Strategic Workforce Planning for Future Success

by Herman Bailey | Jul 22, 2023 | Essays | 0 comments

Introduction

Those in charge of teams, projects, or organizations usually are expected to have a plan on how different activities will be met. These kinds of planning require training, recruitments, and deploying of the people who are expected to offer results. If the managers do not act immediately and wait till the last minute that the particular work is required to do all these, the needed skills and personnel will definitely not be available. Timely workforce and effective planning surpasses headcount and gives great solutions to aggregate a business’s future direction. A workforce plan that is strategic gives good decisions of the business and produces very essential data like productivity time, difficulty, and easy time which in return assists in risk identification early enough and therefore actions are set on time. According to CIPD members’ guide, Workforce Planning Practice is laying out the steps to planning a workforce for Human Resource professionals and managers of particular lines. Cases of uncertainties and change make planning very essential because it helps organizations to prepare themselves for survival by securing resources of the workforce that are required now and in the future (Armstrong et al., p55).

Works cited

Armstrong, Michael, and Stephen Taylor. Armstrong’s handbook of human resource management practice. Kogan Page Publishers, 2014.

Deakin, Simon F., Gillian S. Morris, and Gillian S. Morris. Labour law. Oxford: Hart Publishing, 2015.

Swanson, Richard. Analysis for improving performance: Tools for diagnosing organizations and documenting workplace expertise. Berrett-Koehler Publishers, 2017.

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Herman Bailey

With a student-centered approach, I create engaging and informative blog posts that tackle relevant topics for students. My content aims to equip students with the knowledge and tools they need to succeed academically and beyond.

Unraveling the Motivations Behind Hate Crimes: A Comprehensive Analysis

by Herman Bailey | Jul 22, 2023 | Essays | 0 comments

Abstract

Hate crimes have been a longtime surviving problem and challenge in America. In the early 19^th century, lynching was a common crime, and mostly based on racial segregation. By the early 1950’s hate crimes had advanced from purely racial to include crimes and violence against the gay members of society and gender based hate crimes. Hate crimes are born out of prejudice which comes across in the form of scape goating and stereotyping. For decades now, the focus has been on understanding the effects of such hate crimes, and therefore providing recommendations based on the emergency nature of the problem. Today, hate crimes affect and have effect not on a singular group, race or ethnicity but rather on a diverse range of people. This paper sets itself to examine the main drivers for hate crime offenders. Different forms of hate crime have different drivers. Understanding such drivers provides a basis for providing substantial and sustainable solutions to the problem of hate crimes in America.

Introduction

In every society, there exists a foundation of prejudice and subsequent differences between people living in the society; this is often the foundation of hate crimes. According to Perry (2002) hate crimes are violent crimes that are born out of perceived privilege and intolerance to people who are perceived not to enjoy such privileges. The perpetrator often feels they are privileged by virtue of their choices, membership to particular groups and natural abilities over others. The victim on the other hand, has membership to what is considered lower groups, different natural abilities and lacks the ability to make similar choices to the perpetrator. Levin and McDevitt (2013) cautions that by definition, most people make the assumption that there must be proof of hate for the crime to be considered a hate crime. However, the existence of hate is not a pre-requisite to the action being considered hate crime, rather there must be existence of a bias attitude which propagated the crime thus giving birth to the action.

Hate crimes have become so common that it is difficult to keep track of the rising occurrences across the globe and the country. Today, the pursuit to end hate crimes has become a matter of emergency for governments and human rights organizations worldwide. Herek et al.(2013) estimates that since the year 2013, more than 1300 lies have been lost to hate crimes; and these are only those that were reported and recorded as hate crimes. Even more deaths are estimated to have occurred under this category. In addition, there have been many injuries, accidents and even property damages that are attributed to hate crimes. Even with a society that is considered to be fully modernized, the problem of hate crime seems to be interacted into our very existence.

Background to the problem

For the third consecutive year, hate crimes around the major cities in the USA have increased in prevalence, occurrence as well as seriousness of injury. This is despite growing efforts by many groups to address the growing level of hate crimes (Shively 2005). Both the policing communities as well as human rights organizations have increased the focus on the problem of hate crime following various vigorous responses to incidences. Each group involved in the law has been sensitized to severity and the need of addressing the problem of hate crimes. However, there is considerable disparity with how various organizations and institutions respond t hate crimes. This has led to some level of tolerance as the American society buries its head and ignores what is soon to become an emergency. In some cases, institutions including the police feel that the acts of crime that is hate crime in themselves are either justified or not serious enough to warrant the pursuit of justice. Hate is slowly transforming to a functional element of society, bringing people together instead of drawing them apart.

