the United Kingdom and it oversees the production and flexibly of medication. This demonstration plots three classes of medications: †¢Prescription of prescriptions (POM). These are just accessible from a drug specialist in the event that they are recommended by a fitting specialist. †¢Pharmacy drugs (P). These are accessible from a drug specialist without a solution. †¢General Sales List (GSL). These are drugs which can be purchased from any shop without a remedy. The Medicines Act 1968 controls the flexibly of medications it covers. It doesn't diagram any offense of straightforward belonging as it is just an offense if the medication is additionally controlled under the Misuse of Drugs Act 1971. The Misuse of Drugs Act 1971 and alterations 1985, 2001 The 1971 Act diagrams those exercises which are unlawful corresponding to the medications it controls (this is the reason certain medications are called controlled). Such exercises include: †¢Possession of a controlled medication unlawfully †¢Possession of a controlled medication with the goal of providing the medication to someone else †¢Supplying or offering to gracefully a controlled medication (this incorporates giving, selling, sharing, bargaining and so forth.) †¢Allowing premises you involve or figure out how to be utilized for unlawfully to deliver providing controlled medications Health and Safety at Work Act 1974 The Act sets down general standards for the administration of wellbeing and security at work, empowering the making of explicit prerequisites through guidelines sanctioned as Statutory Instruments or through codes of training. The goals of the demonstration are making sure about the wellbeing, security and government assistance of people at work, ensuring people, other than people at work, against dangers to wellbeing or security emerging out of or regarding the exercises of people at work and controlling the keeping and utilization of touchy or exceptionally combustible or in any case hazardous substances, and by and large forestalling the unlawful obtaining, ownership and utilization of such substances. Control of Substances Hazardous to Health Regulations (COSHH) COSHH is the law that states general necessities on businesses to shield representatives and different people from the dangers of substances at work by chance evaluation, control of presentation, wellbeing reconnaissance and episode arranging. 2.1 Normal Types of Medication and their Effects and Potential Side Effects Stomach settling agents Used to help the processing, for example, consuming acids and now and again tooting Symptoms: Milk-salt disorder is one of the most exceedingly awful reactions of acid neutralizer abuse. The abundance of calcium amasses in the blood and can prompt kidney disappointment. Opposite symptoms could incorporate a pale taste, gentle stoppage, expanded thirst, spotting or whitish staining of stools, stomach cramps. Analgesics These are regularly used to mitigate agony, for example, a cerebral pain. Symptoms: Normal reactions incorporate sickness, heaving, languor, dry mouth, urinary maintenance, blockage, miosis (compression of the understudy) and orthostatic hypotension (pulse brings down upon unexpected standing). Less normal symptoms incorporate disarray, mind flight, wooziness, hives, tingle, hypothermia, bradycardia (slow pulse), tachycardia (fast pulse), raised intracranial weight, muscle unbending nature and flushing. Enemies of histamines These are utilized to stop the reactions of a sensitivity Reactions: Calming antihistamines could may you feel sluggish despite the fact that this may improve in the wake of taking them for a couple of days. Non-steadying antihistamines once in a while cause languor. Less regular reactions, principally from quieting antihistamines, incorporate cerebral pains, troublesomely in passing pee, obscured vision, feeling debilitated or spewing, and dry mouth. Intestinal medicines These are utilized to help solid discharge when clogged up Reactions: Wind and swelling can be brought about by mass shaping intestinal medicines. Energizer intestinal medicines can cause stomach torment and whenever utilized for significant stretches of time can bring about a debilitated or ‘lazy’ gut. Osmotic intestinal medicines can cause stomach torment, swelling and wind. Stool conditioner diuretics can cause stomach issues, sickness and a skin rash. Anticoagulants These are utilized to help blood diminishing Reactions: The most widely recognized reactions are tingling, rashes, simple wounding, expanded seeping from wounds and purplish spots on the skin. The purplish spots are brought about by modest quantities of seeping under the skin and seeping from wounds can be hard to stop. 2.2 Meds which Demand the Measurement of Physiological Measurements Enemies of hypertensives to treat hypertension Circulatory strain is a physiological estimation and would require explicit estimation for the endorsing of enemies of hypertensives Insulin for diabetics Blood glucose should be tried to guarantee the blood glucose isn't excessively high or too low to even consider determining how much insulin is required. Warfarin (a blood diminishing medication) Warfarin requires the blood be checked consistently to screen how viable the medication is, for example is the blood turning out to be too ‘thin’, which could cause an inward drain or if the Warfarin portion isn't compelling enough leaving the patient in danger of blood clusters. 