Causes and Impacts of disruptive Behavior (DB) in Healthcare

Causes and Impacts of disruptive Behavior (DB) in Healthcare Introduction Persons may be fascinated to study and work in the nursing occupation because it is trustworthy and esteemed; though, the reputation of nursing is at risk as nurses are vulnerable to violence at their work more than other professions (Carter 2000 cited in Norris 2003). Indeed, nursing profession is four times more dangerous than most other careers (Gallant, R 2008). Nurses deliver care for displeased patients and families, whether they are mentally or emotionally ill, or they are offenders. They also need to deal with staffs and other healthcare members within the organization who evoke distress and nervousness. Lateral violence (LV) in health organizations has come to be so widespread and troublesome that it has gained the concern of the policy makers, managers and the healthcare organizations. During the past years LV has gained special attention in organization research. According to National Council on Compensation Insurance (NCCI) in 2006, 60% of workplace assaults are presented and intensified in health organizations, social facilities, and personal care employments. Investigators have reported alarming findings about the negative consequences related to disruptive behavior (DB) for the individuals, the health organizations, and the patients. As for the impacts on the organization, DB has been reported to be associated with higher turnover and intent to quit the organization, higher absenteeism, and decreased commitment and productivity (Hoel, Einarsen Cooper 2003). In addition, victim bullying has been reported to experience stress, job dissatisfaction, psychological and physical illness, and possible expulsion from the Job (Hoel Cooper 2000, Keashly Jagatic 2003 cited in Hoel et al. 2003, Vartia 2001) while patient bullying has been reported to result in reduced s afety and quality of care (reference). Although LV is considered a global epidemic (International council of nursing (ICN) (2007) and has long been a concern among healthcare providers, it has frequently gone uninhibited, or even pernicious, accepted as part of the organization. Thus, leaving these behaviors unaddressed, health organization quietly maintained and reinforced them. Fortunately, DB has lately come under better scrutiny. The American Medical Association (AMA) (2002) has commented: Personal conduct, whether verbal or physical, that affects or that potentially may affect patient care negatively constitutes DBs. The American Association of Critical Care Nurses (AACN) in 2005 has noted that the presence of DB is negatively impacting the collaboration among healthcare workers, which is principal to instituting and supporting a productive work environment. Furthermore, Alspach (2007) stated that LV in nursing is insidious, costly, disgusting and affects patient care. These behaviors urge TJC in 2008 to warrant the healthcare organizations of the safety risk caused by intimidating behaviors and asked them to increase their awareness of the individuals and organizational risk resulting from these behaviors. Those exposed to DB can live through stress, frustration, and psychomatic disorders. Sadly, Griffin (2004) found that 60 % of newly appointed nurses quit their work within six months of service upon exposure to LV, 20% leave the nursing profession forever. While, Veltman (2007) stated that DBs pushed the nurses to leave a particular job, and this drain on resources further affect patient care. In order to address this threat TJC (2009) introduced a leadership standard requiring that facilities looking for accreditation must formulate policies to tackle DBs in healthcare organizations. Now all Healthcare givers should be charged with understanding and addressing this needed culture change within health organizations. In this paper, the causes and impacts of DB for both patients and healthcare workers will be reviewed. Strategies to address and combat DBs among healthcare givers will be discussed. LV, DB and bullying are the terms that I will be using throughout this assignment. Laying the foundation Several terms have been used in nursing research to describe the negative behaviors of nurses in health services. These include LV, bullying, relational aggression, intimidation, horizontal hostility, horizontal violence, sabotage, verbal abuse, psychological abuse, oppression and interactive workplace trauma. (Alspach 2007,Dellasega 2009,Longo Sherman 2007, Lutgen-Sandivk 2007, Rocker 2008,Rowell 2005, Rosenstein ODaniel 2008, Stanley 2007, The Joint Commission(TJC) 2008) . Griffin (2004) identified the most common ten features of DB in the nursing literature (Duffy1995; Farrell1997, 1999, McCall 1996, cited in Stanley 2007): non-verbal innuendo, verbal affront, undermining activities, withholding information, sabotage, infighting, scapegoating, backstabbing, failure to respect privacy, and broken confidences. These kinds of DBs may be perpetuated by healthcare providers, patients or their families. High jobs pressure such as nursing tends to create stresses that are often released when further stressors are added. The discharge of the unbearable stress can result in LV. Irrespective of the initiating stress, no one merits to be abused. When LV erupts, everyone is influenced (Rowel 2010).Some researchers