One of the difficulties in addressing the problem of hate crime is under reporting. Majority of the victims often feel that the crime is given little attention and exposes them to more danger. This leads to lower reporting of the same crimes. In fact even with the rising statistics reported by the FBI, it remains clear that even more cases of hate crime are not reported. Petrosino (1999) states that the American law requires proof of hate in the existence of the crime. Such proof is often difficult and in some cases immediately ignored and not directly pursued, the result is that individuals are unable to pursue justice and are less motivated to make reports of hate crimes. The sensitive nature of hate crimes also leads to fear among the victims for further victimization. Taking into account for example, gender violence or hate crimes based on gender, victims often feel that they are victimized once again when perpetrators are either let go, or when they have to prove that they did not invite or incite the attention that led to the criminal behavior. Victims of racially motivated hate crimes on the other hand, often fear the process of justice which in many cases is biased so that the punishment is not equal to the crime itself. It is important to note that in some states, hate crimes are not recognized in a special category but are rather tried as normal crimes making it difficult to prosecute, and seek justice for the victims. Such states include Indiana, Arkansas, Georgia, South Carolina and Wyoming. Coupled with this is the fact that for many prosecutors in the state, hate crimes draw too much attention and are less attractive in comparison to other crimes.

Research has shown that among all other forms of hate crimes, race and sexual orientation crimes continue to remain higher within the country (Iganski 2001). Recent attacks against the country, and continued security measures which have been on the increase have resurrected the hate and emotional abuse that comes with fear. Majority of Americans often feel that the society itself is poorly protected and therefore with an increase of migrant populations comes an increase in crime. This disturbing perception has been made even more popular in the current political climate were policies and agendas have focused on segregating people based on their racial origin. With politicians taking advantage of the sensitivity of the matter, it is not surprising that the country has experienced a surge in hate crimes.

Morality remains a concern for many Americans. There are many who feel that specific behaviors encourage immorality and render the society poor in terms of standing out morally. These includes the increased perceptions and attitudes against the gays and LGBT community. For many, the society does not represent a choice but rather a planting of immoral behavior which in turn infests society. This is why majority of the victims are often figures of authority as well as influential persons in the country. They are often subjected to the situations where they have to justify their choices. The LGBT community often fail to report the cases because they fear further victimization in the legal process which has done little to protect victims and pursue justice on their behalf.

As terrorist attacks increase, concern has been raised over propaganda spread with regard to particular religions especially Muslims. Due to their outstanding dressing and mannerisms, majority of Americans are likely to react in fear when they encounter or come across a Muslim or person of other religion. It is assumed that simply because of their religious choices, they have become radicalized. This is despite the fact that Muslim societies, human rights organization and American Muslims have stood out and spoken against such prejudice (Welch 2006). Muslims are most likely to face hate crime, since perpetrators often feel that society would support their actions and they are justified in the choices that they make. Every time an attack occurs, despite the number of people affected and the distance from the area where the attack occurred, Muslims are likely to face increasing threats, continued harassment and even assault or murder. The problem is that even where they report cases such as this, they are often left to fend for themselves. Police and legal institutions are less inclined to protect them and their beliefs. They may even face further victimization as they are forced to prove their case, endure further questioning and justify their desire to pursue justice. They find that they are often treated as “less American” than others including their perpetrators.

Forms of hate crimes

Religious hate crimes: Jeness and Grattet (2001) states that religious hate crimes have increased by more than 23% in the past decade in the united states alone. Religious hate crimes are crimes that are propagated by differences in religion and faith alone. They are crimes against other people, their property and threats against their own wellbeing based on the fact that they come from different faiths. Recent increase in religious hate crimes can be attributed to the continued popularity and belief that particular faiths emphasize and teach their faithful to engage in violence. In a country where freedom of religion is touted a right for citizens, the concern over growing intolerance for minority religions is alarming. Religious hate crimes are born out of perceived notions with regard to other religions, whether such perceptions are true or not. They also include crimes against religious institutions and organizations such as churches, mosques and centers of worship.

Disability hate crime: this is behavior and hostility that guided to an individual because of their disability or connection to the disability. It remains the most under recorded type of hate crime, since police officers do not take it seriously and often ignore the seriousness of the crime. Because of the nature and ability of the victim, disability hate crimes may take place over a long period of time, covering months and even weeks (Craig 2002). It is simply prejudice that takes advantage of what the victim is unable to do for themselves, so that the perpetrator develops the perception that the victim is particularly or fully to blame for the crime and actions directed towards them.

