Nurse-led Clinics in Respiratory Care: a Literature Review

Nurse-led Clinics in Respiratory Care: a Literature Review INTRODUCTION 1. What is a nurse-led clinic? As the coined term suggests, a nurse-led clinic is a health care centre in which nurses are involved in high level specialist procedures and assessments. In such centres, nurses are the critical decision makers, being involved in patient care at the micro-, meso-, and macro-levels. While the role of the physician in the provision of health care is undisputable, the deity-like status that medical practitioners typically have in the mind of patients, coupled with the limited time available for individual patient consultations, make it hard for these group of health care professionals to tackle the ‘softer’ side of patient care. Nurses, on the other hand, defined by the Oxford Medical Dictionary as health care professionals that are trained and experienced in nursing matters and entrusted with the care of the sick and the carrying out of medical and surgical routines, are better placed to provide this essential follow-up, especially in the care of patients with chronic dise ases. According to Hatchett (2003), a nurse-led clinic is a clinic in which nurses have their own patient case loads of whom they take complete charge. Hatchett broadly describes the components of such a clinic. There would be an increase in autonomy associated with the nursing role in the nurse-led clinic, with the power to admit, discharge or refer patients, as appropriate. In Hatchett’s own words, the roles which nurses adopt in these revolutionary settings can be broadly classified as follows (Hatchett, 2003): Education Psychological support Patient monitoring The initiation of nurse-led initiatives probably owes its origins to the rise in nursing specialties in the United Kingdom. Throughout primary and secondary care, nurses are taking senior positions in health care institutions, such as nurse specialists, nurse practitioners, nurse consultants, nurse prescribers, etc, leading to a marked change in service delivery and the profile of the nursing profession. In addition to the usual registered nurse training, nurses working at higher levels of practice receive training to acquire a range of other medical skills such as physical examination and medical history taking in order to recognise abnormal clinical findings. In a two-phase exploratory study to evaluate the domains of structure, process and outcome of nurse-led clinics in supporting intermediate care after the acute phase of disease, Wong et al (2006) interviewed nurses from 34 clinics and 16 physicians and observed 162 nurse-led clinic sessions. Their findings demonstrated the high level of skill and experience of the nurses who ran the clinics. Their work involved skills such as adjusting medications and initiating therapies, and diagnostic tests according to protocols. Interventions included assessments and evaluations, and health counselling. All patients studied showed improvement after the nurse clinic consultation, with the best rates reported in wound and continence clinics; satisfaction scores for both nurses and clients were high. However, although physicians valued their partnership in care with the nurses, they were concerned about possible legal liability resulting from the advanced roles assumed by these nurses. Ultimately, nurse-led clinics provide an integral and invaluable patient-centred approach to the management of chronic disease which build upon skills such as counselling, teaching and health promotion which are key to contemporary nursing practice, as well as newly acquired medical skills. The advent if nurse-led clinics provides an opportunity for nurses to develop enhanced roles in which they can achieve more autonomy in their practice. This can be made a reality if adequate training and education, as well as effective leadership are in place (Wiles et al, 2001). 2. The general roles of nurses in chronic care management The chief nursing officer, Sarah Mullally has proposed ten key roles for nurses in autonomous patient care. These are outlined below as cited by Hatchett (2003): Order diagnostic interventions: just like a medical practitioner would, the present-day nurse is able to ask for laboratory or clinical diagnostic tests to aid the process of diagnosis. Furthermore, a well-trained nurse will also be able to read and interpret laboratory results effectively Make and receive referrals directly: while the all-important roles of nurses are recognised, the need for a multidisciplinary approach to patient care remains key in order to optimise patient outcomes. Accordingly, nurses should be able to recognise the patients’ needs and refer them to the appropriate health care service as required. Similarly, nurses should be ready to accept referrals from other health care disciplines as necessary. Admit and discharge patients for specified conditions, within agreed protocols: in order to make the best use of the often limited hospital resources, a nurse should have the power to recommend patients for hospital admission and subsequent discharge Manage patient case loads: in nurse-led clinics, nurses are also responsible for managing their individual case loads. It is important to delegate patient cases to other members of the team, when necessary to ensure that patients receive the best care possible. Run clinics: the autonomous role of the nurse in a nurse-led clinic includes all aspects of the management and day-to-day running of the clinic. Prescribe medications and treatments: nurse prescribers are able to advise patients on appropriate treatment, based on diagnosis of ailment and individual characteristics and laboratory findings. Carry out a wide range of resuscitation procedures, including defribillation Perform minor surgery and outpatient procedures: especially in injury clinics. While nurses are probably not equipped to carry out full-fledged surgical operations alone, they are trained to conduct emergency processes as appropriate. Triage patients, using the latest information technology, to the most appropriate health care professional Take a lead in the way local health services are organised and in the way they are run Nurses have always been considered as a supplement to the fundamental care provided by medical doctors. In fact, in some geographical regions, nursing roles are limited to menial tasks such as changing bedpans etc. In the new age, the nursing role as we know it is