argued that nurses are an oppressed group who intern contributes to the oppressive behaviors indicative of LV (Stanley et al. 2007). Moreover, oppression, vulgarity, and sexual harassment are key elements of LV (Lutgen-Sandivk 2006). But these issues are not the only means that DB may manifest itself in personal communications. Norris (2010) added that hostility may take the form of apparent detesting, patronizing language, annoyance with questions from neophyte nurses or unlicensed employees, disparaging, impoliteness, concealing information, and even temper tantrums. DB is used to depict the workplace negative behaviors that may affect the health status of patient (TJC 2008). Dellasega (2009) refers LV to the act of intimidating, degrading that result in physical, psychological or emotional injury on a colleague or group while Rosenstein and QDaniel (2008) described LV as any unsuitable conduct, conflict, or confrontation ranging from verbal abuse to bodily or sexual harassment. According to Piper (2003) DB is any aggressive behavior that may endanger the stability of patient, unit, and the ability of the organization to achieve its mission. The ICN (2007) defined bullying as a behavior that dishonors, demeans, or otherwise shows disrespect for the dignity and value of an individual. Habitually, the fundamental cause of DP turns around communication mishaps (Ratner 2006, cited in Rowel 2010) or intentional obnoxious behaviors. Sheridan-Leos (2008) stated that the term LV has been used for more than 25 years in the nursing literature and described it as an act of antagonism that occurs between nursing colleagues within an organizational hierarchy. DB may be obvious or subtle. Farrell (2001, cited by Leiper 2005) uses the terms active or passive to categorize DP while the TJC uses the terms overt or covert. Active or overt actions range from intimidating body language designed to discomfort another or others to overtly criticizing a colleague in the presence of others, shouting at others and even physical attack (Leiper 2005, Longo Sherman 2007). Passive, covert aggression may take the form of gossiping, cover-up information needed to perform the job, or demonstrating unhelpful approaches during routine doings. Griffin (2004) found that many experienced nurses are not acquainted with the term LV and thought new nurses were making up the term. Likewise, many forms of DB may be so delicate that certain actions are considered nothing more than a personality conflict between two persons. Jackson (2002) contends that DB is an axiomatic phenomenon in health organizations and is recognized by many organizational cultures as a part of doing business. However, when asked precisely about personal experiences with DB, most healthcare providers confess that they know it when they see it, and many acknowledge exposure to some sort of experience with it during their professional life (Alspach, 2007). Owing to the seriousness and continuity of the side effects of LV on patient outcomes, a great attention has been paid to this topic in the literature. Here are some examples of reported cases: In a study conducted by the joint program and reported by the international council of nurses (ICN) (2007).Researchers found that the most common forms of LV are Verbal abuse, bullying and sexual harassment where verbal abuse ranks the highest among them. Verbal abuse had been experienced by 39.5% in Brazil, 32.2% in Bulgaria, in Portugal, 52% in the health center complex and 27.4%in the hospitals, 40.9% in Lebanon, and up to 67% in Australia. Additionally, bullying has been suffered by 30.9% in Bulgaria, 20.6% in South Africa, 10.7% in Thailand, in Portugal ,23% in the health center complex and 16.5% in the hospital, 22.1% in Lebanon, 10.5% in Australia and 15.2% in Brazil. Furthermore, sexual harassment impacted 64% in India, 90% in Israel and 56% in Japan, 69% for the UK, 48% in Ireland and 76% in the US. The Institute of Safe Medication Practice (ISMP) surveyed over 2000 healthcare providers in 2004 including nurses (1565), pharmacists (354), and others (176) and reported that 88% of the surveyed staff suffered bullying by other workers in the form of haughty language or voice intonation. 87% felt impatience when questioned and 79% were unwilling or refuse to respond to questions or telephone calls. The Nursing journal website (2006) asked guests in the last 6 months have you observed any nurse dealing inappropriately with others? 55% of all visitors claimed yes. This was demonstrated by a survey administered in 2007 to 663 nurses; 46% informed that LV was very serious or somewhat serious issue in their healthcare area and 65% reported witnessing DB repeatedly (Stanley 2007). Ulrich (2006) surveyed 4000 nurses; 18% reported verbal abuse from another nurse, while 25% of all participants rated the quality of teamwork and communication with other nurses as fair or poor. A minor study in Boston (2001) involving 26 new graduate nurses reported that 96% of respondents had seen LV during their first year of work, 46% stated that the act was against them. Acts of LV included being set them up to fail with an unreasonable assignment, sabotage, undermining, or not being available (Griffin 2004). According to a survey written by the Workplace Bullying Institute in 2010 and commissioned by Zogby International survey (2010), an estimated 