Racial hate crimes: Race is the most common form of hate crime. For decades now civil societies have addressed the problem of race and racial prejudice. Even in the formal workplaces, the problem of race prejudice is one which cannot be ignored. In fact King et al. (2009) state that racial hate crimes have formed the foundation for all policies directed at hate crimes. Hate crimes are born from the perception that a particular race and color of people are better than others. They therefore have the right to treat or mistreat others as part of exercising their privilege. Racial hate crimes have developed far from individual victims and perpetrators to established institutions that hold particular people higher simply because of their race. Under the law, the actions of the perpetrator must be motivated by the desire to belittle to engage the victim on the basis of their race alone. Secondly, such actions must be deemed under the law to be criminal. Because of the prevalence of racial hate crimes, much has been recorded and recommended in pursuit of ending the centuries old form of criminal behavior.

Sexual orientated hate crimes: The immediate victims of sexual orientation propagated hate crimes include individuals who are gay, lesbian, bisexual and transgendered. What is concerning however is that despite the existence of third form of crime, since the early 1960’s, there are states which are yet to categories and rate policies surrounding this particular form of hate crime. According to the FBI statistics as quoted by Dunbar (2006), 60.4% of the sexual orientation hate crimes were directed at individuals and mostly involved rape , sexual assault, verbal abuse, assault and murder. Many of the perpetrators engage in such behavior following beliefs and perceptions that come from society with regard to the LGBT society. The foundation of sexual orientation hate crime is gender binary. Gender binary is the societal belief that there are only two genders, i.e. male and female and that all members of society need to embrace their roles as defined by their gender. Those who seek out alternative forms of roles and definitions of their gender are therefore considered to be morally wrong and their behavior remains unacceptable in society. Transgender are often the most easily spotted and targeted group, because of their behavior, mannerisms and dressings which may not particularly fit the boundaries of gender descriptions in society.

Gender based hate crime: Traditional culture was built around the belief of specific gender roles. This culture has been taught and passed down in society for centuries. However s more people begin to challenge their gender roles and gender definition, they find themselves as victims of hate crimes based on their specific gender. Sexual assault is only one of the methods that is used to propagate violence and criminal behavior agonist people of specific gender. McPhail (2002) states that when it comes to gender hate crimes, perpetrators are often and more uniquely people who are close to the victim. They believe that the victim is stepping out of the boundaries and legalities of their gender by pursuing particular interests or engaging in different behaviors. Majority of the people who are victims of gender based hate crimes, therefore fail to report the same leading to low records of a behavior that is quite prevalent in society. For majority of the policies, the burden of proof that indeed the motivation was based on gender and the behavior itself was criminal lies with the victim, making prosecution difficult. Below is a chart showing the FBI statistics on the various forms of hate crimes reported:

Drivers of hate crimes

Social environment: The manifestations of hate are plentiful, yet the study into what causes the development of hate itself is quite limited. Morsch (2001) lays his reasoning on social behavioral theories. He determines that the nature of an individual is often crucially determined by the social environment in which they grow. An environment which enhances the differences between people, for example emphasizing the importance of a particular race is likely to lead to privileged thoughts. Jackson and Heckman (2002) agree indicating that children who have grown up in high income families. Are likely to frown upon the behavior and nature of others. They are also more likely to justify their tendency to engage in criminal behavior and tendencies. Families that promote and segregate their children from people of a particular group are most likely to raise children filled with hate. Constant exposure to particular behavior, subjects of discussion and beliefs immediately leads to development of the same behavior.

Thrill seeking: Young people involved in hate crime, have no particular reason for engaging in such behavior rather the behavior is a result of immature pursuit for excitement. The victims themselves are chosen based simply on the fact that their gender, religion and ethnicity differs from that f perpetrators. In the current age of social media fame, thrill seekers tend to think that violence and crimes against their victims provide a one way ticket to stardom. It is important to note that for thrill seekers, their victims are not of concern to society and society applauds their behavior towards the same victims. Although thrill seekers are often young in age, they are also the most dangerous group of criminals, since they lack emotional control, conscience and have a skewed perception of morality.