becoming increasingly important with nurses taking on infinitely more clinical roles. This has led to controversial debates with critics arguing that nurses cannot replace doctors in the provision of health care services. As Richard Hatchett very astutely pointed out (2003), the increased autonomy being acquired by nurses is not a bid to compete with medical doctors. Instead, â€Å"it is a case of considering who can provide the most appropriate service to the patient† (Hatchett, 2003). Thus, it is clear that the roles of nurses in chronic care management is very diverse and can be integrated into any nurse-led clinic intervention to the utmost benefit of the patient and all stakeholders. There have been numerous studies on the role of nurses in the care of patients with chronic diseases. In addition, and more specifically, the feasibility and benefits of implementing nurse-led clinics in practice have also been investigated to some extent. In the subsequent sections, we will review the evidence to support these innovative nursing interventions in an attempt to make the best use of health care resources. 3. Nurse-led clinics in the management of chronic care diseases: the evidence The World Health Organization (2002) defines chronic diseases as health care problems that require ongoing management over a period of years or decades. The nature of these disease conditions make it necessary to provide long term care and follow-up for the afflicted patients. Nurse-led interventions have been investigated a wide range of chronic diseases. It could be a logical, user-friendly, cost-effective and practical approach to improving long-term patient outcomes and should be explored fully to maximise the contributions of nurses to the chronic care management. Although this review aims to analyse the effectiveness of nurse-led clinics in the treatment of respiratory diseases, a prior look at the role of these interventions in the management of other chronic care diseases will provide an insight to the general contributory roles of nurses and will serve as a foundation for complete understanding of this state of the art intervention. 3.1 Nurse-led interventions in the management of diabetes Numerous studies have evaluated the benefits and practicalities of nurse-led clinics in the long-term management of diabetes. The renal diabetic nurse specialist is described as an â€Å"essential player† in organising the management of, and to meet, all aspects of need of this group of patients (Marchant, 2002). An unintended benefit of a nurse-led clinic to reduce cardiovascular risk is improved glycaemic control, HbA1c (Woodward et al, 2005). In particular, nurse-led diabetic clinics have been shown to benefit specific ethnic groups. Matthias et al (1998) identified the needs of diabetic patients from minority ethnic groups, such as blacks and Asians and postulated that nurse-led clinics were of particular benefit in this patient group. As epidemiological data show that diabetes is most common in minority ethnic groups (Carter et al, 1996), the importance of these innovative interventions is further emphasised. 3.2 Nurse-led interventions in the management of cardiovascular disease Care of patients with cardiovascular diseases is broad and involves many aspects, from risk factor management (non pharmacological interventions), primary and secondary prevention of clinical events, pharmacological therapy, surgical procedures, etc. Through a large well-designed randomised controlled trial in Scotland, Campbell et al (1998) showed that nurse-led clinics were practical to implement general practice and led to an significant increase in various aspects of the secondary prevention of coronary heart disease. Significant improvements were noted in aspirin management, blood pressure management, lipid profile management, diet and physical activity, regardless of the individual patient’s baseline cardio performance or status. However, surprisingly, there was no recorded improvement on smoking cessation, which would have been a beneficial intervention in most acute and chronic disease states, including respiratory diseases. In addition to the apparent effectiveness of the nurse-led clinics in the long-term primary and secondary prevention of coronary heart disease, the optimal use of nurses in the care of these patients has been shown to be cost-effective in terms of quality adjusted life years (QALYs) (Raftery et al, 2005). In this large cost-effectiveness analysis, although the cost of the nurse-led clinic intervention was  £136 higher per patient, the differences in other National Health Service (NHS) costs was not statistically significant. Furthermore, there were 28 more deaths in the non-intervention group leading to a gain, in the intervention group, in mean life-years per patient of 0.110 and of 0.124 QALYs. 3.3 Nurse-led interventions in rheumatology The role of clinical specialist medical doctors in the care of their patients is unquestionable; however, the role of nurses in the therapy area of rheumatology (i.e. in patients with rheumatoid arthritis) is also well documented. Hill and colleagues (1994) clearly demonstrated the effectiveness, safety and acceptability of a nurse practitioner in a rheumatology outpatient clinic. Although this was a small study with a sample size that only included 70 patients, the statistical significance of the findings of this randomised controlled trial cannot be ignored. In patients managed in the Rheumatology Nurse Practitioner clinic, pain, morning stiffness, psychological status, patient management and satisfaction all improved significantly (p = 0.001; p = 0.028; p = 0.0005; p In addition, patient satisfaction is frequently higher in patients who are allocated to nurse care than those allocated to standard medical care (Hill, 1997). In yet another study by Dr Jackie Hill, a registered nurse at the Academic and Clinical Unit for Musculoskeletal Nursing in the Chapel Allerton Hospital in Leeds, the researchers concluded that a nurse-led clinic is effective and safe and is associated with additional benefits, such as greater symptom control and enhanced patient self-care, compared with standard outpatient care. 3.4 Nurse-led interventions in cancer care The effectiveness of nurse-led care in different common cancer afflictions has been researched variously. An extensive review article by Loftus and Weston (2001) discussed the patient needs that could be met by nurses working in nurse-led clinics and