2.3 Regular Adverse Reactions to Medication Unfriendly responses to drugs are normal and practically any medication can cause an antagonistic response. Gentle unfriendly responses incorporate sluggishness, dry mouth, unsteadiness, skin rashes, clogging and the runs. Here and there, people beginning treatment with new or new medications may encounter lost craving and weight. The individual’s specialist can be made mindful of any gentle unfavorable responses. Genuine unfavorable medication responses can include anything from draining ulcers to liver or kidney harm. Other progressively genuine responses incorporate trouble breathing, wheezing, fever and joint agony. With genuine antagonistic responses the individual’s specialist ought to be reached. A genuine medication response may create anaphylactic stun which seriously influences the body capacities. The absolute most normal side effects incorporate expanding of the eyes and lips and trouble breathing, disarray and in any event, swooning. On account of anaphylactic stun crisis care must be looked for right away. 2.4 Various Routes of Medication Administration Epicutaneaous †this is application onto the skin and can be utilized for nearby impact for hypersensitivity testing or as an ordinary neighborhood sedation. It can likewise be utilized as a fundamental impact where the dynamic substance is acquainted with the body by spreading through the skin. Subcutaneous †this is the place the medicine is infused into the skin, .for example insulin for a diabetic. Nasal organization †this is the place the course of organization is through the nose. Decongestant nasal splashes can be taken up along the respiratory tract through the nose or a few substances can be breathed in for example inhalational sedatives. Intravenous †intravenous methods ‘within a vein’. This is the place medicine or liquids are acquainted with the body through a needle or cylinder embedded into a vein. Intramuscular †numerous antibodies, anti-toxins and long haul psychoactive medications are infusion straightforwardly into a muscle. It is one of a few elective strategies for the organization of drugs Examples incorporate Codeine, Morphine, Diazepam, Penicillin, Vitamin B12, Rabies and Influenza. Suppositories †A suppository is a medication conveyance framework that is embedded into the rectum (rectal suppository), vagina (vaginal suppository) or urethra (urethral suppository), where it breaks up or softens inside the body to convey the medication. They are utilized to convey meds for neighborhood impact and fundamental impact. The general guideline is that the suppository is embedded as a strong, and will break down or liquefy inside the body to be gotten by the many veins that follow the bigger digestive tract. 3.1 Types, Purposes and Functions of Materials and Equipment required for the Administration of Medication Medicine organization graphs †these should be utilized while managing drug so you know who needs the prescription, how much and when. The prescription graphs must be marked in the wake of controlling drug and be remained careful and secure. Removal sacks †removal packs are utilized to restore any medicine not used to the drug specialists. These ought to be obviously marked. Medications streetcar †this is expected to store all prescription and must have a lock on it for when it isn't being used. It ought to be sufficiently enormous to hold all prescription safely and to compose drug as fitting. Medicine pots †these can be utilized to allot drug in fluid structure for the individual to drink from. These can likewise be utilized to move drug in tablet from the rankle pack to the individual taking the prescription. Spoons †these can be utilized to convey fluid medicine and to move tablets from the drug pots to the mouth with the goal that your fingers don't contact the tablet. Water containers and drinking glasses †it is constantly a smart thought to have water containers and drinking glasses with you so tablets can be gulped with the water or for a beverage in the wake of removing fluid medicine to free the taste or surface from the drug. Jugs and parcels †All prescription should be encased in plainly marked containers or bundles to keep it secured and to guarantee drug is recognizable and guaranteeing the medicine gets to the right individual. 3.2 Medicine organization graphs must have the complete name, age and date of birth of the individual getting the drug so you can guarantee that you are regulating to the right individual. They should likewise have the measurements required and name of drug so you can contrast this with the jug or parcel of medicine to guarantee you have the right prescription and dose and that you manage this as required. The medicine organization diagram ought to have the date of issue and date of expiry of the prescription so that no medi

