New Zealand Oral Health Practitioners Preparedness

New Zealand Oral Health Practitioners Preparedness Title: An update on New Zealand oral health practitioners preparedness for medical emergencies Running title: Medical emergencies Authors: C L Hong, A W Lamb, J M Broadbent, H L De Silva, W M Thomson Corresponding author: C L Hong, Department of Oral Rehabilitation, Faculty of Dentistry, University of Otago, PO Box 647, Dunedin 9054. Abstract Background and objectives: To update information on the preparedness of New Zealand general dental practitioners (GDPs) and other oral health practitioners (OHPs) for medical emergencies. Methods: Electronic and paper survey of a sample of 889 OHPs (comprising GDPs, specialists, hygienists, therapists and clinical dental technicians) randomly selected from the Dental Register. Results: The response rate was 39.7%. About half of the respondents (43.3%) reported encountering at least one emergency event during the last ten years. Vaso-vagal syncope was the most commonly reported emergency event, followed by hyperventilation. The mean ten-year incidence of emergency events (excluding vaso-vagal syncope and hyperventilation) was 2.6 events (SD, 7). Dentists were 6.8 times more likely to experience emergency events than other OHPs (p Conclusion: The majority of New Zealand OHPs were equipped in training, and equipment for medical emergencies, and New Zealand appears better than many other countries in this respect. However, some OHPs still lacked some of the required emergency equipment, drugs, and training. Introduction The New Zealand population (as with other developed countries) is ageing (Statistics New Zealand, 2015). This means that oral health practitioners (OHPs) are (and will continue to be) providing care for an increasing proportion of elderly patients. This demographic shift towards a greying population is not without its dental implications. Ageing is accompanied by chronic diseases, disabilities and poly-pharmacy (Hung et al., 2011), all of which are risk factors for the occurrence of medical emergencies in dental practices. Thus, the risk of medical emergency events is likely to be increasing. Most medical emergencies can be anticipated, and all OHPs should be well-versed in their prevention and management. Training in the provision of basic life support is considered an essential and fundamental component of dentistry. Despite this, studies have shown general dental practitioners (GDPs) to be inadequately trained for medical emergencies (Alhamad et al., 2015; Arsati et al., 2010; Chapman, 1997; Muller et al., 2008). Only about half of German GDPs were able to provide basic life support (Muller et al., 2008). About two in five Belgian dentists had never had adult basic life support training following graduation, and four in five never had pediatric basic life support training (Marks et al., 2013). Some years ago, only half of New Zealand GDPs had a current CPR or first-aid certificate, and one in five lacked an emergency equipment kit (Broadbent and Thomson, 2001). Overseas studies have indicated that the incidence of medical emergencies in dental practice (excluding syncope) is between 3.3 and 7.0 emergency events per practitioner during a ten-year practice period (Arsati et al., 2010; Atherton et al., 1999; Atherton et al., 2000; Chapman, 1997; Girdler and Smith, 1999). A 2001 study of 314 New Zealand GDPs reported a mean 4.5 emergency events per dentist during a ten-year practice period (Broadbent and Thomson, 2001). While this falls within the reported range, most of those studies are dated, and there is a need for more contemporary information, particularly in light of the ageing population (and its greater tooth retention). Published studies also tended to focus on GDPs. There is a lack of published data on the preparedness of other OHPs for medical emergencies. Only one study investigated the incidence of medical emergencies among both dentists and dental auxiliaries. Atherton et al. (2000) noted that dentists experienced more emergency events than dental auxiliaries (nursing staff, hygienists and radiographers). This suggests that other OHPs also encounter medical emergencies, but evidence for this within the New Zealand dental workforce remains unknown. Moreover, in September 2014, the Dental Council of New Zealand (DCNZ) updated its Codes of Practice for Medical Emergencies in Dental Practice (Dental Council of New Zealand, 2014). In this updated standard, the New Zealand Resuscitation Council Certificate of Resuscitation and Emergency Care (CORE) certification level required of OHPs was updated, along with the period of recertification. Little is known about the adherence of OHPs to this updated practice standard. Accordingly, this study investigated the preparedness of New Zealand GDPs and other OHPs for medical emergencies in dental practice. Methods This study was approved by the University of Otago Ethics Committee. Data were collected between March and July 2016. OHPs were randomly selected from the 2015-2016 Dental Register, obtained from the DCNZ. The 896 randomly selected OHPs