highlighted the experience and skills of advanced nursing practice that make such innovative care a reality. The types of nurse-led interventions are as varied as the different types of cancers for which they are used. These range from nurse-led telephone clinics in patients with malignant glioma (Sardell et al, 2001); nurse-led follow up in patients receiving therapy for breast cancer (Koinberg et al, 2004); and nurse-led screening programmes in Hong Kong Chinese women with cervical cancer (Twinn and Cheung, 1999). In a randomised controlled trial in a specialist cancer hospital and three cancer units in southeastern England, Moore et al (2002) assessed the effectiveness of nurse-led follow-up in the management of patients with lung cancer. The findings of the study showed high levels (75%) of patient acceptability. This negates the possibility of patients’ reduced confidence in nurses’ ability and preference for standard medical doctor care. Clinical outcomes were also greatly improved as shown by less severe dyspnoea at three months (p=0.03), better scores for emotional functioning (p=0.03), and less peripheral neuropathy at 12 months (p=0.05). 3.5 Nurse-led interventions in the management of HIV infection Using a rigorous model of comprehensive care nurse-led clinic in genitourinary medicine to compare nurse-led and doctor-led clinics at a central London medicine clinic, Miles and colleagues (2003) reported reliable and valid results to support the use of the nurse-led variety as an acceptable alternative to the existing doctor-led clinics. More specifically, the British HIV Association (BHIVA)/British Association for Sexual Health and HIV (BASHH) advocate the benefits that can be accrued from a nurse-led educational intervention in the care of patients with HIV infection (Poppa et al, 2003). A small pilot study that investigated the effects of a 6-month nurse-led educational programme reported that improved virological responses were seen in treatment-experienced patients (Alexander et al, 2001). While a majority of the studies on nurse-led clinics in other chronic diseases can be broadly applied to nurse-led care in patients with respiratory diseases, differences in the nature of these diseases and the necessary care pathways mean that the extent to which these tested interventions can be applied to other therapy areas is, in actual fact, limited. Government policies that advocate the clinical and economic effectiveness of nurse-led interventions frequently pool together evidence from all therapeutic areas. Indeed, it can be hypothesised that, if nursing interventions are shown be practical alternatives for medical care in complex diseases with poor prognoses, such as cancer, HIV and coronary heart diseases, care of patients with respiratory diseases which generally have better prognoses should be easily, effectively and safely undertaken by qualified and well-trained nurses. Nevertheless, these findings of the effectiveness of nurse-led interventions in the numerous chronic diseases explored in previous sections, should be applied to the different patient population with respiratory diseases. As much as possible, research findings from similar patient groups should be applied in clinical practice in order to ensure that evidence-based practice in this case is relevant. 4. Government policies influencing the establishment of nurse-led clinics Government health policies in the United Kingdom actively support the extension of nurses’ skills into areas such as nurse prescribing and the development of nurse practitioner posts (NHS Plan 2000; Department of Health). Government initiatives that that strive to reduce consultation waiting times and optimise the use of medical practitioners indirectly support the establishment of nurse-led clinics. The Government has endorsed the implementation of nurse-led clinics as a means of increasing access to specialist health care and treatment more quickly and also as an effective way to manage chronic conditions (Hatchett, 2003). In the Department of Health (1999) document, ‘Making a difference’, government plans for strengthening nursing contribution to health care is presented. The Government has launched an ambitious programme of measures to improve the National Health Service and the health of the public, and the role of the nursing profession in this initiative cannot be overemphasised. The key nurse-related points of the document are outlined below: To extend the roles of nurses, midwives and health visitors to make better use of their knowledge an skills – including making it easier for them to prescribe To modernise the roles of school nurses and health visitors in supporting the new health strategy and other policies To see more nurse-led primary care services to improve accessibility and responsiveness The document highlights numerous nurse-led initiatives that have been effectively implemented all around the United Kingdom. A nurse-led minor injury service in rural Cornwall has provided patients with a number of benefits: easier accessibility, reduced waiting times, reduced need for on-site medical; attendance, increased patient satisfaction and reduced need for transfers to local Accident and Emergency departments. Similarly, a nurse-led rapid response team in Peterborough responds to acute crisis cases and allows patients to be nursed at home. Evaluation has shown that 71% of patients referred to this ‘hospital at home’ service would have been admitted to hospital if the service did not exist. Other effective live nurse-led services include a nurse-led rheumatology service in Merseyside and a nurse-led intermediate care unit in Liverpool. Furthermore, several nurse interventions are advocated in the document for contributing to the management of cardiovascular disease. Several of these are also applicable to respiratory diseases; these include: Smoking cessation clinics using national smoking cessation guidelines Healthy lifestyle clinics in collaboration with other health professionals to address factors such as diet, nutrition and exercise, thus improving overall health Care for patients with congestive cardiac failure under ‘home-based’ initiatives Nurse-led chest pain clinics or risk factor screening and reduction clinics Nurse-led blood pressure clinics to identify and help manage blood pressure disorders and medication adherence 5. Review objectives The objectives of this review are: To briefly summarise various studies on effectiveness and