Independent Prescribing | Supplementary Prescribing

Independent Prescribing | Supplementary Prescribing Introduction This portfolio has been compiled in order to complete the non-medical prescribing qualification through the University of Central Lancashire. Throughout the portfolio, the author has analysed situations encountered whilst working along a designated medical practitioner (DMP). The author is a mental health nurse and is employed in a community mental health team, offering support to individuals who suffer with severe and enduring mental health problems. In the practice area, new ways of working (Department of Health (DH), 2007) is beginning to take effect which has enabled expansion of current roles, including non medical prescribing. The portfolio is organised into sections, with an index page for navigation. Two consultations are presented; the first involving an individual with a neurotic illness, where independent prescribing was deemed appropriate in the absence of co-morbid illness or significant risk. The second consultation pertains to an individual with severe and enduring mental health problems who has suffered adverse reactions to medication previously and for whom supplementary prescribing appeared to be the safest prescribing option. The consultations are followed by an evidence section and appendices. Completion of the portfolio has facilitated extensive development of knowledge in terms of pharmacology, including physiological variance (evidence 15). Knowledge of psychotropic medicines has also greatly improved and the importance of physical health monitoring for service users has since become a priority. The author believes that becoming a non-medical prescriber will provide an ideal opportunity to have a direct effect on public health targets such as reducing avoidable death from suicide and offering quicker, more appropriate treatment options to people with mental illness. The author also feels confident that non-medical prescribing in mental health will lead to increased concordance and better service user satisfaction. The required practice hours of the course have been achieved (evidence 1) through working with members of the prescribing team (evidence 2a, 2b, 2c, 2d, 2e). Throughout the portfolio, the author has ensured protection of confidential information, as directed by the Nursing and Midwifery Council (NMC) (2008) by referring to the service users by pseudonyms i.e. Alexander and by anonymising information related to the Trust for which the author works. Furthermore, consent forms have been obtained for named professionals and user perspectives Independent Prescribing Independent prescribing is defined as prescribing by a practitioner (e.g. doctor, dentist, nurse, pharmacist) responsible and accountable for the assessment of patients with undiagnosed and diagnosed conditions and for decisions about the clinical management required, including prescribing (DH, 2006 p2). The author will critically analyse an independent prescribing situation, addressing learning outcomes 1,2,3,4 and 5 in doing so. Reference to the stages of the prescribing pyramid will be made as this is a useful model to ensure appropriate prescribing (National Prescribing Centre (NPC), 1999). The patient will be referred to as Anne Knowles. Anne was a 28-year-old woman with a history of depression, referred by her General Practitioner who suspected a relapse. In order to confirm this, a full assessment was undertaken. Fortunately in mental health, adequate time is allocated for practitioners to gather information. Prescribers are encouraged to approach consultations in a structured way (NPC, 2003) therefore the Calgary-Cambridge model (Silverman, Kurtz and Draper 1998) was used alongside a structured tool in support of this approach. Health authorities have formulated unique Care Programme Approach (CPA) assessment tools based on the original guidance in Caring for People (DH, 1990) to accomplish a holistic assessment and this is what is advocated by the NPC (1999), as the first element of good prescribing practice. The author used the tool designed by the local health authority in the assessment of Anne (evidence 3). While the CPA assessment is comprehensive, the author elected to enhance it with additional tools to better inform prescribing practice. Incorporating Mortons (1992) symptom analysis tool a thorough assessment of Annes presenting symptom was facilitated. Furthermore, an individualised report obtained using a solution-focused approach (de Shazer, 1988), gave the author an appreciation of what was currently happening and how improvement would be detected (evidence 3, page 13). The author also utilised Becks Depression Inventory-II (BDI-II) (Beck, Steer and Brown, 1996) (evidence 4). Although routinely used in the practice environment due to its ease and speed of completion, it has been criticised due to the gender and cultural bias (female, Caucasian), which it represents (Hagen, 2007). This is something with which the author would agree and plans to use the Montgomery-Asberg Depression rating scale (Montgomery and Asperg, 1979) in the future as this has a broader reflection than the BDI-II. The remainder of the assessment, including a full medical, social and medication history, allergy status and exploration of Annes beliefs about her illness and future treatment were also included in the assessment. It is commonplace in clinical practice for staff to present assessments to the medical team where discussion of differential diagnosis occurs. Such discussion facilitates accurate diagnosis and debate of treatment options; however it is reliant on a precise initial assessment and effective presentation of the case. Following this a diagnosis of moderate depression was agreed under section F32.1 of the International Classification of Disease (World Health Organization (WHO), 1992). Considering the prescribing pyramid, the second step requires deliberation of the appropriate strategy to use. As the diagnosis of moderate depression was established, the author knew that a prescription was needed. Guidance from the National Institute of Clinical Excellence (NICE) (2004) suggests that individuals diagnosed with moderate to severe depression should routinely be offered a pharmacological intervention before psychological interventions. When considering choice of products, the third step of the prescribing pyramid, prescribers have available various antidepressants from diverse groups, namely Monoamine-oxidase Inhibitors (MAOIs), Tricyclic Antidepressants (TCAs), and Selective Serotonin Reuptake Inhibitors (SSRIs). There are also listings in the British