represented 20% of the source population for each OHP type (GDPs, dental specialists, hygienists, therapists, and clinical dental technicians). A small number (7) who did not have a clinical role or were not practising in New Zealand were considered ineligible and were excluded from the sample, leaving 889 eligible participants. The electronic survey used Qualtrics TM software. A link to the online questionnaire was emailed to each participant in March 2016. Participants who failed to respond within two weeks were sent a reminder email. Those who did not respond to the electronic survey were then sent a questionnaire with a cover letter and reply-paid envelope. Questionnaire The questionnaire sought information on the respondents socio-demographic characteristics (specifically gender, age, ethnicity, year of primary dental qualification, and practice location), experience and preparedness for medical emergencies. The frequency of specific medical emergencies was also assessed. To maximise the accuracy of recall, the question on the incidence of vaso-vagal syncope and hyperventilation was limited to the past practising year, while other medical emergencies events to the past ten practising years, or as long as the practitioner had been practising if less than ten years. Information on the availability of emergency equipment and drugs (and confidence in administering these) was also sought. The list of emergency equipment and drugs was derived from the DCNZs practice standard (Dental Council of New Zealand, 2014) . Statistical analysis Data were entered electronically and analyzed using version 21 of the Statistical Package for Social Sciences (for Windows) (IBM).The level of statistical significance was set at p Results Responses were received from 353 of the 889 invited practitioners giving a response rate of 39.7%. Dentists (GDPs and dental specialists) represented 65.7% of respondents, while the remainder were other OHPs. Comparison with the 2011-2012 Workforce Analysis suggested an over-representation of New Zealand qualified dentists and dentists aged above 50 years within the sample (Table 1). For analysis purposes, the respondent age was dichotomized to less than 50 years old and 50 years or older. Similarly, the year in which practitioners obtained their primary qualification was also divided into two groups for analytical purposes: before 1990 and after 1990. More than half of the respondents (64.4%) listed their ethnicity as New Zealand European. The mean number of patients seen by a dentist in a week was 49 (SD, 26), and 44 (SD, 23) for other OHPs. Most dentists (96.6%) reported treating patients with local analgesia (mean, 49 per week; SD, 26); 36.2% reported using intravenous sedation (IV), oral sedation (OS) or relative analgesia (RA) (IV: mean, 0.6; SD, 3, OS: mean, 0.3; SD, 1, RA: mean, 0.2; SD, 1); and 8.0% reported treating patients under general anesthesia. The use of local analgesia during dental procedures was reported by 74.4% (n=90) of other OHPs (mean, 19; SD, 14). Almost half (48.7%) of OHPs reported updating each patients medical history at every visit; 45.8% did it at every new treatment plan/check-up, and the remaining 5.4% updated the medical history only occasionally. Vaso-vagal syncope was the most commonly reported emergency, followed by hyperventilation. Excluding hyperventilation and vaso-vagal events, there were 828 emergency events reported, corresponding to a mean of 2.4 events per respondent during the ten-year period (range, 0-62; SD, 7). Nearly half of respondents (43.3%) reported encountering at least one medical emergency during the last ten years. Dentists experienced a mean of 3.4 events (range, 0-62; SD, 8) and other OHPs a mean of 0.5 events (range, 0-11; SD, 1). Dentists were significantly more likely to experience more emergency events. Other significant emergency events reported were 78 episodes of tachycardia, five episodes of allergic reaction to latex, four episodes of Bells palsy, four episodes of vomiting and three episodes of bleeding (Table 2). Most respondents (96.9%) reported having a medical emergency kit available. Only 38.1% reported checking their medical emergency kit more than twice annually. Details of the emergency equipment and drugs kept by respondents are shown in Table 3. Most respondents reported having an ambubag and airway (82.1%), breathing apparatus for oxygen delivery (82.9%), an oxygen cylinder and regulator (82.3%) and a basic airway adjunct (77.2%) available. Among those who reported keeping these items, fewer than three in four were confident in using them. Dentists were further asked to provide information on the availability of a spacer device to deliver salbutamol and disposable hypodermic syringe and/or needles. Of the 70.1% who reported having a spacer device to deliver salbutamol, 82.6% were confident in using the device. A higher proportion of dentists reported having a disposable hypodermic syringe and/or needle available (82.5%), and 76.7% of dentists were confident in using it. A majority of dentists reported having adrenaline (91.3%), glyceryl trinitrate