cost-effectiveness of nurse-led interventions in common respiratory diseases To critically appraise the methods employed by these studies To evaluate, interpret, and where possible, compare the findings of the various studies To explore the applicability and generalisability of the results to practice in the appropriate patient population To make suggestions for future studies in this area. METHODS Literature search A search of two major databases, MEDLINE and EMBASE, was conducted to identify articles published from 1990 through 2008. Search terms that were used include nurse, nurse-led clinic, nurse-led interventions, respiratory diseases, asthma, chronic obstructive pulmonary disease, bronchiectasis, tuberculosis, cystic fibrosis, cost-effectiveness analysis, cost-benefit analysis, and economics. A secondary search of the reference lists was then conducted to identify relevant articles, editorials, and other unoriginal reports that may have been missed in the primary search. Some studies were excluded based on the following criteria: They were not conducted in patient populations with respiratory diseases Independent nurse-led interventions were not investigated The study populations being investigated were mixed in terms of diagnosis, which would affect the integrity of the study findings for respiratory diseases The methodology and/ or statistical analysis methods were not clearly elucidated 6. Nurse-led clinics in the management of respiratory diseases: a review of the evidence The role of the specialist respiratory nurse has evolved since the early 1980’s with the support of the Royal College of Physicians (RCP 1981). The possible complexity of respiratory patients’ regimens necessitates support with various aspects of their care plans, such as: Supervising nebuliser and inhaler techniques Monitoring progress, i.e. by periodical assessment of lung function and exercise capacity Education on the specific disorder, medications, potential adverse events, etc Counselling and education on positive lifestyle, or non-pharmacological, changes Adherence support and monitoring The role has developed further with nurses providing nurse-led clinics in chronic obstructive pulmonary disease (COPD) and asthma along with nurses providing early supportive discharge and ’hospital at home’ for patients with COPD (French et al, 2003). Some schools of thought argue that nurse-led clinics would culminate in the neglect of the more traditional nursing roles, as nurses focus on a more medical-focused aspect of patient care. However, research in other therapy areas, such as rheumatology (Hill et al, 1994) and mental health (Reynolds et al, 2000) shows that nurses can effectively combine the medical role with the traditional nursing approach. Nursing care strives to provide a holistic approach to care through practical management of disability, education and counselling and referral to other health care services as required (Rafferty and Elborn 2002). 6.1 Bronchiectasis Nurse-led clinics have been evaluated, compared with regular doctor-led clinics, in a single randomised controlled trial in patients with bronchiectasis, a respiratory condition in which there is widening of the bronchi or their branches (Sharples et al, 2002). The study was a randomised controlled crossover trial including 80 patients in a bronchiectasis outpatient clinic. Patients received 1 year of nurse led care and 1 year of doctor led care in random order, and were followed up for 2 years. Various outcome indicators were used in the comparison, including lung function and exercise capacity, infective exacerbations, hospital admissions, quality of life and cost-effectiveness of the intervention. The results of this study are illustrated in Table 1 below. Table 1: Nurse-led and doctor-led care in care of patients with bronchiectasis (Sharples et al, 2002) Measurement outcome Nurse-led Doctor-led Mean difference (95% CI) p-value Forced expiratory volume in one second (FEV1) (%) 1.87 1.86 0.01 (-0.04 to 0.06) Forced expiratory volume in one second (FEV1) (L) 69.7 69.5 0.2 (-1.6 to 2.0) Forced vital capacity (FVC) (%) 87.6 87.6 -0.02 (-1.5 to 1.4) 12 minute walk distance (m) 765 746 18 (-13 to 48) Infective exacerbations (patient years of follow up) 262 (79.4) 238 (77.8) 0.34 Hospital admissions attributable to patient’s bronchiectasis 43 23 0.22 As the table above clearly shows, there was no statistical difference in FEV1/FVC percent predicted or distance walked between nurse led and doctor led care in the two treatment periods. Furthermore, 262 episodes of infective exacerbations were recorded by patients in the nurse practitioner-led care group in 79.4 patient years of follow up, compared with 238 in 77.8 years in the doctor-led care group. Thus, nurse practitioner-led care is associated with a relative rate of exacerbations of 1.09 (95% CI 0.91 to 1.30), p=0.34. Using the St Georges Respiratory Disease questionnaire to assess differences in health-related quality of life between the two groups, there was no statistically significant differences in each of the scores for Symptoms, Control, Impact or total score. Also, the study showed that nurse-led care resulted in significantly higher costs per patient compared with doctor-led care; this was largely due to the difference in the number of hospital admissions and intravenous and nebulised antibiotic costs. The authors concluded that nurse practitioner-led care for stable patients within a chronic chest clinic is safe and is as effective as doctor led care, but may use more resources. This study has several potential limitations which could invalidate the findings. As the study relied on patient report to record the prescriptions issued by general practitioners, these may have been underestimated and could grossly affect the cost analysis. Conversely, the nurse practitioner was required to record prescriptions and tests issued at the clinic, and thus these records are probably more reliable and she would be more likely to have ensured that patients left with supplies of routine treatment. Another possible drawback of this study is the use of a crossover design in the methodology. Unless a wash-out period is incorporated in the study design, there is the possibility of a carryover effect with crossover study designs, with the danger that the effects of the earlier treatment is falsely attributed to the final experimental treatment. In this study, there was no allowance for a washout period and thus this could