National Formulary (Royal Pharmaceutical Society (RPS) British Medical Association (BMA), 2007) for other antidepressant drugs that cannot be classified into specific groups due to their unique pharmacology i.e. Mirtazapine and Reboxetine. In choosing between the agents, the author consulted national guidelines (NICE, 2004) which examine the effectiveness, appropriateness, safety and cost-effectiveness of drugs. NICE (2004) favours use of SSRIs to other antidepressant groups. This is because they are as effective as TCAs but concordance is higher because of the better side effect profile (NICE, 2004). Barbui and Hotopf (2001) reported that Amitriptyline, a TCA was more effective than SSRIs however conceded that use of SSRIs was higher because of their enhanced tolerability. SSRIs are less likely to cause sedation and cause much fewer anti-muscarinic effects than TCAs (RPS BMA, 2007). The other major distinction is that should they be used in overdose, SSRIs are considered less toxic than TCAs. Use of an MAOI was not considered as first-line treatment for Anne. Although once viewed as less effective than other antidepressants, when used in adequate doses, MAOIs are as efficacious (Riederer, Lachenmayer and Laux, 2004). However MAOIs are generally better in treating atypical depression (Riederer et al, 2004) and are associated with dangerous dietary and drug interactions (Nash and Nutt, 2007). SSRIs are the agents of choice in the practice area (evidence 5), in line with national guidelines. The common pharmacology of SSRIs is the prevention of reuptake of the neurotransmitter serotonin into the pre-synaptic cell, leaving increased amounts of serotonin available to bind to post-synaptic receptors (Carrasco and Sandner, 2005). Although the central nervous system is the desired site of action, SSRIs also exert their effect throughout the body, which explains their side effects. Aside from the primary pharmacology of the SSRIs, each has diverse properties, knowledge of which assists prescribers to choose the most appropriate agent. NICE (2004) directs prescribers to opt for Fluoxetine or Citalopram due to their ease of discontinuation as with other SSRIs, users have reported distressing discontinuation symptoms. A review by Haddad (2001) found as many as fifty different discontinuation symptoms, ranging in severity from mild to severely disabling. These included dizziness, nausea, lethargy, headache, electric shock like sensations, insomnia and nightmares. An understanding of the physiological mechanisms underlying the syndrome has yet to be realised. Theorists such as Tamam and Ozpoyraz (2003) and Blier and Tremblay (2006) speculate that the readaptation of the neurotransmitter systems, which rapidly increase reuptake of serotonin and subsequently decrease the amount of serotonin able to bind to post-synaptic receptors, are the likely triggers. Drugs with shorter half lives i.e. Paroxetine are the most problematic and those with longer half-lives and active metabolites i.e. Citalopram and Fluoxetine appear to fair better (Taylor, Paton and Kerwin, 2007). In terms of appropriateness, all SSRIs share identical cautions and contraindications and research has shown that Citalopram is just as effective as Fluoxetine in treating depressive symptoms (Patris, Bouchard, Bougerol, Charbonnier, Chevalier, Clerc, Cyran, Van Amerongen, Lemming and Hopfner Petersen, 1996). Consideration of patient-specific factors during the history taking identified that Anne found previous success with Citalopram. The medical history had not highlighted any conditions where cautions apply such as epilepsy, cardiac disease, diabetes mellitus, allergies etc and the author was aware that use of all antidepressants was contra-indicated in mania (RPS BMA, 2007). The choice of product was made in discussion with Anne. She had a preference for Citalopram and after reviewing the available evidence, the author concurred with this choice and prescribed Citalopram (evidence 6). See evidence 7 for a profile of Citalopram. Next, it was necessary to negotiate a contract with Anne, stage four of the prescribing pyramid. Anne understood Citalopram from previous use, however education regarding what the prescription was for and how long it would take to work (evidence 7) was given. Anne did not have a preference in terms of formulation and therefore tablets were prescribed, as this was the cheapest option. The side effects and red flag concerns of the medication were then identified to Anne (evidence 1, section 6). All antidepressants have been linked with a possible increased risk of suicidality. Research into SSRIs and suicidality demonstrates conflicting findings in that Healey (2003) found increased risk in early treatment and Isacsson, Holmgren and Ahlner (2005) reported a reduction. The Medicines and Healthcare products Regulatory Agency maintain that prescribers of SSRIs should monitor and assess for this regularly. Due to the possibility of suicidality occurring as a red flag, a prescription for treatment to last seven days was given and the rationale explained to Anne and her partner. In the practice area, service users are given information from the United Kingdom Psychiatric Pharmacy Group (UKPPG), available via the Trust intranet; the data regarding Citalopram was given to Anne (Appendix 1). Furthermore, Anne was encouraged to refer to the patient information leaflet, dispensed with the product from the chemist. Annes partner expressed concerns about media reports questioning the efficacy of antidepressant medication; this was addressed by giving him a copy of the Trusts response to the information (Appendix 2). This information was successful in reassuring him (evidence 8), along with the arrangements for reviewing Anne on a regular basis. In terms of reviewing Anne, stage five of the prescribing pyramid, a further appointment was made for seven days, in line with NICE (2004) guidance due to her higher background risk of suicide as an individual under the age of thirty years. Based on the evidence that SSRIs can increase risk of suicide, planning to see any patient commenced on antidepressants within a week would better ensure safety and professional accountability, in addition to addressing the public health target to reducing suicide. Although increased energy and motivation is apparent a week into treatment, the antidepressant effect is not, therefore the individual may continue to experience depressive symptoms and have the impetus to act on suicidal thoughts (NICE, 2004). Frequent monitoring thereafter is recommended by NICE (2004) who suggest professionals look for signs of akathisia, suicidal