How we grew organic traffic by 332.91% with user-generated content - Focus

How we grew organic traffic by 332.91% with user-generated content - Focus Can you name a more iconic duo than content and SEO in the history of marketing? Go ahead, I’ll wait . . . As  marketers, it’s our duty to take SEO into consideration when we’re creating pages and content. Product feature announcements, use case blog posts, guides for certain verticals whatever the content, youll want it to rank well on search engines. User-generated content, or UGC, can be defined as any piece of content created by users/consumers of a product or service. UGC can also help you massively with making content rank. User-generated content is different for SaaS. It’s not only a chance to create a cornucopia of exponential search traffic. It’s also an opportunity for users to be creative with their ideas and use your platform as their public canvas. This means theyll share the content online, publish it, present it, share it across social platforms, embed it in blog articles. If your product is visual and promotes UGC, your users should be proud to showcase the content they create. UGC at MindMeister: Our Public Mind Maps Library At MindMeister, weve worked towards developing a library of user-generated content with our collection of public mind maps. It’s our belief that people can distill and share concepts easier through mind maps, so we encourage users to publish their mind maps and share their knowledge with others too. As a result, from the very start of MindMeister, weve worked to build up an extensive library of user-generated mind maps. Luckily for us, Google loves to rank content generated by your users too. Not only is UGC original, but it’s also an unbiased page of content that’s created by someone outside of your marketing team. Plus, by indexing and ranking user-generated content, we reward power users with more exposure for their mind maps and content. Its a win-win situation. We currently have almost 4 million public mind maps indexed in Google and were not planning to stop anytime soon. After a manual penalty from Google in 2014 and multiple modifications to the tech stack, our website traffic started to flatten out. This meant our public mind map library needed some love, so we rolled up our sleeves and got to work. The results speak for themselves: That’s an increase in organic traffic of 332.91% YoY! Heres how we made this jump in traffic and what’s next on our UGC roadmap: Organic search isn’t what you think it is In the past, you would pursue a handful of keywords like crazy and throw everything and the kitchen sink at them. Today, Google is a more dynamic environment, where your search results may be influenced by a multitude of factors that are not even under SEO reach. According to  Dawn Anderson, your search engine results page, or SERP, may show different results based on: Your personal search experience The device youre searching on The time of day/week youre searching on Your local and geographic location. And it doesn’t even matter if you’re logged in or not to your Google account. Google slowly moved from update to update, from a one size fits all SERP, to a more personalized approach, to results and suggestions. This is because two different people can easily have two different search intents for the same query. Google’s Search Liaison, Danny Sullivan, tweeted in May 2018 that the personalization of search results is very light. This either implies that they don’t take search history into consideration, or that theyre uncomfortable admitting it Either way, its clear that the customer journey is not a well-defined funnel anymore, but a cyclical system where the path to conversion is created from a number of micro-moments. After all, if youre providing UGC, in our experience, almost 90% of your traffic will be made up of people browsing for unrelated information. Discover Project Planningwith Mind Maps Try MindMeister Creating a library of linkable assets Creating a library of UGC makes a lot of sense, especially for freemium SaaS businesses. Surprisingly, not a lot of companies deploy these tactics. It combines the best of both worlds: an unlimited pool of creativity from the users and a public example of how you can use your platform. A win-win-win situation for your SaaS, the content creator, and the visitor.  