35% of the U.S. workforce has been bullied at workplace; 62% of bullies are men; 58% of targets are women,68%of bullying is same-gender harassment; an additional 15% witness it. Half of all Americans have directly experienced it. Simultaneously, 50% of targets and witnesses never report the incident (silent epidemic). Leymanns (1993, cited in Einarsen1999) asserts that four elements are noticeable in prompting bullying at workplace: (1) lacks of work design, (2) deficits in leadership performance, (3) a socially visible status of the victim, and (4) reduced ethical standards in the working department. Einarsen et al. (2003) designed a workplace bullying framework; which gives an overview of how factors on different levels may interact at different stages in the multifaceted bullying process. This framework calls the attention not only to individual factors (in victims and perpetrators) but also to contextual, organizational and social factors. Salin (2003b) adapted this framework (Fig. 2), which builds and argues a planned adjustment of the framework by constructing on organizational factors of intimidation and its tolerance/intolerance by using terms such as enabling/disabling factors (Fig. 3). The Problem A survey conducted by TJC (2008) involving 4350 healthcare providers revealed that 77% witnessed DP by doctors and 65% by nurses. These behaviors are frequently demonstrated by professionals in positions of power and include unwillingness or rejection to answer questions; return telephone calls or pagers; patronizing language or voice intonation, and impatience with questions. In response to these events, TJC (2008) issued a patient safety alert affirming that the existence of threatening and unapproachable behaviors weakens the effectiveness of teamwork, erodes professional behaviors, and creates an unhealthy work environment. This sort of toxic environment can lead to malpractice risk (Rosenstein and ODaniel 2005, Morrissey 2003, ISMP 2008), patient dissatisfaction and to preventable adverse outcomes, (Rosenstein and ODaniel 2005, Gerardi 2008, Ransom and Neff et al 2000), increase cost of care, (Gerardi 2008, Ransom and Neff et al 2000) and causes competent clinicians, administrators and managers to look for new workplaces in more professional settings. Lutgen-Sandvik (2009) stated that nurses employed in a toxic, threatening environment often dread going to work and many face the day with feelings of impending doom. Recurrent exposure to bullying headed some nurses to retreat into silence, which led to disruption in communication and teamwork. Furtherm ore, continuous bullying may alter nurses self-confidence, initiativity and innovation resulting in psychological and occupational impairment (WBI 2003). All of these factors combine their effects to disrupt the stability of employees, the organization, and the patients safety. Unfortunately, there is no research study in the United Arab Emirates (UAE) handling the issues of LV except for a minor one conducted in Saqr Hospital in Ras Al Khaimah. The executive director stated that DB by physicians, including Sexual harassment and verbal abuse is a major cause of nurses stress and dissatisfaction at the hospital. Such abuse pushes the nurses to turnover (Zain 2010). Moreover, unhealthy nurses-physicians rapport and authority abuse by the doctors have contributed to nurse turnover in the UAE (khaleej, T 2009).The absence of studies involving the whole emirates does not mean that the problem does not exist. Based on my observation as part of the healthcare system, many nurses especially Asians suffer from different kinds of hostility from physicians, superiors, peers, patients and their families in their work. This hostility take the form of shouting, oral degrading expressions, oral ironic remarks, raised eyebrow, unflattering face gestures, apparent detesting , and sexual harassment. Literature Review History The notion of LV is not a new phenomenon. Horty (1985, cited by Piper 2003) defined the disruptive doctor as as a very clinically competent to the extent of considering himself as the most experienced in the healthcare organization. The troublesome physician is naturally very tough to contact and hence argumentative and antagonistic. In the 1990s, DBs by doctors began to be labeled in the literature as a form of physician impairment (Piper 2003). Gawande (2000) revealed in his article When Good Doctors Go Bad how the medical community was not set to suitably address physicians DB. Rosenstein et al. (2002) found out that lack of physician awareness, appreciation, value, and respect for nurses were serving to fuel the countrywide nursing shortage, profoundly impacting job satisfaction and morale for nurses. So what motivates TJC to ask the medical community to act against violence after two decades? Researchers agree that two milestone matters brought the dispute of LV to the front (Lu tgen-Sandivk 2007, Rocker 2008, Rosenstein ODaniel 2008, Seidel, 2006). The Institute of Medicine (lOM) published in 1999, To Err is Human. The report determined that medical errors cause between 44,000-98000 deaths yearly- more than result from vehicle accidents, breast cancer or AIDS (Baker 2009). The report emphasized the necessity to consider organizational resources and human factors that harmfully influenced patient care (Rosenstein ODaniel 2008). The risk