ideas and increased anxiety and agitation, which can occur with all antidepressants, including Citalopram. The author elected to give Anne and her partner the contact details for the Crisis Team in the local area, should support be needed out of working hours, explaining that they could be contacted if her mental health further deteriorated or she began to suffer with suicidal thoughts. It was indicated to Anne that she would be unlikely to feel the full benefit from the treatment for approximately two weeks due to the pharmacology of the drug (evidence 7) and that once the depression had lifted; guidelines suggest treatment should continue for at least six months after this marker. Geddes, Carney, Davies, Furukawa, Kupfer, Frank and Goodwin (2003) found that treatment continued for this time frame reduces the risk of relapse. In terms of keeping records, stage six of the prescribing pyramid, Annes progress was recorded using the electronic Care Programme Approach (eCPA) system. Use of eCPA in the practice area is a new development, intended to replace the paper-record system, allowing immediate access to relevant mental health staff. It is currently inaccessible to other health professionals; therefore duplication of work is necessary in order to ensure effective communication. Currently, professionals involved in the care of an individual seen by psychiatric services are identified as part of the initial assessment (evidence 1, section 19) and are advised of their treatment plan and progress via separate letters (Appendix 3). Working in this manner ensures safe, ethical practice by good communication with members of the multi-disciplinary team (NMC, 2008). In line with the NMC standards for recordkeeping (NMC, 2005) the author recorded and disseminated the information in a timely manner, using the same format as her DMP. In the future, the author plans to work with the non-medical prescribing lead to develop an appropriate format for her practice, which should enhance professional accountability. The seventh and final principle of the prescribing pyramid encourages reflection on prescribing practice. The author was confident that a prescription was necessary and therefore did not feel pressured by the patient to issue treatment against better judgement as can be the case (Britten, Ukoumunne and Boulton, 2002). Neither did the advertising activities of the relevant drug company influence the choice of product. Reliance on independent research was used to inform prescribing practice. Supplementary Prescribing Supplementary prescribing is described as a voluntary partnership between an independent prescriber (a doctor or a dentist) and a supplementary prescriber to implement an agreed patient-specific Clinical Management Plan with the patients agreement (DH, 2005a paragraph 8). A critical analysis of a supplementary prescribing scenario will follow, addressing learning outcomes 1, 2, 3, 4 and 5. As in the IP scenario, reference will be made to the prescribing pyramid (NPC, 1999). The patient will be referred to as Alexander Stewart. Alexanders General Practitioner (GP) had been managing his care; however he had been referred to the service following discontinuation of antipsychotic medication Risperidone, due to sexual dysfunction. Alexander was under the care of a consultant psychiatrist who had diagnosed Schizophrenia of the paranoid type, under Section F20.0 of the International Classification of Disease 10 (WHO, 1992). At the time of meeting Alexander, early warning signs of relapse were evident in that he believed others were against him and were sending messages via media sources. Alexander had sufficient insight to be able to recognise that his mental health was declining and had attended the appointment in the hope that an alternative treatment could be prescribed. The independent prescriber (IP), Dr Gater, felt that Alexander was a suitable candidate for a supplementary prescribing arrangement as there were no issues of substance misuse, no co-morbid illnesses and he had a good history of engagement. It is recommended that these factors be considered before contemplating supplementary prescribing in mental health care (DH, 2005b). New Ways of Working in Mental Health (DH, 2005c) dictate that individuals with highly complex needs, including those with dual diagnosis, history of poor engagement, co-morbid physical illness and assessed high risk of harm to self or others are seen by more advanced, highly trained professionals such as consultants. Dr Gater discussed with Alexander the possibility of supplementary prescribing and he agreed to work in this way, with the author as the supplementary prescriber (SP), who also took on the role of care co-ordinator. The IP set the parameters of the Clinical Management Plan (CMP) and this was then drawn up and signed, (evidence 9) indicating agreement by the IP, SP and Alexander as is mandatory for supplementary prescribing situations (DH, 2005a). The IP and SP had shared access to the patient record. The CMP in this instance was broad and permitted prescription of antipsychotic medication from a wide choice of agents, however CMPs can be specific, for example, only allowing the SP to make dose or frequency of dose changes to an identified medicine (DH 2005b). In such cases, if a patient were to develop adverse side-effects from the medicine, a new CMP would have to be developed, leading to increased workload and time delays for treatment. In this instance, because of the knowledge and experience of the SP, the close working relationship of the IP and SP and the accessibility of comprehensive guidance regarding the management of Schizophrenia (NICE, 2002b) a broad CMP was considered appropriate. The author used the prescribing pyramid to aid practice (NPC, 1999) and adhering to the first principle, considered a holistic assessment. The IP had already taken a thorough history and made a diagnosis, however the history taking was repeated by the SP to ensure that Alexanders presentation had not changed. Difficulties can arise if this occurs (evidence 2d). A CPA assessment was carried out (evidence 10), supplemented by a symptom analysis tool, namely Morton (1992). The assessment confirmed the original diagnosis. The National Service Framework for Mental Health (DH 1999a) reported that individuals suffering with this illness are nine times more likely than the general population to commit suicide and that the risk of death from other violent incidents is over twice as high. Government policy since this time has aimed to ensure that people with mental health problems are better able to access services and