However, as mentioned, only a handful of B2B SaaS companies have built UGC platforms. After all our changes, MindMeisters public mind maps started ranking rapidly, going up to 166k keywords. But it wasnt a smooth ride. As you can see in the chart below, at the end of 2017, we implemented a new mind map layout that was heavily dependant on JavaScript. As Google was discovering and indexing these new pages, our rankings started dropping. To work out how to fix it, we looked to other successful SaaS businesses, sharing UGC themselves. One of the most known examples of SEO ready user-generated content is SlideShare. It became a popular destination for B2B companies that wanted to diversify their content strategy and maximize the output of their content. While they consistently dropped from the beginning of 2017, SlideShare ranks for 7 million keywords. They created the perfect environment for users to upload, convert content and share slides. They also made sure their content is easily picked up and indexed by search engines. This gives an extra incentive for users to repurpose their content on the platform. Another example of a SaaS business that profited a lot from embedding user-generated content into their acquisition strategy is Trello. By allowing their users to create public boards, they encouraged users to get creative with the product. From organizing cooking recipes to roadmaps for software, people started creating and sharing their boards and template boards. Trello was exposed to more and more people through the help of their users, creating a snowball effect. Not only have they managed to rank for 419k keywords, but theyve also received an impressive number of backlinks. Another company that benefits from UGC is Airtable. They combine a curated library of template spreadsheets on a multitude of topics with a “Universe” of content pages created by their users. While their user-generated content is not fully optimized for search engines, you can see it gave them quite a big boost. They rank for over 25k keywords. Some companies try to create such public libraries on their own, for example, design tool  Canva. And theyre doing a good job at it. They are ranking for 654k keywords on a multitude of topics. Even so, their pages lack crawlable content and a UX that enables sharing.  But the biggest issue with their approach is the lack of user-generated content. As a result, theyre missing out on a lot of creative potential. As you can see in the examples above, you can get a lot of exposure by enabling users to share their creativity through the unique perspective of your SaaS product.   Turn Plans Into Actionwith agile task management Try MeisterTask Creating a library of linkable assets Creating a library of UGC makes a lot of sense, especially for freemium SaaS businesses. Surprisingly, not a lot of companies deploy these tactics. It combines the best of both worlds: an unlimited pool of creativity from the users and a public example of how you can use your platform. A win-win-win situation for your SaaS, the content creator, and the visitor.  However, as mentioned, only a handful of B2B SaaS companies have built UGC platforms. After all our changes, MindMeisters public mind maps started ranking rapidly, going up to 166k keywords. But it wasnt a smooth ride. As you can see in the chart below, at the end of 2017, we implemented a new mind map layout that was heavily dependant on JavaScript. As Google was discovering and indexing these new pages, our rankings started dropping. To work out how to fix it, we looked to other successful SaaS businesses, sharing UGC themselves. One of the most known examples of SEO ready user-generated content is SlideShare. It became a popular destination for B2B companies that wanted to diversify their content strategy and maximize the output of their content. While they consistently dropped from the beginning of 2017, SlideShare ranks for 7 million keywords. They created the perfect environment for users to upload, convert content and share slides. They also made sure their content is easily picked up and indexed by search engines. This gives an extra incentive for users to repurpose their content on the platform. Another example of a SaaS business that profited a lot from embedding user-generated content into their acquisition strategy is Trello. By allowing their users to create public boards, they encouraged users to get creative with the product. From organizing cooking recipes to roadmaps for software, people started creating and sharing their boards and template boards. Trello was exposed to more and more people through the help of their users, creating a snowball effect. Not only have they managed to rank for 419k keywords, but theyve also received an impressive number of backlinks. Another company that benefits from UGC is Airtable. They combine a curated library of template spreadsheets on a multitude of topics with a “Universe” of content pages created by their users. While their user-generated content is not fully optimized for search engines, you can see it gave them quite a big boost. They rank for over 25k keywords. Some companies try to create such public libraries on their own, for example, design tool  Canva. And theyre doing a good job at it. They are ranking for 654k keywords on a multitude of topics. Even so, their pages lack crawlable content and a UX that enables sharing.  