of a nursing shortage. Aiken et al. (2001) found in his global study in a sample of 43,329 nurses that job dissatisfaction was highest in the USA (41%) followed by Scotland (38%), England (36%), Canada (33%) and Germany (17%). More striking, however, was that 27-54% of nurses less than 30 years of age intended to quit within 12 months of data collection in all countries. The U.S.A had a shortage of 150,000 nurses and that number is expected to reach 800,000 by the year 2020 (Childers 2005). Consequently, the nurses will be incapable to meet the forthcoming patients needs if this continues. One reason of turnover is the frustration caused by DBs. Rosenstein et al. (2002) noted that nurse-physician relationship is the key element for retaining nurses. Rosenstein surveyed 2562 from 142 hospitals from 11 Voluntary Hospital Association regions. The sample included 389 physicians, 1615 nurses and 104 senior level executives. More than 90% informed witnessing DB by physician and over 33% of nurses tend to turnover. Using a scale of 1-10 to identify the level of nurses satisfaction and moral; LV ranks pretty high (8.01) Figure 4 Theoretical Framework Rowell (2010) suggested five theories about LV. (See Appendix I). Causes of LV Physicians related Several researchers stated that the physicians training at the hospitals make them vulnerable to DB (Kuhn 2006, Rosenstein ODaniel, 2008). During their training; doctors learned to think individualistically and to become accountable for their activities. This mentality promotes self-reliance, self-sufficiency and an autocratic, bullying conduct which is the antithesis of teamwork (Rosenstein et aI. 2002). According to Kuhn (2006), the absence of quality control starting in university and it is nearly difficult to be fired from internship. This leads the physicians to see themselves as the so-called captain of the ship but possibly do not have the necessary skills to keep it right. This also produces a hierarchal model of healthcare which builds passive roles for nurses and other subordinates (Rosenstein ODaniel 2008) Piper (2003) found that DB is usually demonstrated by excellent clinicians who are accepted by their patients and the society. As they habitually have a notable record of accomplishments; victims may be unwilling to intervene considering the behavior as an exceptional one. Moreover, Piper stated that hospital managers who are supposed to implement the policies are confronted with the challenge of whether to ignore the behavior, or take a difficult decision of firing a great physician who shows too much enthusiasm. According to Rosenstein ODaniel (2008) some hospital directors are disinclined from averting the aggressive attitudes of the physicians because they are not hospital employees and willingly admit their patients to the hospital and thus considered a source of organizational income. Growing external forces such as governmental supervision, pressures for more productivity, managed care restrictions, lower payment, and increasing liability risk cause disruptive physician behavior (Rosenstein et al. 2002). Practicing physicians are overwhelmed with paperwork. As a result, demoralization, and anger will develop leading to oppressive conducts. Another likely cause is the stress inherent in todays medical environment such as mental exhaustion and environmental stressors experienced by physicians lead them to commit medical errors (Kuhn 2006). Staff related The oppression theory will be applied to understand the nurse-to-nurse aggression. Healthcare institutions are controlled by the administrators and physicians who use their authority to rule subordinates. It is obvious that when any oppressed group recognizes that it is not possible to direct its power upward, the group then places their powerlessness and frustration on one another. These peer-to-peer hostilities, which reduce self-esteem, are called LV (Sheriden-Leos2008, Griffin 2004, Leiper 2005). Dunn (2003) confirmed in a study involving 500 nurses in the operating theater that the great numbers of nurses were verbally attacked by the surgeons. This sort of offensive abuse led the oppressed group to develop personal characteristic such as disunity and inability to oppose the physicians because of their positions, authority and ability to revenge from the nurses. Rowell (2005) estimated that 81% of oppressors are bosses, 14% peers, and 5% lower rank staff. Referring to Griffin (2 004) this form of oppression causes the nurses to feel helpless, disrespected and self-loathing. Stanley and Martin (2007) have suggested an applied model of oppressed group behavior to demonstrate how LV seems to manifest itself in the workstation (Fig. 4).It also useful in predicting nurses retention and satisfaction. Gender is another factor. Many studies revealed that females are more susceptible to LV than males. Dunn (2003) rationalized that women tend to suppress their feelings of bitterness. In addition, women are habitually considered inferior to men within society in general and healthcare organization in specific. Accordingly, it is not astonishing to see recurrent acts of sabotage in the nursing as 90% of nurses are females. Leiper (2005) has a parallel opinion and said that females generally underestimate their efforts and have lesser self-esteem than males so they can be irritated more easily and have a