appropriate treatments in a timely manner, to prevent the aforementioned likelihoods. The author was keen to uphold these principles and treat accordingly. Theorists such as Wyatt (1991) and McGlashan and Hoffman (2000) have speculated that prolonged non-treatment of Schizophrenia can result in brain-damaging neurotoxicity and synaptic plasticity, respectively; however there is limited research into these theories (McGlashan, 2006). Findings from duration of untreated psychosis studies have lead to the recent development of Early Intervention Services which aim to ensure that people with mental illness receive timely treatment in order to prevent biological, psychological and social decline (Whitwell, 2001). Personal experience has further demonstrated that non-treatment of the illness results in further loss of insight, increased distortions of judgement and the possibility that the active phase will last indefinitely. This knowledge meant that the second principle of the prescribing pyramid was satisfied since the appropriate strategy was to issue a prescription. Alongside this, the author, working as care co-ordinator for Alexander highlighted interventions to address issues relevant to his quality of life and well-being including housing, finance and employment support etc as suggested by government policy (DH 1999a, DH 1999b). The third principle, consideration of product choice, was initially agreed via the CMP. This indicated use of antipsychotic medication; however the selection of agents was open for discussion between Alexander and myself. To aid the decision, referral was made to the NICE guidance for treatments in Schizophrenia (NICE 2002a). The guidance recommends use of atypical antipsychotics in the treatment of Schizophrenia. Evidence 12 explains typical versus atypical antipsychotics in further detail. Alexander previously had a good response to an atypical drug, namely Risperidone, however stopped it due to the adverse drug reaction (ADR) he suffered. Alexander developed retrograde ejaculation, a reasonably high reported adverse effect of this drug (Taylor et al, 2007). Alexanders G.P had been satisfied that the symptom was not caused by other conditions such as diabetes mellitus or multiple sclerosis; and as the symptom ceased following discontinuation of Risperidone, was satisfied that it was an ADR. Although evidence suggests that this effect is dose related (Raja 1999, Loh, Leckband, Meyer and Turner 2004), Alexander did not wish to recommence this treatment. In choosing the most appropriate treatment, the criteria was therefore further simplified to an atypical agent, where possible, with a low affinity for alpha1 adrenergic antagonism since this is thought to be the cause of retrograde ejaculation with Risperidone (Loh at al, 2004). From the atypical agents listed in the current British National Formulary (RPS BMA, 2007), the two with the lowest affinity for alpha1 adrenergic antagonism are Aripiprazole and Quetiapine (Loh et al, 2004). Alexander was also presented with information comparing antipsychotics in terms of other commonly experienced side effects (Appendix 4) and then given the opportunity to ask questions. Finally, Alexander and I agreed on Aripiprazole and a prescription was issued (evidence 11). In addition to the importance of the positive side effect profile, Aripiprazole also rated as less expensive than comparable treatment with Quetiapine (Taylor et al, 2007) and this is a factor which prescribers are directed to pay attention to (NPC 1999, NICE 2002). In terms of preparations, Aripiprazole is manufactured in tablet form, orodispersible tablets and as an oral solution. As Alexander was happy to take tablets, this was the preparation prescribed. Aripiprazole is described as having a uniquely robust pharmacology (Davies, Sheffler and Roth 2004), centred on it being a partial agonist at Dopamine D2 receptors. Evidence 12 provides a profile for Aripiprazole, which explains this in further detail. It is distinctive from the other atypical agents as it stabilises the spread of dopamine in two of the four major pathways (mesolimbic and mescortical) where the neurotransmitter Dopamine is found, as opposed to purely blocking dopamine receptors or working as an antagonist at D2 receptors. Despite this difference, a recent systematic review of Aripiprazole actually found that it did not have significant advantages over other atypical medicines, neither did it demonstrate increased efficacy over typical drugs (El-Sayeh and Morganti, 2004). Coupled with this, Aripiprazole was shown to instigate similar adverse effects as treatment with typical agents, with the exception of akathisia, which lead to improved compliance (El-Sayeh and Morganti, 2004). Aripiprazole has not been shown to cause elevation of prolactin levels, nor is it associated with the development of impaired glucose tolerance or weight gain, therefore in theory, monitoring of these factors is not required (Travis, Burns, Dursun, Fahy, Frangou, Gray, Haddad, Hunter, Taylor and Young, 2005). In fact, Travis et al (2005) purport that no specific monitoring is required outside of the basic screening advocated in NICE (2002b) i.e. monitoring for endocrine disorders and cardiovascular risk factors etc. Despite this, the NHS Trust for which the author works recommends extensive monitoring (Appendix 5). The author would therefore be compelled to work within the guidance of the employing authority. In negotiating a contract (stage four), because Alexander and I shared the decision to try Aripiprazole, it was hoped that concordance would be achieved. Evidence 14 highlights the implications of excluding service users from the decision making process. Delivering the choice agenda in mental health is considered key to an effective prescribing value base for nurses (Jones and Jones, 2007), however it must be identified that issues of capacity for individuals with mental health problems can jeopardise this. For individuals lacking capacity during an acute Schizophrenic episode, guidance recommends the use of oral atypical medications, prescribed after consultation with the individuals carer or advocate (NICE, 2002a). Government policy has stated that service users should be encouraged to compile an Advanced Directive (AD) as part of their care plan, highlighting their treatment choices (NICE 2002b), although in practice, the author has limited experience of this happening (evidence 13) and does not feel it is something that the Trust encourages. Concerns have been expressed that service users might draw up unrealistic and illogical plans, refusing all forms of treatment, however a