spray or tablets (86.9%), aspirin tablets (82.1%) or a salbutamol inhaler (79.0%) available in their emergency kit. Most respondents (92.9%) reported holding a current NZRC certificate. The majority (97.2%) of dentists who did not use sedation reported holding a NZRC certificate of level 4 or above. Three dentists did not provide information on their NZRC certificate level and one dentist reported having NZRC certificate level 3. For dentists who reported using any form of sedation excluding RA, 76.1% had a NZRC level 5 certificate or above, 22.5% reported having a NZRC level of 4, and 1.4% did not provide information on their certificate level. Most other OHPs (90.2%) had a NZRC level of 4 and above. Four other practitioners had a NZRC level of 3 and two reported having a NZRC level of 2. Five other OHPs did not provide information on their certification level. Data on the emergency items available among dentists who uses any form of sedation (including no sedation) are presented in Table 4. Just over one in four dentists using sedation (excluding RA) reported having an opioid antagonist. Excluding opioid antagonists, dentists who reported not using IV sedation were significantly more likely to have these emergency items than dentist not practicing sedation. The mean number of emergency events reported by dentists over the past ten years by the use of varying modes of sedation (including no sedation) are presented in Table 5. A statistically significant difference was observed in the frequency of angina pectoris, respiratory depression, allergic reaction to a drug, acute asthma and prolonged epileptic seizures between dentists who reported using sedation and those who did not practice sedation. Dentists using GA sedation reported significantly higher occurrence of angina pectoris than dentists used other form of sedation or did not use sedation, and those using RA reported more episodes of acute asthma than those who did not use sedation. Discussion This survey aimed to investigate the preparedness of New Zealand GDPs and other OHPs for medical emergencies. It was found that dentists were significantly more likely to encounter emergency events than other OHPs and that the majority of New Zealand OHPs were adequately prepared to manage a medical emergency. The response rate of 39.7% was higher than that reported by Muller et al. (2008) but lower than other studies (Atherton et al., 2000; Broadbent and Thomson, 2001).This may be attributed to the use of an online survey, which are less likely to achieve responses rates as high as surveys administered on paper (Shih and Xitao Fan, 2008). As with other self-administered survey, there is a tendency to under- or over-report the incidence of medical emergencies. Certain characteristics of the study respondents and differed significantly from the wider New Zealand dental workforce (Table 1). Dentists aged under 50 years and those who qualified overseas were under-represented. Such a difference may affect the generalizability of the findings. Despite these limitations, this is the first cross-sectional survey study which attempts to evaluate the incidence and preparedness of all New Zealand OHPs for medical emergencies in dental practices. Vaso-vagal syncope is the most commonly reported emergency by OHPs, followed by hyperventilation. This is in accordance with previously published studies (Alhamad et al., 2015; Marks et al., 2013; Muller et al., 2008) with the exception of Broadbent and Thomson (2001) who reported hyperventilation as the most common emergency event. Comparison of the findings of the current study in respect of GDPs to those of Broadbent and Thomson (2001) found that while the percentage of GDPs reporting vaso-vagal syncope and hyperventilation was lower than the 2001 study, the overall mean number of events per reporting participant in this study was higher. The incidence of respiratory depression reported by GDPs was 1.5 times lower than in the 2001 study (Broadbent and Thomson, 2001). This may be due to greater awareness and preparedness among GDPs, combined with stricter regulations imposed by the DCNZ. The use of sedation in dentistry has a positive influence on patients, but while it reduces anxiety and fear, it also increases the risk of respiratory depression. This was reflected in this study. Dentists using IV sedation reported a significantly greater incidence of respiratory depression than those who did not. This is, perhaps, unsurprising, as airway complications are the greatest threat to the safety of sedated patients (Tobias and Leder, 2011). However, the overall incidence of hypoglycemia reported by OHPs in our study was higher than that reported by Arsati et al. (2010) and Broadbent and Thomson (2001). Proper diagnosis of hypoglycemia is dependent on the observation of the Whipples triad; elevated plasma glucose concentration, hypoglycemic symptoms and relief of symptoms following carbohydrate administration, (Nelson, 1985). It is possible that any one of these symptoms may be overlooked by the practitioner when making a diagnosis resulting in over-diagnosis. Excluding