predisposition to yell at others. Dellasega (2009) concluded that males express their anger more frequent with bodily violence and this is usually accepted and women exhibited it through character insult, mortification, disloyalty and rejection. ISMP (2004) surveyed 2095 nurses (86% female and 14 % male) and found that DB was nearly equal. Thomas (2003) agrees with this finding. Not all Researchers support the oppression theory as the mechanism for DBs. Ratner (2006) view the oppression theory as condescending to nurses, making them appear as the powerless victim. Another standpoint suggests that organizational cultures, sustained struggles for authority, inconsistent work standards and management styles results in LV (Hallberg 2007). Further organizational causes include shortage, work overload, lack of administrative support, relations among groups, and organizational reform (Rocker 2008). Patient/Family related Patient or family members with a history of DB should be considered at high risk for becoming violent. Violence results from those who are frustrated, rampant, mentally ill, and substance abuser. Finally, LV is not frequently reported by victims and therefore run unaddressed. Fear of revenge, the stigma related to blowing the whistle on a peer, a wide-ranging averseness to oppose an oppressor (TJC 2008), the status quo, lack of confidentiality, lack of administrative support, and lack of awareness or reluctance among doctors to change inhibit the reporting (Rosenstein et aI. 2002). Similar to other kinds of mistreatment, staff violence is repeatedly viewed as an isolated matter and individuals are occasionally unwilling to talk about it (Gammons 2006). On several occasions, LV is not informed because it isnt identified. Some practitioners doubt that bullying has happened except when somebody shouts or uses attacking language (Beyea 2004). Forms and Manifestations OF LV: (see Appendix II) Effects of LV on: Nursing workforce, Organization and Patient The Nursing workforce Defamation of professional dignity, stress, anxiety, frustration, and anger (Rosenstein ODaniel 2008), sleeping disorders, reduced self-esteem, low morale, disconnectedness from their colleagues, depression, apathy, and excessive sick leave (Alspach 2007, Longo Sherman 2007), Suicide attempt (Griffin, 2004). According to the WBI, 45% of respondents had stress-related health problems which include debilitating anxiety, panic attacks, clinical depression (39%), and even post-traumatic stress. Not astonishingly, the adverse effects of LV are not only restricted to the targets. Co-workers witnessing LV report stress and job dissatisfaction. Witnesses who never report are confused how to stop assailant. Unluckily, their silence often leads them to despair and turnover (Lutgen-Sandvik 2007). Healthcare Organization Manifestations include: increased patient illnesses, increased healthcare costs, unplanned absences, law suits (Rowell 2005), malpractice risks (TJC 2008) and turnover (Rosenstein QDaniel 2008, Griffin 2004). Rocker (2008) states that between one third and one half of all work related absences and illnesses are a result of office bullying. According Yamada (2009) some victims pursue compensation or disability benefits as they are no more able to endure work stress and intimidation. Along with Stanley (2010) the overall increase in nurses turnover induced by LV from 2002 to 2007 is 32%. Turnover costs the organization per RN for 2007 $82,000 88,000. Additional costs are decreased productivity and loss of experienced and knowledgeable nurses. Malpractice of physicians and other healthcare providers, which is estimated at 4-6%, has a vast impact on organizational costs. Patients and families detect aggressive work environments (TJC 2008) and are ready to sue when they are faced with arrogant or insensitive behavior from healthcare workers (Aleccia 2008 as cited by TJC 2008). The Patient Rosenstein (2008) surveyed 4530 participants from 102 USA organizations from 2004-2007. The survey questions were intended to assess the respondents perception of the link between DB and patient care. The links were as follow: 66% adverse events, 71% medical errors, 53% compromises in safety, 72% detrimental impacts on quality of care, 25% patient mortality,18% were aware of a specific adverse event, 75% of them believe that the adverse event could have been prevented. According to Dunn (2003) some nurses may control patients by putting off their response to the patients needs- pain medicines, etc. Displeased nurses can also keep patients family uninformed about the patients health status or not support them when needed. Stanley (2010) reported that 1.5 million patients are harmed by medication errors yearly. DISCUSSION In todays sophisticated healthcare setting, each system brings particular skills to patients care. Whether the clinician is a nurse, or any other healthcare workers; each has a unique set of expertise and acquaintance that enable them to view the patient from a particular standpoint. Each field is taking care of the patient at distinctive times and intervals of the day. The doctor visits the patient one or two times a day for 15-20 minutes whereas the nurse employs several successive hours bedside his patient. Therefore, the nurse is the first one who detects and attends the alteration in patients status, not the physician. The