recent study found evidence to the contrary of this (Papageorgiou, Mohamed, King, Davidson and Dawson, 2004). It is the opinion of the author that where possible ADs should be formulated, allowing the patient to be autonomous, however the author also acknowledges that there may come a point where decision-making is replaced by that of the prescriber. At present ADs can be over-ridden if the patient is subject to compulsory treatment under the Mental Health Act (1983). In Alexanders case, an AD was offered but refused. Alexander was considered capable of providing informed consent and therefore, following the principles of good practice (United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1996), the author communicated to Alexander, various details about the prescription. These included information on what the prescription was for, how long the drug would take to work, how long to take it for, what dose to take and the possible side effects. The UKPPG data regarding Aripiprazole was given to Alexander (Appendix 6). The fifth principle of the prescribing pyramid, review of the patient was dictated by the CMP. Weekly review was carried out in order to ensure that the treatment was effective, safe and acceptable. Had it not been, the broad CMP permitted use of alternative agents. The IP and SP reassessed Alexander as planned three months later. In this time however the IP and SP met frequently to discuss the progress of Alexander and record keeping was kept up-to-date using the eCPA system. At present, GPs are advised of supplementary prescribing arrangements and changes in these via Trust devised letters (see Appendices 7 and 8). In this instance the letters were compiled and sent within 24-48 hours in line with local policy. The author reflected on her prescribing decision as recommended by the final stage of the pyramid and is confident that neither patient pressure nor the action of pharmaceutical companies affected decision-making. In practice, the author has experience of nursing individuals on a range of antipsychotics and is aware that this may affect choice of drug in the future Conclusion The author has described and analysed an independent and supplementary prescribing experience and has attempted to meet the module learning outcomes in doing so. The author is confident that her rationale for prescribing decisions is based on sound comprehensive guidelines and practice experience. The author plans to base future decisions on the prescribing pyramid model, making a conscious effort to see outside of the prescriptive toolkit so as to remember the importance of other nursing interventions. It is the intention of the author to utilise the support and clinical supervision available in the practice area, including discussion about differential diagnosis and treatment options with the medical team following assessments. This will ensure safe practice, professional development and recognition of the contribution of non-medical prescribers within the team. Evidence 16 details the authors plans for continuing professional development in prescribing practice, both as an independent and a supplementary prescriber. These goals are important to ensure competency in prescribing practice is maintained. By ensuring that practice is updated, monitored and evaluated, service user experience is hopefully improved leading to increased concordance and better health outcomes

International Business Finance Essay

1.Introduction This report is specific for JKX Oil & Gas. She is a petroleum company focusing on exploration and production in countries of the ex Soviet Union and the Ukraine. Her management is considering weather following her competitor expansion into Far East and Oceania. In this report I am going to show analysis in two sections. The first section is analysis on motivation of cross border investment in using FDI and find out the reasons of home countries & host countries encourage company to FDI. The second section is evaluating any key causes of a financial crisis and show how financial crisis affect the international trading. 2.Motivations of using FDI as cross border investment Basically FDI could be divide into three type of motivates they are market-seeking, resource-seeking, and efficiency-seeking (Malllampally and Sauvant 1999). Other than above there are a lot of academics theories, which could explain the motives behind the FDI by enterprises. In these theories I have chosen five theories that is common to be use for explain the motivations of FDI. First is international product life cycle theory (Vernon 1966), every product ought to go thought some stages from a new product to a mature product. In order to take efficient and cost advantages in different stage, production plant move towards foreign. This theory help explain the motive of manufacturing business efficiency-seeking and market-seeking in using FDI but fail to explain reason of using FDI instead of using others methods such as licensing. For example car producer such as Honda, their new car will be firstly starting design and produce in Japan during the new product stage, then shift to USA for listen to the market where have a huge demand and lastly the production will be shift to the East-Asia to produce in order to lower the production cost in the standard product stage. Second is transaction cost theory (Williamson 1993), it stated that when enterprises business is affected by market imperfection, which lead transaction cost increase. They will go international which benefit the efficiency and decrease the transaction cost. Be remind that this theory fail to explain reason of enterprises using FDI instead of using others methods and it is usually apply to manufacturing business efficiency-seeking which products are low in price, heavy, and easily to product in every where. For examples cement manufacturing industry as the raw-material is easy found in every where and easy to product also it is cheap in price and heavy so that firm will be product it locally instead of export it. Third is market imperfection approach, (Hymer 1970) assume that due to market imperfection FDI present. Theory stated that when any factors which lead failure of perfect market. Because of extra cost of cover the barriers, advantage present in foreign countries, and advantages in using FDI over licensing such as full control, unique knowledge, and skill cannot be transferred. Enterprises will do the FDI to achieve profit maximization on their business. This theory help explain the motive of efficiency-seeking in every business by using FDI when they facing market imperfection. Fourth is eclectic theory (Dunning 1993), theory stated that following factors found by enterprise FDI will be present. Firm will get advantage over particular location ownership, the advantage of have location ownership are not by selling or leasing, for the advantage a profit advantage must be gain. This theory help explain the motive of industries using FDI to take advantage of market-seeking and resource-seeking. Fifth is following competitors theory (Knickerbocker 1973), this theory stated that in oligopolies industries firm will follow her competitors to move towards foreign countries. Following competitors in order to reduce the chance monopoly in a new oversea market by her competitor. This theory help explain the motive of oligopolies industries go international for market-seeking But this theory fail to explain the reason of first mover and reason of using FDI to expand other than licensing. Eclectic theory, following competitors theory, and market imperfection approach which help explain why JKX chose to invest internationally with FDI. JKX is focusing on petroleum exploration and production of oil. It is just perfectly apply the eclectic theory because JKX is fully depending on use of local resources oil field. FDI is the only way to gain the resource by takeover the location ownership, and JKX uses the location resource to generate profit by production. Also maybe reason of addition cost on oil production JKX will decide move to other country because of the unique knowledge and skill cannot be transferred JKX need to use FDI to build new production plant. Also exploration and production oil industry in oligopolies. If JXK do not follow her competitors she will lost the potential oil field and her potential customer in new location. Moreover when JKX decides to invest internationally she needs to beware of the following such as economic risks, political risk, exchange rate risk, and cultural risks. 3. FDI impact on nation states Because of FDI bring a lot of advantages to nation states (host & home), nation states attempt to encourage FDI to do so. 3.1Advantage of FDI to host country There are seven advantages of FDI to nation states, which explain why host countres attempt to encourage foreign to do FDI. First is resource transfer effects, FDI by foreign firm bring along with their capital, technology, and management skill to host country. Capital bring alone by FDI is an importance source of stable private external finance for every country especially to developing countries. For example JKX buy an oil field form the host country and invest on the oil drilling equipment and build production plant ,which is a long term investment, profit making though production ,and could not leave easily. Moreover the external finance give a big hand on the balance of payment and foreign exchange reserve which is importance element for the economic health. Technology and Management Skill are another resources bring alone with FDI, which enhance productivity and competitiveness of host country. Both of them are importance elements for success in global market when chance comes. Foreign firm provide training on knowledge and skills on how to produce and management skill to local employee in order to facility the production. These knowledge transfer direct benefits to local labors and enhance productivity and competitiveness of host country. For example in the 90’s computer parts MNCs build production plant in Taiwan by FDI, nowadays Taiwan is be came another computer parts manufacturing kingdom in Asia. Second is employment effect, FDI creating employment for host country. Foreign firms build up their manufacture plant in the host country which increases the employment directly by foreign own plant and relative industry, for example in Mexico FDI create every 1 job in the foreign production plant and create 7 job in the relative industry (Farrell 2004). Also the local trained employees may start their own business. But there will be opposite effect in market-seeking† FDI raise unemployment by forcing less competitive companies out of business as foreign firm will bring along with advance technology reduce employment need in same production, For example Wal-Mart’s entry into the Mexican food Market which decrease the margin of that industry push less competitive companies exit (Farrell 2004). But actually this effect is just base how government manage the FDI for example in the 90’s china government restrict of the sold inside market of foreign firm which protect the local employment would not be substitute. Third economic growth and local multiplier effect, high employment leads more consumption by the local country citizen. As a result encourage industries further develop to fulfill increasing consumer needs; lower prices, better quality, and more selection for consumers. It is because of further developed of the industries, which increase employment, and new products encourage consumer to do more purchase, the cycle will go on and on. Fourth credibility in international market because of demonstration of first mover success, build up a model for the followers others foreign firms will be more confident to FDI to the same country. As followers could learn the first-comer experience, enjoy the effort done by first comer in host country such as infrastructures, educated customers, trained labors, and research done. Also stop the first-mover to become monopoly. In additional the credibility may attract short-term investment others than FDI. For example India starting by the first mover to starting computer software relating industry, nowadays it became another silicon valley in. Fifth access to return markets (Malllampally and Sauvant 1999), as FDI by foreign firm increase accessing international marketing network. The network benefit to transnational systems related industry, domestic firm to getting spillovers foreign business, and wider economic of host counties, by greater the links between foreign and domestic. This also helps spread the enhanced productivity and competitiveness of host countries. Sixth tax revenue from profit (Razin 2002), profit generated by FDI contribute to tax revenues to the host country in general. But some countries may cancel out direct taxes for the MNCs to attract for investment, tax revenues will still be benefit as more consumption in local {Sales Tax} and better income of citizen {Income Tax} Seventh reinvestment within local economy, the credibility of host country established the foreign firm may reinvestment into same country by using the profit earns in there. Moreover host counties encourage foreign firms to do so as foreign firm bring the profit back to their home country may deplete the foreign reserve and the profit earned put back to host country will bring along with new benefit to host country. In additional FDI force host country improve their economic health such as policy system, industry, and better the living standard of the host country by better income, lowing price, improve quality and more selection for customer. 