vaso-vagal syncope and hyperventilation, the overall rate of medical emergency events among OHPs in New Zealand was lower than reported in previous overseas studies (Table 6). Comparison with Broadbent and Thomson (2001) suggests a decrease in the incidence of emergency events reported by GDPs, dipping from 4.5 to 2.9 emergency event per practitioner over a ten-year period in this study, pFigure 1). Dentists were 6.8 times more likely to experience an emergency event than other OHPs. This is consistent with findings of the 2000 United Kingdom survey, which also reported a greater frequency of emergency events by dentists than ancillary staff (Atherton et al., 2000). Several factors could contribute the latter difference. First, dentists are more likely to provide more complicated treatment than other OHPs. Second, patients who have more complex medical problems (or who are more anxious) may be more likely to attend a dentist than other OHPs for dental treatment. Being prepared with the proper equipment and drugs for the management of an emergency event is important, and most OHPs did have access to an emergency kit. With respect to GDPs, an 18.2% increase over 2001 was observed in the proportion of GDPs with an emergency kit (Broadbent and Thomson, 2001). The four basic emergency pieces of equipment meant to be contained within an emergency kit (regardless of practitioner type) are an ambubag and airway, breathing apparatus for oxygen delivery, oxygen cylinder and regulator, and basic airway adjuncts. The majority of GDPs (85%-89%) had these items, which was a marked improvement from the 2001 study where it ranged between 24% and 81%. Other OHPs were lacking in the availability of an ambubag and airways (30.3%) and basic airway adjunct (35.2%). The drugs required by the DCNZ practice standard were available to the majority of GDPs, but a relatively high proportion of specialists lacked some drugs, namely glyceryl trinitrate spray or tablets (21.9%), aspirin tablets (40.6%), and salbutamol inhaler (34.4%). The availability of oxygen was not specifically asked about in this survey, instead, the availability of an oxygen cylinder and regulator was assessed. We did not specifically asked OHPs whether the oxygen cylinder was filled. It was assumed that, if respondents had this equipment, oxygen would available. Dentists using sedative agents would be expected to be best prepared with appropriate medications and equipment. While they were well equipped (>86%) with the four basic pieces of equipment (listed in the previous paragraph), they were not well equipped with the additional equipment required for sedation, especially in the availability of an opioid antagonist (27.6%). This study found that overall, dentists practising sedation were better prepared with these additional items than those who did not. It is likely that some practitioners may be using a form of sedation that negates the use of these equipment. However, regardless of the form of sedation used, the requirement set by the DCNZ should always be followed. Proper training in the management of medical emergencies is important. A majority of dentists not using sedation (97.2%) and other OHPs (90.2%) had the appropriate NZRC CORE Level 4. Comparison with other overseas studies found OHPs in New Zealand to be better equipped in this area. Arsati et al. (2010) showed that only 59.6% of Brazilian dentists had undergone some form of resuscitation training, while only 47.5% of Belgium dentists (Marks et al., 2013) and 64% of Australian GDPs had undertaken basic life support trainings or CPR courses (Chapman, 1997). However, additional reinforcement is necessary to ensure that all OHPs have the appropriate NZRC CORE level, and thus the skills required to manage medical emergencies. For dentists using sedation, NZRC CORE Level 5 as outlined by the DCNZ guideline (implemented in 2014) is mandatory. However, almost one in four dentists using sedation (excluding RA) did not have a NZRC Level 5 or above certificate. This may be a concern because these practitioners are likely to undertake more complex procedures, possibly in patients with complicated medical conditions. We observed that they were more likely to experience emergency events in their practices. Conclusion Most New Zealand OHPs were equipped in training and equipment for medical emergencies, and New Zealand appears better than many other countries in this respect. However, the different groups of OHPs were still lacking some of the required emergency equipment and drugs. Our findings also clearly show that while there has been a marked improvement from the 2001 study, some OHPs still lacked training (NZRC CORE), and so, it is possible that these practitioners may lack competence in treating medical emergencies. References Alhamad M, Alnahwi T, Alshayeb H, Alzayer A, Aldawood O, Almarzouq A, Nazir MA(2015). Medical emergencies encountered in dental clinics: A study from the Eastern Province of Saudi Arabia. J Fam Community Med 22(3):175-179. Arsati F, Montalli VA, Florio FM, Ramacciato JC, da Cunha FL, Cecanho R, de Andrade ED, Motta