Intolerance: Intolerance according to Ferber (2004), intolerance is the unwillingness to adapt, and accept the views and beliefs of others who are considered “different” .Unlike thrill seekers who attack people and groups without any reason or ample warning, intolerance leads to targeting of specific groups. It justifies the crime and behavior e.g. assault, destruction of property and threats as a necessary tool to keep invasive ideas and behavior at bay. Intolerance is often difficult to identity and thus correct, rather it seems to crop up during a major shift or event in the perpetrators life e.g. immediately after a Muslim or black family moves into what the person may consider a fully Christian and white community. Perpetrators believe that it is their duty to maintain the purity of society and therefore part if not all of the society supports their behavior and even encourages them to pursue such behavior according to their thoughts. Intolerant individuals are unable to accept that others can exist who are different in terms of belief and behavior to themselves. Intolerance is the most difficult cause of hate crime to address, because it is quite difficult to change the beliefs of people even when they are faced with overwhelming contrary evidence. It is born out of prejudicial information that is often misconstrued and misinterpreted leading to false beliefs.

Revenge: Hate crimes can also be caused by the pursuit of revenge over imagined mistakes and slights over an individual, society or group or in response to other hate crimes and criminal behavior. Avengers are likely to act in small groups or as individuals, since it is based on the fact that all members faced the same situation or were caused to endure the same challenges. They target embers of specific groups based on race, religion or ethnicity, who are believed to have been engaged or caused the original crime even though they may have had nothing to do with it. Gerstenfeld (2017) suggest that most of the revenge hate crimes in modern times are likely to occur immediately after an act of terrorism. Facing security challenges and experiencing raw emotions, perpetrators may seek out Muslim Americans and other races . He provides an example, where hate crimes against the Muslims and people of Arabic origin increased by more than 1600% immediately following the 9/11 attacks. Surprisingly, the attacks have been hard to resolve and bring to an end especially as more young people become converted to join the ISIS movement.

Fear: Sometimes hate crimes are born out of simple fear that people who are different or who hold different beliefs are a cause of danger. The perpetrators believe that they are in turn defending themselves from the possibility of harm from others. Fear is a complex emotion that immediately leads an individual to become defensive. The stronger the fear, the more likely that the response will be violent as well as fatal. There is likelihood that cases of increased fear can be traced to media reports and sensalisation of crimes by people of specific sexual orientation, race and ethnicity. For example, in the past decade there has been unwanted attention to crimes committed by Mexican, African American and other races. It is therefore not surprising for simple actions such as reaching into the pocket become misconstrued as actions that are likely to endanger others. The perpetrators therefore feel it is their duty to protect themselves as well as the community which they live in. they may take actions that prevent the comfort and socio-wellbeing, threaten or assault the victims in an attempt to insure their own security and wellbeing. Hate in this case can be reassuring and self projection because it is based on confirming and assuring the belief in a world where justice prevails as per the perpetrator’s image.

Combating hate crimes

It is not a secret that the government has been struggling with dealing with hate crimes. Many recommendations have been made, but few see to take root and work within the society. This is despite much research and resources being directed towards resolution of hate crimes across the board. Having noted that the problem is not local community one, but on which is encountered across the country as well as globally. Haider-Markel (2008) notes that this is simply because there is little collaboration between agencies which are directed towards addressing the problem of hate crimes. The human rights organizations are often bent on working independently as well as showing the government that there is little they are doing to combat the problem. The communities themselves are directed towards even more towards shaming the government and other institutions. A hate crime provides a unique opportunity for society to bring together all its institutions to work together towards resolving the problem from the root.. independent resolutions often lead to band aid kind of solutions, which are not only temporary in nature but in fact cause festering of a situation which is already sensitive in nature and which then is likely to blow up and out. Local law enforcement agencies can work hand in hand with humanitarian organizations to bring about awareness of hate crimes, encourage victims to record and bring forth cases of hate crimes and finally ensure proper follow up of such cases. This not only discourages future perpetrators but also allows the victims to gain confidence in the legal system.

The traditional legal system when it comes to hate crimes has unfairly focused on the perpetrators of the crime. They often receive much more attention and in some cases may even be considered more valuable than the victims. According to Beale (2000) government research and attention is often focused on reducing the desire of the perpetrator to commit the same crime. Despite the legalities and the law statutes on hate crime, it is likely that the same criminals will face minimum punishment if any. Prosecutors are not motivated by the legal process to pursue cases against perpetrators of the hate crime. Victims of hate crimes are often left alone in a situation which they barely understand and which causes emotional harm to them. They have been attacked and put in a susceptible situation simply because of something which they can change: their sexual orientation, race, ethnicity and disability, yet the burden of proof still remains with them. They must prove that first a crime was committed, a crime which is defined under law and from which they must be protected. Secondly, they must prove that the crime itself was hate motivated, and that such hate was brought on by their unique behavior and natural abilities. It is important for the legal system to restructure so that maximum support is given to victims. From local courts, police departments even to the national level, support for victims allows for cases to be addressed, perpetrators discouraged and support granted to the victims appropriately. Victims need to know that the legal system supports their very lives and seeks to give them justice.