affect the reliability and validity of the study results. This order and time effect needs to be checked for within the analyses but it can rarely be excluded as potential biasing factors (Pocock 1983). However, as recruited patients received the interventions in random order, this may negate the carryover effect. Despite the possible limitations of the study that could potentially hinder its applicability in practice, the findings support the implementation of a nurse-led clinic in patients with chronic cases of bronchiectasis as an alternative to the standard rigid medical care. 6.2 Asthma Similar to the findings in the study by Sharples and colleagues (2002) in patients with bronchiectasis, Nathan et al (2006) more recently compared the effect of follow-up by a nurse specialist with follow-up by a respiratory doctor following an acute asthma admission. In a single centre prospective randomised controlled trial, 154 patients admitted with acute asthma were randomly assigned to receive an initial 30-min follow-up clinic appointment within 2 weeks of hospital discharge with either a specialist nurse or respiratory doctor. The intervention comprised a medical review, patient education, and a self-management asthma plan. Further follow-up was then arranged as was deemed appropriate by the corresponding doctor or nurse, and all patients were asked to attend a 6-month appointment. Despite hospital outpatient follow-up, there was a significant proportion of patients in both groups who had exacerbations. However, there was no statistically significant difference between the two groups (Table 2). In the same manner, there was no statistically significant difference in quality of life assessed with two different validated questionnaires, the Asthma Questionnaire and the St George Respiratory Questionnaire. Mean change in peak flow at 6 months was similar between the two groups, probably indicating equivalence of the two tested interventions. Nathan et al (2006) concluded that follow-up care by a nurse specialist for patients admitted with acute asthma can be delivered equivocally with comparable safety and effectiveness to that traditionally provided by a doctor practitioner. Table 2: Nurse-led and doctor-led care in follow-up care of patients admitted with acute asthma (Nathan et al, 2006) Measurement outcome Nurse-led Doctor-led Odds ratio (95% CI) Mean difference (95% CI) p-value Change in peak flow 1.39 (-3.84 to 6.63) 0.122 Infective exacerbations (%) 45.6 49.2 0.86 (0.44 to 1.71) 0.674 Quality of life 87.6 87.6 -0.02 (-1.5 to 1.4) Asthma Questionnaire 0.78 (-0.64 to 2.19) 0.285 St George Respiratory Questionnaire 1.08 (5.05 to 7.21) 0.891 The possible limitations associated with this study is the large amount of missing data for some outcomes, especially peak flow and quality of life

Do you think that Mary Tudor deserved her title “Bloody Mary”?

History has not been kind to Mary Tudor. Compared to what followed, her reign seems like a brief but misguided attempt to hold back England's inevitable transformation to Protestantism. Compared to what came before, her regime looks like the regressive episode of a hysterical woman. Considered on its own terms, however, the regime appears much more complex, leading contributors to this volume of essays to reach far different conclusions about her reign: reestablishing traditional religion in England was an enormous undertaking that required rebuilding the Marian Church from the bottom up.Moreover, given more time it might have succeeded. Finally, as these essays continually remind us, concepts differentiating Catholicism from Protestantism — ideas taken for granted today — were still being sorted out during this period. David Loades's introduction begins the volume by surveying the disturbance in religion during Mary's lifetime. He links the spread of humanism and class ical scholarship to a substantial portion of this disturbance because it created an educated populace capable of raising questions about religious practices for which the traditional Church had no answers.Mary herself received a first-rate humanistic education and contemporaries even considered her well-educated. Loades suggests that, instead of unquestioningly embracing the tenants of the traditional Catholic faith, Mary was a â€Å"conservative humanist with an extremely insular point of view† (18). Nevertheless, her humanistic training did not extend to her devotion to the sacrament of the altar and her uncritical acceptance of the doctrine of transubstantiation. Ultimately, her uncompromising position on the latter would cause the downfall of many.After this introduction, the first section of the volume, entitled â€Å"The Process,† explores obstacles confronting the restoration of Catholicism in England, beginning with David Loades's examination of the degraded st ate of the episcopacy upon Mary's accession, and her administration's attempts to restore it. Next, Claire Cross discusses Marian efforts to enact Catholic reforms in those strongholds of Protestant dissent, the English universities. The queen's decision to restore a community of monks at Westminster is the subject of a study by C.S. Knighton, who includes a detailed appendix identifying members of this community.In the section's last essay, Ralph Houlbrooke argues that swift acquiescence by one of Norwich's leading evangelical ministers, and the diligence of clergy and Church courts in upholding the Marian restoration, helped Norwich avoid large-scale persecution. Essays in the volume's second section, â€Å"Cardinal Pole,† focus on his role in reestablishing the legitimacy of the restored Church. Thomas F.Mayer begins with an analysis of various court documents, and concludes that even though Paul IV had apparently revoked Pole's legatine office, the matter remained unsettl ed, and Pole probably continued to function in that capacity until the end of Mary's reign. In the following chapter, Pole's 1557 St. Andrew's Day sermon provides evidence for Eamon Duffy's defense of the cardinal's record — not only as an outspoken advocate for the importance of preaching, but also as a hard-nosed realist confronting an entire population of apostatized Londoners.In the final essay of this section, John Edwards reveals that, unlike English documents, records from the Spanish and Roman Inquisitions indicate greater Spanish involvement in the restoration of English Catholicism than has been previously recognized. The subject of the final section of this book, â€Å"The Culture,† undertakes issues regarding the Marian Church and its people. Lucy Wooding's essay considers how the multiple layers of symbolism found in the Mass provided a wide focal point for popular piety in the restored Church.In his essay on the theological works of Thomas Watson, William Wizeman, S. J. , discusses Marian efforts to reeducate worshipers who, after a generation of religious turmoil, were unfamiliar with even the basic tenets of Catholicism. In the following chapter, Gary G. Gibbs reconsiders the eyewitness evidence provided by one Henry Machyn, Merchant Taylor of London, concluding that the Marian regime had indeed connected with enough loyal subjects to provide the queen with an effective base of power