RHL (2010). Brazilian dentists attitudes about medical emergencies during dental treatment. J Dent Educ 74(6):661-666. Atherton GJ, McCaul JA, Williams SA (1999). Medical emergencies in general dental practice in Great Britain. Part 1: Their prevalence over a 10-year period. BDJ 186(2):72-79. Atherton GJ, Pemberton MN, Thornhill MH (2000). Medical emergencies: the experience of staff of a UK dental teaching hospital. BDJ 188(6):320-324. Broadbent JM, Thomson WM (2001). The readiness of New Zealand general dental practitioners for medical emergencies. NZ Dent J 97(429):82-86. Chapman PJ (1997). Medical emergencies in dental practice and choice of emergency drugs and equipment: a survey of Australian dentists. Aust Dent J 42(2):103-108. Dental Council of New Zealand (2014). Medical Emergencies in Dental Practice Practice Standard. Wellington: Dental Council of New Zealand. Girdler NM, Smith DG (1999). Prevalence of emergency events in British dental practice and emergency management skills of British dentists. Resuscitation 41(2):159-167. Hung WW, Ross JS, Boockvar KS, Siu AL (2011). Recent trends in chronic disease, impairment and disability among older adults in the United States. BMC 11(1):1-12. Marks LA, Van Parys C, Coppens M, Herregods L (2013). Awareness of dental practitioners to cope with a medical emergency: a survey in Belgium. Int Dent J 63(6):312-316. Muller MP, Hansel M, Stehr SN, Weber S, Koch T (2008). A state-wide survey of medical emergency management in dental practices: incidence of emergencies and training experience. EMJ 25(5):296-300. Nelson RL (1985). Hypoglycemia: fact or fiction? Mayo Clin Proc 60(12):844-850. Shih T-H, Xitao Fan (2008). Comparing Response Rates from Web and Mail Surveys: A Meta-Analysis. Field Methods 20(3):249-271. Statistics New Zealand (2015). 2013 Census QuickStats about people aged 65 and over. Wellington: Statistics New Zealand. Tobias J, Leder M (2011). Procedural sedation: A review of sedative agents, monitoring, and management of complications. SJA 5(4):395-410. Author details: C L Hong BDS. Department of Oral Rehabilitation, Faculty of Dentistry, University of Otago, PO Box 647, Dunedin 9054. A W Lamb BDS. Dental and oral health department, Level 10, Wellington Hospital, Riddiford St, Newton, 6021. J M Broadbent BDS, PGDipComDent, PhD. Department of Oral Rehabilitation, Faculty of Dentistry, University of Otago, PO Box 647, Dunedin 9054. H L De Silva BDS, MS, FDSRCS, FFDRCSI. Department of Oral Diagnostic and Surgical Sciences, Faculty of Dentistry, University of Otago, PO Box 647, Dunedin 9054. W M Thomson BSc, BDS, MA, MComDent, PhD. Department of Oral Sciences, Faculty of Dentistry, University of Otago, PO Box 647, Dunedin 9054. Table 1. Comparison of respondents sociodemographic characteristics with those of the New Zealand (NZ) dental profession. Dentist (%) Dentists in NZ dental profession a (%) Other OHPs (%) Other OHPs in NZ dental profession a (%) Sex Male Female 140 (60.6) 91(39.4) 1347 (64.6) 738 (35.4) 9 (7.4) 112 (92.6) 54 (4.3)c 1191 (95.7)c Age Less than 50 50 and over 104 (45.6) b 124 (54.4) b 1220 (58.5)b 865 (41.5) b 68 (56.2) 53 (43.8) 881 (61.1) 561 (38.9) Country of qualification New Zealand Other 184 (81.4) b 42 (18.6) b 1456 (69.8) b 629 (30.2) b 112 (92.6) 9 (7.4) NR NR a Dental Council of New Zealand (Workforce Analysis 2011-2012) b p c Excludes clinical dental technicians NR: not reported Table 2. Incidence of medical emergencies by practitioner type. Emergency event Number of GDPs reporting during a one-year period (%) Number of specialists reporting during a one-year period (%) Number of other practitioners reporting during a one-year period (%) Mean number of events for per reporting practitioners (sd) Total number of events reported (max) Vaso-vagal syncope a 71 (36.0) 10 (37.0) 1.5 (12.8) 3.3 (6.0) 313 (50) Hyperventilation a 40 (20.3) 3 (11.1) 1.2 (10.3) 3.5 (5.1) 185 (25) Angina pectoris (chest pain) 2.4 (12.2) 5.0 (18.5) 1.0 (0.9) 1.7 (1.3) 51 (5) Swallowed foreign body 2.9 (14.7) 3.0 (11.1) 1.2 (10.3) 1.8 (2.2) 79 (12) Epileptic seizures (grand mal) 1.7 (8.6) 4.0 (14.8) 3.0 (2.6) 1.8 (2.0) 43 (10) Hypoglycemia 4.4 (21.3) 7.0 (25.9) 3.0 (2.6) 3.7 (3.7) 192 (15) Myocardial infarction 0.3 (1.5) 1.0 (3.7) 0.0 (0.0) 1.3 (0.5) 5 (2) Respiratory depression 1.0 (5.1) 5.0 (18.5) 0.0 (0.0) 6.0 (6.4) 90 (80) b Allergic reaction to a drug 2.8 (14.2) 5.0 (18.5) 2.0 (1.7) 3.2 (4.6) 112 (20) Anaphylaxis 9.0 (4.6) 4.0 (14.8) 0.0 (0.0) 1.7 (1.4) 5 (5) Overdose (eg of anesthetic) 4.0 (2.0) 2.0 (7.4) 1.0 (0.9) 1.4 (0.8) 10 (3) Circulatory depression or collapse 4.0 (2.0) 2.0 (7.4) 2.0 (1.7) 2.1 (1.6) 17 (5) Stroke (cardiovascular accident) 3.0 (1.5) 1.0 (3.7) 0.0 (0.0) 1(-) 4 (1) Inhaled foreign body 2.0 (1.0) 0.0 (0.0) 1.0 (0.9) 1 (-) 3 (1) Acute asthma 7.0 (3.6) 1.0 (3.7) 2.0 (1.7) 1.8 (1.3) 18 (5) Hyperglycemia

Dell’s Strategic Management Plan Essay -- Computers, Business