But the biggest issue with their approach is the lack of user-generated content. As a result, theyre missing out on a lot of creative potential. As you can see in the examples above, you can get a lot of exposure by enabling users to share their creativity through the unique perspective of your SaaS product.   Turn Plans Into Actionwith agile task management Try MeisterTask Its free! Try MeisterTask 6 Major Takeaways from a Successful User-Generated Content Strategy You can see in the examples above, each company takes a particular approach to creating user-generated content. But whether it’s MindMeister, SlideShare, Airtable, Trello or Canva, the same principles apply: 1. Make sure your content is crawlable and indexable One of the biggest problems with SaaS user-generated content is having content that’s inaccessible to Google. So that means you need to ease off on the JS and avoid (or build around) iframes. While Google says they don’t have a problem reading content that’s served through JavaScript, we saw an overall better performance when we transferred many elements to HTML and reduced the dependency on JS. The best solution is to isolate the JS or iframe and serve HTML content around it. As a result, we now have two URLs instead of one: Old URL layout /548246400/kanban-vs-scrum?fullscreen=1 New URL layout /548246400/kanban-vs-scrum The process of having your pages on Google is more complex. The URLs need to be accessed by the Crawler a.k.a. Googlebot. Then it sends the pages to the Indexer a.k.a Caffeine, which analyzes the pages layout and its content. The Google Crawler doesn’t render pages or execute JavaScript, so any content embedded won’t be discovered in this phase. Instead, the page needs to go from the Crawler to the Indexer to find the URLs and send them back to be crawled. It makes the discovery and indexing of new pages very painful. Inspired by Barry Adams Pubcon presentation Another solution that was announced at Google I/O 2018 is  serving “Dynamically Rendered” HTML to search engine bots. The server detects the bot by checking the user agent and serves a version of the page that can be fully understood by crawlers, while serving the initial page to the users. And all of this can be done by telling the servers to serve different content based on the user-agent. John Mueller explained that this can be done for any type of search engine bot and it’s especially useful for large websites with JS heavy code, such as user-generated SaaS pages.  2. Remove crawl waste and dead-ends The problem with SaaS websites that have user-generated content is that Google will only crawl a small portion of your website. Plus, it will try to prioritize what it thinks is important. For example, for MindMeister, from over 3 million URLs, only 200k get crawled on a daily basis. To make sure that our crawl budget doesn’t get wasted, we looked at what ranks and gets traffic, in order to ensure that search engine crawlers ignore the rest. We found out that a huge portion of our crawl budget was wasted on user profiles. The majority of public users had between 1-2 mind maps on their profile. And they werent getting any traffic from Google either. We scrapped all user profile URLs from the XML sitemap and we blocked them in robots.txt to make sure Googlebot ignores them completely. All the pages we excluded from Google were pages that had thin content, no traffic, and no backlinks. This change helped Google invest more crawl budget into public mind maps, which gave us more ranking opportunities.  Worth mentioning that having those pages removed from the sitemap or placing a noindex tag won’t have an impact on the crawl budget. 3. Canonical and Hreflang tags need to work together After we’d implemented the URL system above, none of the old URLs were being replaced in search results by the new URLs. Apparently, Google thought the un-optimized, JS filled iframes were better than the crawl friendly pages. Our website supports 12 languages, which means 12 URLs for each piece of user-generated content. This is the case for both new layout and old layout pages. In short, thats a lot of pages. . . As we wanted Google to organically replace all the old layout pages with the new layout pages, we set canonical tags between them. These created a conflict of signals for Googlebot. The hreflang says Hey, pay attention to me! and the canonical says Hey, Im not in charge here! When this type of conflict happens, Google will disregard both tags and will take a decision based on other factors, which was bad for us. We had to create a scheme of directives that made it clear to the crawler which pages need to be indexed. This tagging structure ensures Google will not override any tags and will index and rank the proper pages. 