patient and the efficacy of the healthcare team are dependent on each other to thoroughly and assertively communicate the changes in the health status of the patient. Unhappily; DB hinders this communication process which affects patients outcomes. It is of merit to mention that the international picture of LV is no difference from UAE.I have been working in the clinical setting for 16 years in different hospitals as a nurse and in a health institution as a teacher and clinical instructor. I have been exposed to and witnessed many episodes of Dbs. For example, I remember a situation when the head nurse asked the Surgeon whether he wants to start the patient on diet or continue keeping him nothing by mouth. The doctor replied in an offensive manner; give him Shoes. The head nurse asked him to write this in the order sheet. Sadly but true, the doctor did it without giving consideration to anything. The nurses felt that they were disrespected and were frustrated because of the recurrent response from the administration when DB is reported as status quo. That instance happened before 9 years but this troublesome situation impacted my psychological status that I recall it as if it occurred yesterday. Another incident, Though I do no t like to recall it, but its profound effect keeps it all the time in my imagination when the nurse came to the nursing counter crying once an aged patient got the money from his pocket and asked her to satiate his sexual desire. Furthermore, nurse on nurse aggression is also clear and take different forms ranging from verbal and non-verbal attack such as intentional rolling of eyes, folding arms, gazing into space when communication is being attempted, backbiting, withholding informationà ¢Ã¢â€š ¬Ã‚ ¦etc. to physical assault such as pushing each other. These DB extended also to the patient particularly the dependent and the unconscious patients who were insulted either by bad words or inappropriate care. The negative effect of these DBs was manifested by medical errors, reduced patient safety and care, decreased performance and productivity, frustration, dissatisfaction, turnover, and poor hospital reputation. Although these are merely anecdotal notes, there are comparable events recognized in the research. Rosenstein ODaniel (2006) presented selected comments acquired from a survey of 4530 healthcare providers. They include terms such as RN did not call doctor about change in patients health status because the doctor had a history of abusive behavior and particular surgeons give the impression that they have the right to be impolite and verbally offensive. It is hard to maintain a high level of performance when repetitively scared of being yelled at (Rosenstein ODaniel2006). Unhappily, DB is not solely restricted to doctors. Rosensteins survey data supports the issue that DB spread to other non-physicians employees. Remarks include; DB from nurses is much more upsetting. I expect it from the surgeons but not from my peers and please realize that most stress is from RN managers, not MDs. According to Rosenstein ODaniel (2008), the most common situation that triggered DP by doctors, as conveyed by nurses, was calling physicians to report a decline in the patients condition. This shows a failure in communication that ought to bring dreadful results on the patient. For instance, if the physicians order is inaccurate or not clear. The nurse many not carry out the order until clarified by doctor. If the nurse is anxious about making a telephone to the doctor due to fear of an annoyed eruption, she might postpone the call or make another work around by evading the doctor entirely and including another party. If there is inaccurate order of medicine, this situa tion can be revealed in various ways, all with awful outcomes for the patient. Primarily, the issue will not be verbalized as the practitioner did not desire to confront the stellar reputation of the doctor or because they were demoralized by previous behavior (ISMP 2008). Consequently, the incorrect medicine will be given. If the nurse calls the doctor and feels that the physician is irritated, the incorrect medicine can still be given and secondary repercussions such as being unable to correct the order in the future can result. Unfortunately, several nursing staff has to live with the guilt of a serious error because they did not follow up on a questioned situation (ISMP 2008). The negative outcomes of such an error can result in stress and frustration for all involved and thus can bring about DB. Limitations Workplace LV is a complicated issue. A diversity of expressions is used to reveal similar behaviors .Although they possess distinctive meanings, the terms are frequently used interchangeably in the nursing literature. There are also a many workplace abuse that might be categorized as DB. First, the paper has focus merely on psychological and/or verbal abuse and not physical or sexual harassment. Second, the majority of literature focuses on LV in nursing profession in particular and to a certain degree

Use of Model Rockets in Education Essay -- Education Essays