3.2Disadvantage of FDI to host country There are also some bad points together with FDI incoming such as, Adverse effects on local competition due to spending power and brand of MNC, MNCs become an impact on government decision due to the economic power of MNCs, Over exploitation of country mineral wealth etc†¦ 3.3Advantage & Disadvantage of FDI to home country Looking on the surface impact of FDI to home country surely will be lot disadvantages follow by such as negative impact balance of payment and increase unemployment. But why home country will encourage company to do FDI aboard , FDI will benefit the country in such ways, company go aboard may increase the export due to new development demand, MNCs will bring the FDI profit back to home country that benefit the balance of payment, jobs will be create as additional need of support activity represent by FDI aboard. FDI increase the long-term competiiveness by learn from others countries. Home country could benefit from the FDI of the sunset industries to free labor force form the costly and low-value industry. FDI good to host country and long-run good to home country FDI need management and benefit to both MNCs and host government For FDI to be successful it require win-win situation benefit both MNC and Host country, but require a good control in order to manage FDI well. If the management of FDI is done badly which may result in harmful to whole host country’s economic system. On the other hand FDI going aboard not only bring alone with disadvantage to host country in the long-run which may also give a huge benefit to the home country. The following paragraph will be shown both advantages and disadvantages of FDI to nation states 4.Root causes of financial crisis  There are many underlying reason which form a financial crises such as excess capital inflow, speculation activities, poor financial infrastructure, monetary policy etc.. all these factors encourage financial crises breakout. The following is a simple flow of twin crises (Kaminsky and Reinhart 1999). Starting form establishes of credibility of a country, foreign investors will start to invest into the country because expectation of return high. When the capital going into the local economic, that increase the economic health, local money supply, economic activity, foreign reserves, and government budget. All these factors increase country credibility and once again increase the attractiveness of capital inflow. The continuous increasing expectation of return will form rational bubble (Blanchard 1979) investors and speculators will holding an overvalued currency but would not sell it yet, they believe there will be a further appreciation on the local currency. Because of more and more capital inflow, banks in the country will facing difficult in generating profit as they have too much cash on hand, the banks will decrease the liquidity ratio lend more money out of the banks which result in increase risky loan, overinvestment, over-consumption, and asset price bubble. Banking crisis will more like to happen when bubble bursts and increasing bad loan. When the Banking Crisis outbreak which decline economic activity, costly fiscal bailout, decline the country credibility and lead capital flight. (Aghevli 1999) Capital outflow, costly fiscal bailout, decline economic activity, and speculation activities fasten decline the foreign reserves that result currency crisis.

Mystic Monk Coffee Case Essay

1. Does Mystic Monk Coffee have a competitive advantage? If so, what is it and is it sustainable? Throughout what Mystic Monk Coffee has done, I believe it has the ability to build a competitive advantage. According to the case, the Mystic Monk Coffee was produced by using the high quality fair trade Arabica and fair trade/organic Arabica beans with variety of blends and flavors. They also produce T-shirts, gift cards, CDs featuring the monastery’s Gregorian chants, and coffee mugs that give different choices for the consumers. Mystic Monk Coffee might create less sustainable compare with other competitors in the industry due to the quality of the coffee. However, Mystic Monk Coffee’s target market was on 69 million members of the Catholic Church in the United State that generate enough profits for them to be sustainable. 2. Evaluate Father Mary’s strategy using the â€Å"three tests of a winning strategy† from the text. * The Fit test: The strategy fits t he company’s situation since the products were made in high quality and differentiate with others’ products. The case states that the specialty coffees had grown dramatically with retail sales increasing from $8.3 billion to $13.5 billion in the last seven years and the retail sale of organic coffee has grown for $1 billion. The company also focuses on U.S. Catholic customers and using their loyalty to advertise to the others. They also make sales through website, telephone, etc. * The competitive advantage test: the strategy might bring a sustainable competitive advantage for the company. It’s proved that Mystic Monk Coffee’s sales of coffee and coffee accessories average about $56,500 per month. The company can focus on building a strong loyalty with customers. * The performance test: be able to generate $56,500 per month is an impressive number for Mystic Monk Coffee since none of them have certain experience to manage an operation. I believe the strategy producing good financial performance. 3. If you were a volunteer consultant (because Father Mary probably couldn’ t afford your consulting fee otherwise) and based on the evaluation above and other information in the case, what recommendations would you make to Father Mary and why (i.e., support your recommendation with analysis from the case). * The monastery should specialize in the production process and highly train to improve quality of coffee. That can help to reduce time and cost of goods sold; thus generate more profit. * Father Daniel Mary can contact with other Catholic Church to spread the letter to the supporters so they can know about Mystic Monk Coffee was working hard on to acquiring a new Mount Carmel – a building for 30 monks, a retreat center for lay visitors, a Gothic church, a convent for Carmelite nuns and hermitage. * Try to minimize the cost from suppliers, shippers, etc. Kelleher Video: 1. Reiterate from the video the Mission and Vision of Kelleher for Southwest Airline. Kelleher vision is short distance travel, friendly customer, low fare and point-to-point travel airline. Kelleher mission is to democratize the sky. Reinvent the idea of travel and de-regulate the airline industry with low fare and friendly customer service. 