4. Internal links are a powerful ranking factor Having a good internal link structure is beneficial for multiple reasons. Google finds and indexes pages on your website based on your internal link structure. You’ll have to index a large database of user-generated content, and you’ll keep adding a lot of new pages on a weekly basis. Having an optimized and easy to crawl link structure enables Google to find new pages more easily. Another reason would be the fact that they pass link equity from page to page. Having an organized taxonomy for your URLs is considered a solid foundation. But that can only take you so far. You need to create links between UGC pages that are relevant and offer more context to the content (for Google and for the user). For MindMeister, this is the Recommended Maps section: Each page has 5 relevant mind maps that users can click through. That way we can both reduce the bounce rate and ensure that crawlers have relevant URLs to crawl through. 5. Make use of Schema markups While schema markups are not a ranking factor and they do not cause pages to rank higher, there is certainly some correlation. User-generated content does not have a specific schema for structured data, so youll just have to be as generic as possible. You can use either CreativeWork or  MediaObject  to help with this. By having Schema markups you can specify to Google different types of information, like a featured image, the content, author, comments and likes, and so on. There are multiple formats, but I prefer JSON-LD. It is the newest format to express structured data and its also the preferred format by Google. This is also the only method through which you can move the code from the HTML body to the head. Having JSON-LD markup allows us to offer the Indexer more information regarding our public mind maps. This might lead to Google featuring the page into a rich snippet, improving SERP visibility, leading to higher click-through rates. 6. The UI needs to enable visitors to share or convert These user-generated content pages also act as landing pages. The problem with most UGC strategies is that, as shared, 90% of your traffic will be from people who are not interested in your product. Most of the keywords youre going to rank for will have an informative intent, rather than commercial. But at least these visitors are exposed to how your product can be useful. As a result, you still need to appeal to the visitors that could potentially qualify as your target audience. You need to make sure that you have the right actions to enable users to either share the content further or create an account. Our visitors have the possibility to download, share or embed the mind map on their website. In the recommended maps section, we inserted CTA banners offering the possibility to create a free account. You can play around and test what type of call-to-action provides the best conversion rate. The type of action your visitors might be interested in depends on how your SaaS works. For example, Airtable offers their visitors the possibility to create a free account and copy the public database. Make sure to not hinder the interaction of the visitors too much and ensure that its a helpful interaction rather than a forced one. People are more likely to remember a bad experience than a good one. In Summary While weve achieved an increase of 332.91%, the SEO pipeline is far from over. There are still lots of low hanging fruits for us to address, like page speed and XML sitemap optimization. By scaling the number of indexed pages, we will encounter growing pains along the way, but were now in a much better position to deal with these challenges as they arise. In summary, if you consider implementing a user-generated content strategy for your SaaS business, make sure that: The pages have crawlable content. Bear in mind that usually a SaaS product is heavy on JS, which the Crawler cant access. Look at the structure of the website and remove any redundant pages from being crawled. Make sure the search engine crawler is paying attention to the pages that are UGC. Make sure all the tags and attributes dont have any conflict. It can easily happen when working at scale and Google might end up ranking the wrong pages. An optimized internal link structure is a multifaceted diamond. Make sure content pages link to and are linked from other relevant content pages. Schema markups are extremely helpful, as search engine algorithms become smarter at understanding code and content. Make sure you enable your visitors to share or convert without being too aggressive. Implementing a user-generated content strategy in SaaS can provide a great way for your target audience to interact with your platform and learn it’s best use case from your existing users. As you’ve seen in this article, if optimized properly, UGC can expose your brand to a continuously increasing audience. As you increase your user-base, the amount of published content and the amount of URLs will increase as well. If youre careful and abide to Googles rules, you should enjoy an  abundance of traffic. If you have any questions or comments, make sure to reach out to us in the comments below! Intuitive Task Managementwith MeisterTask Get Started Its free! Get Started

Nature of Management - Free Essay Example