Dell, Inc. got its start in 1984 when Michael Dell, a University of Texas student, began building computers for fellow students under the company name PCs Limited (Edwards, 2007). Within the next decade, Dell experienced phenomenal success by pursuing growth through catalog and corporate sales (Hunger, 2006). Dell made technology affordable and in doing so became a fierce competitor in the computer technology industry. However, the company’s disorganized structure could barely support their impressive growth. There are three specific measures of performance that I would have incorporated into Dell’s strategic management plan if I were leading Dell. Furthermore, I would include behavior and output controls in the control system to regulate organizational activities to ensure that they are consistent with company standards of performance. Dell, Inc. pursued an aggressive growth strategy which was met with equally aggressive customer demand. Dell delivered a quality product for a reasonable price and this value that Dell created for their customers was initially unmatched by rival computer companies. In fact, Dell saw this as an opportunity to expand their product line to include items such as printers and software. The company’s sales increased from $389 million in 1989 to $2.9 billion in 1993 (McGraw, 1994). However, the management structure did not grow with the company (McGraw, 1994). Financial results were not analyzed properly and the company was not being strategically managed (Hunger, 2006). Dell’s management team decided to slow their growth initiatives in part by eliminating retails sales of their products (Hunger, 2006). This decision created three distinct problems for the company. First, customers were unhappy that t... ...nagement (6th ed.). Mason, OH: South- Western Cengage Learning. Edwards, O. (2007, August). Baby Dell. Smithsonian, 38(5), 34-36. doi: 131320451 Hunger, D. J. (2006). Dell, Inc. In T. L. Wheelen & J. D. Hunger (12th ed.), Strategic management and business policy (pp. 31-1 – 31-5). Upper Saddle River, NJ: Prentice Hall. Matthews, J. R. (2011). Assessing organizational effectiveness: The role of performance measures. Library Quarterly, 81(1), 83-110. Retrieved from EBSCOhost. McGraw, D. (1994). The kid bytes back. U.S. News & World Report, 117(23), 70. Retrieved from EBSCOhost. Rogers, B. (2006). High performance is more than a dream - it's a culture. T + D, 60(1), 12. Retrieved from EBSCOhost. Wheelen, T. L., & Hunger, J. D. (2012). Strategic management and business policy: Toward global sustainability (13th ed.). Upper Saddle River, NJ: Prentice Hall.

Fishing from heaven

The frost clung to the surroundings as I made my way down the old crooked path. It was early morning and the sun was attempting to wedge its way through the clouds: it remained ice cold. There was little life to be seen – most animals were hidden away from the dangers and cruelty of winter. They had collected their food and were snuggled away ready to sleep the months through. At that moment I wished I could join them. Why couldn’t I run away and hide until I was ready to face life again? As I trod over the cold granite with the fellow mourners I could see nothing of happiness. Everything hung in dismay as if even nature knew this was a wretched and lonely place. I imagined the gloomy individuals walking this route over the decades. It was a path that had to be travelled but very few were ready or willing to face its destination. Instead we all hoped something would suddenly change and that our fate would be reversed. The daunting doors appeared ahead and I made my way inside along with the others – all of us coated in black. I shivered, no longer because of the temperature but rather fear, as I made my way inside the thick stone walls. The mighty roof towered over me shadowy and oppressive. I found my pew and sat down alone to wait. The tranquilising smell of burning incense combined with my tired state almost lulled me to unconsciousness but a stern voice suddenly called for the beginning of the service and I turned to face the altar. It was covered in a white cloth which hung loosely over the sides clearly too big. A cross made up the centrepiece and a candle stood on either side. I’d never been to a church before but I knew granddad had. I imagined him looking at this cross and, like me, wondering why life had to happen the way it did. The music sounded and they began to enter – the robed man and the six friends of my grandfather. I only knew one of them. They had gone to school together and granddad would always tell stories of their misbehaving – tricking the teacher and missing classes. I saw his friend dim with dread no longer a schoolboy with a future of brightness ahead. His head hung low as he made his way down the aisle. The lid of the coffin was lifted and his face tightened as he saw his friend for the last time. Granddad’s face was withered and frail, his lips rose pink and dry. They had dressed him in his favourite suit especially for the occasion. His body lay stiff, fragile and delicate – but strangely imposing. This was not how I remembered him. Vulnerability and helplessness had overcome him. His intelligent being was hidden – deposed by death. * * * It was a spring morning and the lake glistened in the sun. Not a ripple disturbed