As students go about their lives in school, many of them are disengaged and what they do learn, they manage to forget over the matter of a few days. Many teachers have tried to find new ways of teaching that will both interest the students and help them to retain what they learn. Some of these ideas have worked well, while others do the opposite of what they are meant to achieve and disengage the students even more. One activity that a few organizations, such as Air Force Junior Reserve Officer Training Core, the Boy Scouts of America, and the Girl Scouts, have begun to use is the activity of building model rockets. Model rocketry has been a fun pass-time for many youth for years; they find it fascinating to watch something that they built soar hundreds of feet into the air, and then as the parachute deploys, see their masterpiece drift slowly back to them. All that these clubs are doing is taking this activity and using it to explain and teach the many concepts that go into th e launching of the rocket. James Goll and Lindsay Wlkinson, professors at Edgewood University, once said rockets can spark â€Å"classroom discussions about the chemistry topics of homogeneity, intermolecular interactions, kinetics, thermodynamics, and oxidation—reduction chemistry† (Goll & Wilkinson). In addition, Sylvia Nolte (Ed. D., Estes Educator) said, â€Å"rocketry is an excellent means of teaching the scientific concepts of aerodynamics and Newton’s Laws of Motion. It integrates well with math in calculating formulas, problem solving and determining altitude and speed.† (Nolte) One example where rockets help students in school is science. Chemistry, one branch of science, is a huge part of rocket building because of the fact that the fuel is comp... ...act right surface area, while making a shape that allows the rocket to do things that the designer desires such as be free standing, to spin on the way down as to stay straight, or even just to look cool. These are just the tip of the iceberg of the ways that model rocketry can help students. Model rocketry is a way that any organization can help their members to understand anything that they are trying to learn. Model rocketry will keep students engaged, help them retain what they learn, and let teachers teach in a new way. Works Cited Goll, James G., and Lindsay Wilkinson. â€Å"Teaching Chemistry Using October Sky." Edgewood.edu. Edgewood College, n.d. Web. 7 Mar. 2014 Nolte, Sylvia, Ed. D. â€Å"hysics and Model Rockets.† EstesEducator.com. Ed. Thomas E. Beach, Ph. D., Tim V. Milligan, A.E., and Ann Grimm. Estes-Cox Corp, 20123. Web. 13 Mar. 2014

Daimler Chrystler

Mergers and acquisitions take place to realize the synergies between the two or more companies. Why do you think the Daimler- Chrysler merger failed to realize the synergies that were expected from the merger? If mergers and acquisitions take place to realize the synergies between the two or more companies then Daimler- Chrysler were heading for failure from the beginning itself. The merger was not just between the companies but between two drastically opposite cultural bodies. While Germany was characterized as a society that lays importance to success, money and material possessions and that which feels threatened by ambiguity, the American culture is characterized as individualistic, where people value having a high opportunity for earnings and getting recognition they deserve for a good job. They do not feel threatened by uncertainty. The merger between these two companies was followed by an agreement to let each of their cultures and practices prevail and to manage the new found entity Daimler Chrysler in that manner. The companies failed to address their differences and caused a sense of uncertainty in the minds of employees from both companies. While the Germans think through each and every step involved in decision making and implementation and the Americans lacked the urgency to build that sense of security for themselves. Lack of open communication, corporate cultural clash, inadequate planning, a laid back leadership bench at Chrysler, differences in leadership and management styles and over all organization culture gave room for doubts about their ability to make the merger work. The merger seemed more like an empire building exercise by Juergen Schrempp. Daimler did not look into the facts and figures and draw a map for the future of thenew found company and to a certain extent this ambiguity created havoc. Daimler and Chrysler were each strong players in their market but failed to diffuse their differences and create a company that had the potential to compete for a far bigger market share. Q2. Many a cross cultural merger has failed because proper attention was not given to the difference in cultures between the two companies. What issues must be addressed to make a cross- cultural merger a success? There are plenty of examples of how mergers and acquisitions failed in the past. Roughly two thirds of big mergers lose value at the stock market. All motivations that lead to the merger prove false once the process is done and any cost benefit from the premium paid will become evident as overestimated. Having said that, a cross cultural merger would have that much lesser chance to survive and reap profits compared to the similar culture mergers. Apart from miscalculations about economies of scale and revenues, the company has to deal with the cultural aspect that will affect the business day in and day out. To make any cross cultural merger a success there has to be an audit of the characteristics and cultures of the two companies. Unless an audit is done, one would