Mergers and acquisitions continue to be made when so many fail Essay

Critically evaluate why so many mergers and acquisitions continue to be made when so many fail. The phenomenon of mergers and acquisitions (M&A’s) triggers an array of opinions and viewpoints. Often it is a strategy that is seen as a perfect way of achieving growth. It is by no means an organic or natural route to success, but has tended to be a quick and easy way of increasing an organisations size and power. However although there has been ‘waves’ of popularity and success since its introduction in the 1960’s it has also suffered criticism due to the amount of failures it has accounted for. Despite the strong suggestion that this strategy has been the architect for many an organisations downfall there still remains a propensity in the current business environment for managers to adopt it. Throughout this essay I am going to examine some of the areas that explain M&A’s volatility and attempt to discover why managers are persevering with the strategy when it is seemingly flawed. Over the last few decades it has become increasing apparent that the effect of mergers and acquisitions is not as beneficial as once thought. When the growth strategy was pioneered in the middle part of the nineteen hundreds it was looked upon as a way of creating an empire across different sectors and countries. Many experienced managers were sucked into the strategy, only having eyes for the apparent synergistical and positive affects of M&A’s. Although over the following years there has been many success stories concerning M&A’s, when the big picture is examined it displays a more ugly side of the phenomenon. Hodge (1998) discovered that ‘in the go-go ’80s, 37% of mergers outperformed the average shareholder return in that period; in the first half of the ’90s, that figure rose to 54%’. Despite the encouraging increase during the early ’90s there remains a disturbing reality that ‘barely one-half of the m&a deals of recent years delivered shareholder value that outperformed even the relevant industry average, much less provided an adequate return on investment’. Added to this he also highlighted that ‘only a paltry 25% of deals valued at 30% or more of the acquirer’s annual revenues could be counted as success’. These statistics represent the flaws that exist within the strategy of M&A’s and clash with the positive theory that ‘analysts and investors expect the merged enterprises to be greater than the sum of its parts’ (Doitte and Smith 1998). Coopers and Lybrand (1993) along with many other writers have studied and expanded on some of the key factors that limit that usefulness of M&A’s. Target management attitudes and cultural differences ‘heads the list of impediments to the successful melding of two organisations’ (Davenport 1998). This is appropriate not only in the case of cross-border mergers (Daimler Benz-Chrysler) where there many obvious points of concern such as language and communication, but also within the collaboration of firms based in the same country and even industry. Management often have their own ‘way of working’ that suits both themselves and their employees, which may be generated through national or corporate culture. This is generally characterised by unique and individual working practices amongst different firms nation and worldwide. Therefore when a merger or acquisition takes place the result is the combining of two sets of cultures in an attempt to work together. In most cases the merge looks both safe and profitable in theory, however management frequently underestimate the power of culture. For example when Mellon Bank and the Boston Co merged in 1993 they failed to consider how ‘cultural conflict could drain the combined company of its most important acquired asset of the talents of Boston Co.’s money-management wizards. Offended by Mellon’s cost-conscious management style, a key executive left the organisation. Within the next three months, he had taken 30 of his co-workers with him, along with $3.5 billion assets and many of the firm’s clients’ (Davenport 1998). I think this example emphasizes the risk associated with M&A’s due to their inevitable degree of unpredictability. For this reason alone it is hard to imagine a full proof argument advocating their use in modern business. Another factor that makes M&A’s a high-risk strategy is the fact that management often have limited knowledge of the industry they are entering. This is obviously the case when two firms from unrelated backgrounds merge (conglomerate integration). In this case management are unaware of the way the industry works and are restricted to simply understanding the bare bones of the business. ‘Differences in traditions, expectations, buying and specification practices, packaging, logistics, labelling, and legal customs and issues can have a surprisingly profound impact on the post-acquisition viability of a target company’ (Price and Sloane 1998). These differences along with more obvious changes such as product, market and customers make life awkward for management. In most industries it takes time to develop and form bonds with suppliers, customers and even local communities. These types of bonds are usually a result of personal relationships and even friendships that have grown through dealings and negotiations over a long period. M&A’s break up many of these ties across the industry and leave new management with the task to start fresh alliances. In many cases the change is not well received and an organisation that essentially is unchanged in terms of its core activities can fail. The art of creating a post-acquisition integration plan is also extremely important, but is difficult to master. ‘Unfortunately, for many