the perfect reflections. The smell of freshly painted wood hung in the air as the boat entered the water. Its green body caused it to appear like a lily-pad against the still expanse. I was trembling with excitement: I had never been on a boat before. We lived in the town where buildings filled the landscape. It was only when I came here on holiday that I got to see the amazing aspects of nature so forgotten in cities where cars and buses have taken over. First grandfather gave me a rod. He smiled as I looked at this alien object with uncertain eyes. He loaded the reel, explained how to make a blot knot, stuck on the tiny squirming pinkie and cast into the distance. He stressed the importance of doing this properly so as to avoid whipping your neighbour or startling the surrounding fish. Looking at granddad I stared intently at the thick folds throughout his face, his hunched over body and the shadows b eneath his eyes. As he cautiously scanned the horizon he noticed my attention had wavered and stared right into my soul seemingly extracting my thoughts. â€Å"Ethan, old age is nothing to fear but something to grasp with open arms and imagine the life past and still to come. You must remember that. This moment will pass but the memory remains forever and that’s what we hold on to even when death arrives.† I turned away not sure what he meant and focused back on my fishing. My line went taut and I was pulled back to the present. The fish wriggled desperately trying to free itself from the cruel spike threatening its life. It was helpless against my strong grasp. My determination to impress granddad and the weak power of the fish enabled me to reel the rod all the way in. I had caught a fish – a trout! It was avocado green speckled pink. I knew little of the types of fish but granddad told me it was a Yellowstone Cutthroat Trout native to this area. He smiled proud of what I had gained. * * * I wept bitter with regret as the pastor began to talk of grandfather’s life in such a dispassionate way. He knew nothing of the love I felt for him, of the kindness grandfather showed or of the suffering he endured in his last years. I wished I could have stood up and conjured up something which may have done him justice rather than this monatomic drone of weddings, birthdays and jobs. This was not all that my grandfather was. He was more than this. The room silenced as the pastor took to his seat. The roof of the coffin was replaced and the congregation bowed their heads remembering the man in their own way. I saw, not the cold lifeless face that had been laid before me this morning but the bright and warm-hearted glow from that fishing day. I saw him in his heaven with doves fluttering above a crystal ocean full of the most beautiful creatures.

Still Separate, Still Unequal By Jonathan Kozol - 1121 Words

The essay â€Å"Still Separate, Still Unequal†, written by Jonathan Kozol, discusses the actuality of intercity public school systems, and the isolation and segregation of inequality that students must be subjected to in order to receive an education. Jonathan Kozol illustrates the grim reality of the inequality that African American and Hispanic children face within todays public education system. In this essay, Kozol shows the reader, with alarming statistics and percentages, just how segregated Americas urban schools have become. He also brings light to the fact that suburban schools, with predominantly white students, are given far better funding and a much higher quality education, than the poverty stricken schools of the urban neighborhoods. Jonathan Kozol brings our attention to the obvious growing trend of racial segregation within America’s urban and inner city schools. He creates logical support by providing frightening statistics to his claims stemming from h is research and observations of different school environments. He also provides emotional support by sharing the stories and experiences of the teachers and students. His credibility is established by the author of Rereading America by providing us with his collegiate background. This is also created from his continual involvement with isolated and segregated educational school systems and keeps tone sincerity throughout his essay. Within the essay, Still Separate, Still Unequal, Jonathan Kozol’s argument isShow MoreRelated`` Still Separate Still Unequal `` By Jonathan Kozol999 Words   |  4 PagesIn Jonathan Kozol â€Å"Still Separate Still Unequal† the author discusses how education for inner city school kids greatly differs from white school kids. â€Å"Schools that were already deeply segregated twenty-five or thirty years ago are no less segregated now† (Kozol 143). Although in 1954 the popular court case Brown vs Board of Education should have ended segr egation in schools. The author shows how â€Å"the achievement gap between black and white children continues to widen or remain unchanged,† (KozolRead MoreEssay about â€Å"Still Separate, Still Unequal† by Jonathan Kozol699 Words   |  3 PagesIn the essay â€Å"Still Separate, Still Unequal† by Jonathan Kozol, the situation of racial segregation