Sample details Pages: 1 Words: 398 Downloads: 4 Date added: 2017/09/16 Category Advertising Essay Did you like this example? Nature of Management 1. Universality: Management is an universal phenomenon in the sense that it is common and essential element in all enterprises. Managers perform more or less the same functions irrespective of their position or nature of the organization. Don’t waste time! Our writers will create an original "Nature of Management" essay for you Create order The basic principles of management can be applied in all managerial situations regardless of the size, nature and location of the organization. Universality of managerial tasks and principles also implies that managerial skills are transferable and managers can be trained and developed. . Purposeful: Management is always aimed at achieving organizational goals and purposes. The success of management is measured by the extent to which the desired objectives are attained. In both economic and non-economic enterprises, the tasks of management are directed towards effectiveness (i. e. , attainment of organizational goals) and efficiency (i. e. , goal attainment with economy of resource use). 3. Social process: Management essentially involves managing people organized in work groups. It includes retaining, Developing and motivating people at work, as well as taking care of their satisfaction as social beings. All these interpersonal relations and interactions makes the management as asocial process. 4. Coordinating force: Management coordinates the efforts of organization members through orderly arrangement of inter-related activities so as to avoid duplication and overlapping. Management reconciles the individual goals with the organizational goals and integrates human and physical resources. 5. Intangible: Management is intangible. It is an unseen force. Its presence can be felt everywhere by the results of its effort which comes in the form of orderliness, adequate work output, satisfactory working climate, employees satisfaction etc. 6. Continuous process: Management is a dynamic and an on-going process. The cycle of management continues to operate so long as there is organised action for the achievement of group goals. 7. Composite process: Functions of management cannot be undertaken sequentially, independent of each other. Management is a composite process made up of individual ingredients. All the functions are performed by involving several ingredients. Therefore, the whole process is integrative and performed in a network fashion. 8. Creative organ: Management creates energetics effect by producing results which are more than the sum of individual efforts of the group members. It provides sequence to operations, matches jobs to goals, connects work to physical and financial resources. It provides creative ideas, new imaginations and visions to group efforts. It is not a passive force adopting to external environment but a dynamic life giving element in every organization.

The Battle Over Russian Foreign Policy Essay Topics and How to Win It

The Battle Over Russian Foreign Policy Essay Topics and How to Win It What Everybody Dislikes About Russian Foreign Policy Essay Topics and Why For that reason, it's important to make them experience its different facets to better their knowledge. A superb idea does not need to be contained or restricted to a single religion because its origin is specific. Strategy There are lots of unique strategies which you will disclose in your work. Learning There are plenty of techniques and approaches to learning and grasping the exact same materials. The Importance of Russian Foreign Policy Essay Topics Large parts of the labor force in the present developing countries work in the informal sector. Living in region of a little community there are numerous issues to address, local individuals are still living in their previous traits, that's traditionally, and to fit in is difficult with individuals of different mentalities. There are many explanations as to why a country would have t o get foreign support, such as environmental issues, medical guidance, and the most important one being poverty. Many developing countries all around the world receive foreign aid. Russian Foreign Policy Essay Topics For initiatives created to support sustainable governance to be prosperous, they have to be attuned to the gendered trade-offs related to different nation-building strategies. In some instances, those operational records is going to be the focus of in-depth research. Your dissertation might concentrate on the interpersonal, psychological and institutional elements that result in particular varieties of foreign policy outcome, like decisions to heighten a rivalry or dispute. It is imperative to know to know the entire process of decision. The crisis provides a chance to implement reforms that would not be possible in a climate of stability. Russia due to increased prices was able to attain greater revenues and enhance its economical circumstance. The Canadian foreign policy is just one of the world foreign policies that have a wonderful history behind them. There are a number of reasons to