companies, it is this phase that the deal fails because the parties focus too much on the financial aspect of the merger or acquisition without adequately addressing the people components that must be considered to forge two organizations into one cohesive entity’ (Doitte and Smith 1998). Employees are often neglected through the process of M&A’s and even if attention is given to them there is generally a lack of meaningful consultation. Although it is an area that is very tricky to get right from a managerial perspective it is vital if the strategy is to succeed. ‘If managers of each company shut themselves off from their employees, employees will feel adrift. Employees’ resulting low morale and lack of direction will lead to high personnel turnover’ (Heitner 1998). This is simply another factor, which makes the strategy of M&A’s so difficult to implement and along with the previously mentioned problematic areas explains why their success rate is only around 50%. However despite the fact that many investment bankers and journalists believe the difference between their success and failure is ‘a coin toss at best’ (Davenport 1998) organisations continue to utilise them. A major reason behind M&A’s continued use is the amount of advantages an organisation can potentially gain by undergoing a successful merger or acquisition. Although there are many risks and pitfalls involved when the strategy is undertaken management clearly believe the prospective benefits outweigh these possible drawbacks. In modern business globalisation has in many cases become a necessity rather than a luxury. Firms are now desperate to expand into foreign countries in order for them to compete in uninhabited lucrative markets and increase their competitive advantage. If global markets are entered successfully it gives organisations the chance to exploit resources, synergies and opportunities. However there is also a sense that in the global marketplace ‘bigger is better’ (Doitte and Smith 1998) and firms have to be of a certain size to be able to compete. In order to break into global markets organisations need to grow and often quickly so ground is not lost on competitors. In this situation M&A’s are the most attractive option for managers. They represent a ‘leap’ approach whereby firms can experience this desired growth rapidly. Managers are aware that it is the growth strategy that carries the highest risk, but often feel they have little choice. The modern busin ess world demands innovation and expansion and if companies stand still they will simply get left behind. Firms often use M&A’s as a way of diversifying. A well-executed diversification strategy can widen an organisations product portfolio and therefore spread an organisations risk. This means entering different markets in order to reduce dependence upon current products and customers. Selling a range of different products to various groups of consumers will mean that if any one product fails, sales of the other products should keep the business healthy. As a result firms in this situation are less susceptible in market downturns and recessions. It is unlikely that a slump occurs in two diverse markets, but even in a case of a recession, where there are generally negative affects across the board, the organisation with added critical mass is in a better position to weather the crisis. The simplest way for management to achieve this diversification is to merge or takeover another company. It saves time and money being spent developing new products for markets in which the firm may have no expertise. Richard Branson and Virgin has been a major exponent of this over the last decade. His brand now covers air travel, music and even soft drinks! This is a perfect example how M&A’s can produce multi-million pound empires extremely quickly. However many organisations can become influenced by such stories and attempt to mirror the success without fully understanding whether it’s the right move in their own business situation. Market power is also a reason firms adopt M&A’s. This is usually generated when two competitors in the same market merge in what is called horizontal integration. The potential benefits for the purchaser are extremely attractive and hard to ignore. There is huge scope for cost cutting by eliminating duplication of sales force, distribution and marketing overheads and by improved capacity utilisation. There is also the opportunity for major economies of scale and increased prices due to the reduction in competition. Coca-Cola achieved this type of acquisition when taking over Orangina, a distinctive product with very strong distribution in France. Here Coca-Cola identified Orangina’s customer base as one that they struggled to attract and decided for them to increase their market power they needed to acquire the brand. However, this is by no means the correct move for all firms. The merge between car manufacturers Daimler Benz and Chrysler has been ridden with problems since its launch in 1998. Sometimes a merge in this way creates twice the size, but double the problems. Similar to the idea of joining forces with a competitor to gain market power, management can undertake a merger or acquisition to ‘block’ competitors in doing so. This tactic usually comes in the form of a vertical integration where one firm takes over or merges with another at a different stage in the production process, but within the same industry. An example of this is brewery Whitbread’s purchase of restaurant chain Beefeater. This type of M&A does not only guarantee outlets for your products or develop closer links with suppliers, it can also go some way to freezing out the threat of competitors. However it is not wise for management to undertake a merge with the sole intention to damage competitors. It is important, first and foremost, that the strategy has synergistical affects for them the acquirer as otherwise it may struggle. As I have highlighted there are undoubted gains offered by successful M&A’s. These attractive advantages can often persuade managers, sometimes wrongly, to implement a mergers or acquisitions of their own. The hope is that their organisation can in practice reap the rewards that the theory says is possible. The reality is that many fail because the strategy is mismatch with other objectives and inappropriate in their current position. Despite managements good intentions their judgement has been clouded by the large potential gains M&A’s can offer. However