is refurbished with the author’s beliefs that minorities (i.e. African Americans or Hispanics) are being placed in poor conditions while the Caucasian majority is obtaining mi32 the funding. Given this, the author speaks out on a personal viewpoint, coupled with self-gathered statistics, to present a heartfelt argument that statistics give credibility to. Jonathan Kozol is asking for a change in thisRead MoreStill Separate, Still Unequal Analysis Essay1233 Words   |  5 PagesStill Separate, Still Unequal â€Å"Still Separate, Still Unequal†, written by Jonathan Kozol, describes the reality of urban public schools and the isolation and segregation the students there face today. Jonathan Kozol illustrates the grim reality of the inequality that African American and Hispanic children face within todays public education system. In this essay, Kozol shows the reader, with alarming statistics and percentages, just how segregated Americas urban schools have become. He also bringsRead MoreEducational Fears Are Lack Of Ability, Not Belonging, And Failure Essay1427 Words   |  6 PagesGreatest Fear Essay Educational fears are lack of ability, not belonging, and failure. Jonathan Kozol explores these fears in â€Å"Still Separate, Still Unequal: America’s Apartheid†. Lack of ability is an example of an educational fear, as Kozol says that about minorities not having prior experience in school, so they don’t have the same ability as other students. Not belonging is another example of an educational fear, Kozol says these minority students feel like they don’t belong, when most of the school’sRead MoreStill Separate, Still Unequal1648 Words   |  7 PagesStill Separate, Still Unequal Segregation is a topic that has been discussed for decades. Segregation in schools wasnt really dealt with. The government basically disguised it and kept it away from the public. Brown V. Board of Education, Plessy V. Ferguson, and Jim Crow Laws was the cover, but it didnt solve anything. Segregation isnt just about race, its also financially. When money is involved in the situation theres a major advantage. Johnathan Kozol talks about how were still separateRead MoreThe Logical, Emotional, And Credible Evaluation Of `` Still Separate, Still Unequal ``1482 Words   |  6 Pagesand Credible Evaluation of â€Å"Still Separate, Still Unequal.† Jonathan Kozol is an American writer from Boston, Massachusetts, and a graduate of Harvard University. He began his career as a teacher in the Boston school system and also became involved in the study of social psychology. Later he became an activist for low income and poverty destined children who are not provided the means for a proper education. The essay â€Å"Still Separate, Still Unequal†, by Jonathan Kozol, discusses the harsh truthRead More`` Still Separate, Still Unequal `` By David Matthews Essay1579 Words   |  7 Pagesbenefits are granted to the most disadvantaged people. The articles, â€Å"Still Separate, Still Unequal† by Jonathan Kozol, â€Å"Rethinking Affirmative Action† by David Leonhardt, and Progress Made, but Science Still a Man s World: News by David Matthews, all illustrate how John Rawls’s principles are still not being realized today to their fullest extent. In Jonathan Kozol’s article, he demonstrates how the educational system in America is still racially divided despite the end of segregation in the 1900s. InRead MoreStill Separate, Still Unequal: America’s Educational Apartheid767 Words   |  4 Pagesessay â€Å"Still Separate, Still Unequal: America’s Educational Apartheid,† Jonathan Kozol brings our attention to the apparent growing tren d of racial segregation within America’s urban and inner-city schools (309-310). Kozol provides several supporting factors to his claim stemming from his research and observations of different school environments, its teachers and students, and personal conversations with those teachers and students. As we first take a look at the frightening statistics Kozol providesRead MoreFremont High School By Jonathan Kozol879 Words   |  4 Pages In the writing Fremont High School by Jonathan Kozol he discusses the reality of urban schools and how they are unable to obtain the proper education. At Fremont High School children are not always able to eat during their lunch period, the proper education needed for college is not obtained, the school reflects institutional discrimination, and the building is overcrowded limiting course offerings for children. Kozol shares his experiences with students and teachers while visiting FremontRead More Jonathan Kozols Savage Inequalities: Children in America’s Schools1185 Words   |  5 PagesJonathan Kozols Savage Inequalities: Children in America’s Schools In this detailed and shocking book, Jonathan Kozol describes the horrific and unjust conditions in which many children in today’s society are forced to get their education. Kozol discusses three major reasons for the discrepancies in America’s schools today: disparities of property taxes, racism, and the conflict between state and local control. The first of these reasons is that of the differences of available property