be uncertain of how different or how similar the companies are; the level of compatibility will be unknown. Any planning done without this vital information will only lead to the way to disaster as in the case of Daimler-Chrysler. A deal that makes financial and cultural sense is the only deal that will stand the test of times and reap benefits of the merger. Moreover, a strong leadership bench is absolutely important. It is the people who take decisions that make or break a company. For example, the mergers between Daimler and Chrysler wouldnot have taken such drastic shape if Chrysler had a competent and strong leadership bench. Daimler had intentions of taking over Chrysler from the very beginning of negotiations but Chryslers management was not able to hold their position and did not do enough due diligence to ensure the motivation behind the merger was mutual. Even after the merger, the change in leadership at Chrysler gave way for Daimler to dominate and turn things around for themselves. Lastly, the employees of both companies should assimilate cultures and working patterns such that there is no shock later. Training and planning and implementation of the plan have to be carried out. The merger process must be carried out together by both the companies. Q3. Very often companies involved in a merger claim it to be a merger of equals but this is not the case always . The Daimler-Chrysler deal was never expected to be a merger of equals . Comment . The manner in which the dealings in Daimler-Chrysler merger have been carried out is clear evidence that this merger was never meant to be among equals. Daimler obviously did not have any intentions to work hand in hand with Chrysler. The comments made by Juergen Schremppare evidence that he had hidden the real motivation to have initiated the merger process. The dealings that followed- no concrete plan of integrating Chrysler and Daimler, the change in organization structure in Chrysler, the losses that Chrysler incurred, the loss of employment at Chrysler etc shows that Daimler saw Chrysler as the reason for loss. Had this been a merger of equals, there would have been proper measures to smoothen out the process of integration and ensure the communication was open. Daimler-Chrysler would have had chalked a plan for the integration process and assimilated their management style. Moreover there would have been a management team who would look into implementing the merger process ensuring that events that occurred at Chrysler would not have occurred- (Loss of leaders, appoint of Daimlers executive as Chryslers head of management, no presence of Chrysler inthe supervisory board of management, Chrysler reduced to an operating division, Chrysler sailing division called for retrenchment). Daimler had intended to use Chrysler for it facilities and never intended to make it a partner in decision making and growth plans. Most importantly what is the motivation behind the merger or acquisition is what decides the fate of that merger. In this case, it was clearly not a case of mergers between equals. Daimler- Chrysler did not use its resources to create synergies and one of the companies had to end up being absorbed into the other.

Unit6 P1 P2 M1 - 1442 Words

Unit6 – Preparing for Employment in Travel and Tourism P1, P2 M1 Marites Marzan TT L3 Yr1 GrpB Harish Tutor P1 - Describe career opportunities within different industries in the travel and tourism sector. Tour Operators A tour operator requires a holiday representative to work throughout the summer and winter season to ensure that holiday makers have an enjoyable trip. They are the first point of contact for customers so a holiday representative needs to be prepared to answer question and resolve problems. They usually start the day meeting the excited new arrivals at the airport and overseeing transfers to their accommodation. From there their duties may include, giving an introductory talk on the facilities and the†¦show more content†¦In each element within this chain has their own specific needed; the producer should take account along with the needs of their consumer. The first level of the chain of distribution is the Principal. Principals are the one who provides the products or service to pass down to the next organisation in the chain of distribution; the principals are the one who produces the products or services. Tour operators are the one who combine or mix all the principals t ogether to pass it down to the Travel Agents which is the next level of the chain of distribution. Tour operators like Thomson and First Choice merges as one to gain competitive advantage. These two organisations are now owned by TUI Travel they are both targeting different markets because First Choice organisation will focus on younger and more family-orientated customers while Thomson will focus more on the wealthier and empty nested customers. Additionally, empty nested customers are the couples whose children are living on their own and already left home. Tour operators are mostly the one who design and plan a holidays ahead of time they forecast the holiday and plan them two years before they sell a holiday to Travel agencies. While Travel agencies is more likely on marketing they sell and they promote to make profit according to their negotiation between Tour operators and Travel agencies this will depends how much