it is not always the case that management adopt the strategy strictly because of the apparent advantages it can for their firm. There is a school of thought that justifiably believes that top management frequently have ulterior motives when adopting M&A’s. The belief is that decisions made concerning them are not necessarily in the main interests of the organisation, but more centred on what is best for them as individuals. As a result managers may proceed with poor value acquisitions in order to meet personal goals or even objectives they think ‘should’ be met. The ’empire-building syndrome’ is a main contributor here. As an organisation grows it becomes a more important player in its industry. Naturally as the size and power of the firm increases as does the importance of its management and with this comes higher remuneration and social status. Also ‘executive compensation may increase as a result of an increase in firm size, even when there is no corresponding increase in shareholders’ wealth’ (Jenson 1986). It is clear that a merger or acquisition strategy can work well for top management regardless of its overall success for the firm. In the same way management can be influenced by prospective financial and prestige rewards, they may also be interested in satisfying their self-fulfilment goals. In low growth markets management can feel they are not exhausting their full energy and talents. In order for them to experience this type of self or job fulfilment they may choose to grow their firm via a merger or acquisition. This may present the perfect challenge for management, but not necessarily ideal challenge for their organisation. Finally job security is also an important managerial motive. A merger or acquisition can diverse risk and minimise the costs of financial distress and that of bankruptcy. This added stability helps prevent an organisation becoming an acquisition target themselves. Although the decision might not be in the best interests of the firm and shareholders, management solidify their own position. Along with the other negative managerial motives they represent a clear reason why M&A’s continue to be used in the light of so many failures. In conclusion I feel the topic of M&A’s and the reasons behind their sustained use in business is now much clearer. It is initially very difficult to fathom any organisation adopting a strategy that only has a success rate of around 50%. Dominant factors such culture and management inexperience seem to make any merger or acquisition an uphill struggle. However when the topic is examined closer the reasons behind these decisions are more obvious. In the modern business environment businesses are constantly looking to better themselves and stay one-step ahead of competition. It is wrong to claim that as a result organisations are forced into strategies that stimulate rapid growth, but there is a definite feeling that factors such as globalisation and increased market power are the best route to success. As these are two hallmarks of the M&A phenomenon it is no real surprise that management frequently decide that it might be their best strategy regardless of their poor success rate. It is this risk taking mentality, that has become a characteristic of 21st century management, allied with the more cynical decision making habits some managers have adopted has kept the use of M&A’s high. Added to the fact that in the right context M&A’s can be an efficient and highly profitable growth strategy it is easy to see how they have had and will continue to have a great use in business regardless of their failures. Bibliography Textbooks Glanville & Belton (1998) ‘M&A’s are transforming the World’ Ivey Business Journal, Autumn; Customer text-section 2, topic 11. Kieran et al (1994) ‘Planning the deals that generate value and gain advantage’, Mergers and Acquisitions, March-April; Custom text, topic 12. Journals Doitte S & Smith G (1998). ‘The morning after (avoiding mistakes in acquisitions and mergers)’. Winter v63 i2 p32(8). Davenport, T (1998). ‘The Integration Challenge (managing corporate mergers’ Management Review. Heitner M (1998). ‘The thorny business of merging rival firms’, Mergers and Acquisitions. Hodge, K (1998), ‘The art of the post deal (outcomes of mergers)’. Management Review. Price, A & Sloane, J (1998). ‘Global Designs: Tough Challenges for Acquirers’. Mergers and Acquisitions.. Whipple J & Frankel R (2000), ‘Strategic Alliance Success Factors’. The Journal of Supply Chain Management.

Notes On Practice Faith And Religion - 972 Words

Outline Intro: In practice faith is limited to one religion, and by restricting a person’s understanding to one set of beliefs, a person is unable to experience life entirely. Religion is interchangeable, and provides information the other may lack, but believers tend to limit and turn people away from their religion from fear of new concepts. The exclusive disciples believe their ideals are the only ‘truth’ and that nothing can be gained from the other religions. Followers of one faith tend to have prejudice and preconceived ideas towards people of other faiths and beliefs and their stubbornness and wariness leads to not wanting to understand an opposing belief when they could have learned and grown. By connecting to other people and religions, the community as a whole would be able to learn and develop into more sympathetic and empathetic people had they not sectioned themselves into pre-designed circles of judgement and narrow-mindedness. Religious pluralism theoretically being practiced and the connotation of religion being the same. (Source 2) â€Å"Is it theologically and morally acceptable to maintain that one religion is uniquely true and that the others are at best incomplete or even false?†Ã¢â‚¬ Christian faith is merely one of many equally legitimate human responses to the same divine reality.† Transcending into a higher being; a person with a better understanding of the world isn’t limited to a single path. There are many different ways to reach a singleShow MoreRelatedBuddhism From The Indian System Of Life1644 Words   |  7 PagesIn the view of many, religion is entrenched and founded in what people believe. In the case of Buddhism, it is understood that it originated from the Indian systems of life. In the process of their trading activities, the Arab traders made it possible for the religion to spread to the other nations such as Japan and China. 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