2. How would you characterize Southwest Airlines strategy? Southwest Airline characterized by low profit margins and yet managed to profit and stay in business from doing so. Through product differentiation and a strategy of low cost and no frills, Southwest has been successful in distinguishing itself from its competitors in order to sustain profitability in this aggressive industry. 3. What elements of the company’s operations support the strategy? Southwest campaign and advertise free liquor to those who flight Southwest at a regular price of $26 when rivalry airline are lowering the fare by $13. So Kelleher came out with an idea and a dvertises free liquor to his customer. The flight attendants were handing out Vodka, Rum, Royal, and Whisky. In the 1970’s they were the top distributer of whisky in the state of Texas. By this campaign they manage to drive their competition out of business and out of the state of Texas. 4. Given today’s economic, political, social, governmental environments, what issues do you see emerging in that will have positive or negative effects on the airline industry generally and on Southwest specifically? First identify the issue and then the impact. With today economic crisis, airline are laying off employee, baggage fees were charged and serving meals on the airplane. These known issue were present by the competition airline which Southwest stand their ground and act differently. They did not lay off employees but rather employed more. They advertise free baggage travel and successfully gain more travels because they do not have to pay for ridiculous baggage fees. In return southwest have gain more shareholder and confident investor. They served free peanuts and drinks when other served whole meals in return  they have proven and delivery their promise as fast turns around time to board and lower airfare. They only flight Boeing 737 so their employees know the plane inside out in return they saved millions on the aircraft maintenance fees. These strategies make positive effect to the airline industry, which make southwest special, unique and fun airline to travel with.

Example of an Essay about Money Issues in the US Economy

The American economy is an important issue for all students. This area affects all disciplines and people as the economy influences areas such as employment, funding, investments and the general well-being of the country. Students must gain an understanding of economic trends, and writing about it is one excellent way to better understand. At some point throughout their time in university, it’s likely that students will be asked to write about the economy. Below is an example of an essay about the current troubles in the US economy. Interesting Economic Trends May Indicate Slowing Economy Although in some ways things were looking up for the American economy at the start of 2016, with low unemployment rates of 5% and gas prices also consumer-friendly, an inexplicable trend of low consumer spending has had economists concerned. A number of factors showing very mixed predictors of the economic future of the country. Through this information, it’s clear that policy makers will have an important role to play in the coming months. Now that we’ve reached the third month of the year, consumer spending has increased, although very slightly. Some economists see this as the sign that the economy although not booming, is strong and plugging away. Consumers have been slower to return to spending as they’re still recovering from losses, and choosing to play it safe by saving more. This seems to indicate that consumers are now slowly making their way back to the cash register. Despite this more cheery news, the most recent analysis by economists is mixed. Many economists see the world environment as a troubling one. With the strong dollar and suffering worldwide economies, exports aren’t being sold. Another sign that the economy is at the best slow and at worst likely to experience a recession is the freight and truck transport numbers. These figures show the pulse of the economy by giving an indicator of the level of economic activity. Declining levels of freight and truck transports have been associated with recessions. This news is accompanied by other reports that manufacturing has stalled due to low demands for highly priced American made goods overseas. This is due to the strong dollar. Finally, some of the biggest and strongest companies in the country are making less money. Profits are down for companies such as Apple, who claims that their sales for iPhones are declining for the first time in 13 years. A clear analysis of all of these factors hasn’t been made by economists, however it seems clear that policy makers have an important role to play. The recent stimulus package in 2010 hasn’t had as much of an effect on the economy as would be hoped and government spending is now lower than when the recession began. The government action, particularly of the Federal Reserve, is a key factor for emerging from the recession. While no one can tell the future, careful policies could help turn things in a more positive direction. References Statista. (2015).  Employment rate in the United States from 1990 to 2014. [online] Available at: http://www.statista.com/statistics/192398/employment-rate-in-the-us-since-1990 Buttonwood. Feb, 2016. The Trucks and Trains Test; Barely Rolling Along. The Economist. Available at: http://www.economist.com/blogs/buttonwood/2016/02/american-economy Gillepsie, Patrick. Feb 1, 2016. Will Americas economy get dragged into recession? CNN Money. Available at: http://money.cnn.com/2016/02/01/news/economy/american-economy-manufacturing-consumer-recession/ Helmore, Edward. US economic slowdown may be less severe than previously thought The Guardian. Available at: http://www.theguardian.com/business/2016/feb/26/us-economy-slowdown-gdp-less-severe-than-previously-thought Gillepsie, Patrick. January 29, 2016. Cracks in Americas economy are growing. CNN Money. Available at: http://money.cnn.com/2016/01/28/news/economy/cracks-in-the-us-economy/ Torry, H. Feb 26, 2016. US Economy Starting 2016 On Solid Footing. Wall Street Journal. Available at: http://www.wsj.com/articles/u-s-growth-revised-higher-in-fourth-quarter-1456493673