why they need foreign help, but the principal ones are environmental difficulties, medical aid and poverty. Using Russian Foreign Policy Essay Topics In addition, it may also be dependent on difference of opinion between people. Regardless, the secret to a thriving speech is receiving the audience to comprehend the issue, and to instill in them an urge to solve it. The majority of them visit at least one time every month whilst others visit every week and some even pay a visit to daily. It may be a rough choice, but you'll have the ability to write about something in which you're interested. Military activity on each side of the border is going to be viewed as a provocation and an element of hybrid warfare. Poverty is often as a result of conditions where you reside, and consequently your quality of living is poor. Reducing oil dependence will take some time. Russia is an increasing threat. Russian Foreign Policy Essay Topics Features Now a more sophisticated work program is required. For instance, in college, you might be requested to compose a paper from the opposing perspective. Always be certain you have a look at the review my essay section of any writing service website you're thinking about using. You need to do your homework before planning your travel. Therefore, every paper needs to be written carefully. It's vital that the service you decide on knows for sure they're only choosing the very best essay writers. Utilizing a writing service is the best means to have a well-written essay to use as a guideline to guarantee the essays you write are hitting all the vital points and are at the appropriate depth necessary for your academic grade. Defend your status in the type of a 500 word newspaper editorial. Reading a book involves a good deal of attention, thus a library is the best location for reading books and exploring the world. Students are unable to think of an excellent item of prejudice essays, not because they can't write essays but probably on account of the simple fact they're unable to create fantastic titles for essays on prejudice. They often find that most of their work on these essays is done before they even start writing. But What About Russian Foreign Policy Essay Topics? Applicants may select a single research proposal on a single research topic. These topics are designed to help students identify some helpful sources. Therefore, students who study industry and other associated subjects may be interested in writing on a number of the next topics. General information Students that are new to the topic of social studies need to be ready for in-depth education at their very first lessons. Free example US foreign policy research paper is a significant supply of knowledge on this issue. It might look like a daunting job, but perhaps the toughest area of the job is choosing from the many social studies topics out there. It also needs to be a topic where the speaker may get highly proficient, and there ought to be adequate research and data to back up any argument for or against the topic.

The Use of Intraosseous Vascular Access Free Essays

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

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Sample exam question and model response p. 19, from â€Å"And the Baths †¦Ã¢â‚¬  to â€Å"the water is absolutely dangerous to use, either internally or externally. † Question: How does Ibsen portray the Baths is this extract, and for what purposes? This extract occurs in Act I, during a conversation between Doctor, Petra and Mrs Stockmann with Hovstad, Horster and Billing. The subject of the conversation is the town Baths, and their poisoning by effluent from Morten Kiil’s tannery at Molledal. This discussion foreshadows the action in the remainder of the play, where Dr Stockmann discovers that the corruption of the waters feeding the Baths is also in the minds of the townspeople who oppose the closure of â€Å"the town’s life-blood†. The fact Stockmann and Billing refer to the Baths as the â€Å"main artery of the town’s life-blood†, â€Å"the nerve centre of the town† and â€Å"the town’s pulsating heart† metaphorically links the Baths to vital organs in the human body, an appropriate image for a doctor whose job it is to assist the health of individuals in any community. We will write a custom essay sample on Model Answer or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page Of course, this metaphor on one level simply means the town is very dependent on the Baths for its material prosperity. On another level, however, it connects with imagery throughout the play of moral health and corruption, whereby the Baths become a symbol of what taints the community – that is, their leadership’s dishonesty in dealing straightforwardly with Dr Stockmann’s scientific evidence that the Baths are in fact contaminated, and the people’s materialistic fears for the loss of their livelihoods. Ibsen, by linking the Baths to the body, links them to health and illness, so they reflect the moral as well as physical wellbeing of the town.