Hate continues to thrive because it remains hidden. Even when exposed, it is often hidden in code and unfathomable systems. Majority of the time, hate crimes are rarely reported. Even where they are reported victims are discouraged against exposing the nature of the crime. Society in itself has become dependent on the nature of hate, to hide it. Most people behave as if hate itself does not exist. Even victims being victimized publicly rarely if ever get support from the public. Individuals who have been killed because of hate, even where evidence exists continue to be hidden under the cover of other crimes that are not driven by hate. We, as a society rarely have the time and energy to pursue cases of crime against others that are driven by hate. Politicians and other major influencers rarely want to talk about hate crime even when seeking votes. Those who speak out tend to face major challenges in completing their duties and seeking re-election. As such, society encourages all members to shy away from speaking against hate crime, which in turn accuses it to fester and grow under the cover of other crimes. It is important to expose the hate crime, speak against it in major forums and expose the filth that lies underneath. This will allow the society to address the problem and force the government to face the problem directly. When people are aware that the nature of their behavior has been exposed, they are more likely to change and alter such behavior in favor of what society deems acceptable.

Exposure also means education. From schools and institutions, it is important to educate people first on what exactly entails a hate crime. There are those who believe that that is hate crime is indeed just normal behavior that is justified by their privilege. Education gives boundaries of what is considered normal behavior, and what is morally wrong as per societal standards. Media houses which are known for sensationalizing stories should be more focused and directed towards educating the public on the nature of hate crimes. Further education should be done for the victims, to understand their rights and what the law covers in terms of hate crimes .

Conclusion

Media and especially social media is a tool that reaches thousands of people at the same time with the same message. In the past, media has been considered the enemy. This is because of the nature of information that they report. To the victims, the news often seem to make the situation much worse than what they are experiencing. In turn , they may also feel that the media houses are favoring and reporting more favorably about the perpetrators. To the community and even the government the news often seems over sensationalized. What is ignored is the value of the media houses when it comes to spreading the right information. The media can be an ideal tool for education and teaching others the value of acceptance and lack of prejudice. The more people become aware, the more tolerant they become thus reducing the hate crimes.

With many policies in place, what remains is the action on the basis of the policies. Several commissions have brought out recommendations for addressing the problem of hate crime. Yet, the actions which have been recommended including education and training of legal officers and police officers to support victims of hate crimes have rarely been implemented. During sensational periods, the community outcry often leads to formulation of great policies. But such policies are rarely implemented in the long run. Resources and individuals are rarely put in place to address the problem of hate crime.

Solutions of hate crime are no longer short term but rather long term. The various forms of hate crime need to be defined within the confines of the law, with specific processes and punishments to be meted out for each.

Hate crimes have garnered much attention in the last year. What looked like a problem that identified and focused on a generation stuck in the 60’s is now drawing the interest and focus of millenials. While attempting to understand the prognosis of hate crimes, an important element is gaining knowledge on the root causes of hate crimes. Hate crimes are designed to act as a message to two groups: the first being the group who which the perpetrator is a member, a message that there are those who are not similar and thus must be dealt with. And secondly, a message to the victim’s group, a message that is meant to cause discomfort, fear and threats. It is built on the premise that victims will understand that they do not belong to the neighborhood, school or other social amenity that they share with perpetrators.

The effects of a hate crime are more long lasting in comparison to other forms of crimes. This is because, they are likely to cause psychological trauma which lasts for years sometimes even decades for the victim. In order to generate policies that effectively address the problem of hate crimes, it is vital that the underlying causes of the crime are understood. It is only when the root causes of hate crime are openly addressed that the solutions being offered will be effective rather than seemingly band aid solutions. Not all perpetrators of hate crime are driven by the same desire. Discouraging hate crime therefore means removing any sort of pleasure that may arise from engaging in such crime and making the punishments so severe that they outweigh the benefits of considering such crime.

References

Beale, S. S. (2000). Federalizing Hate Crimes: Symbolic Politics, Expressive Law, Or Tool For Criminal Enforcement. BUL Rev., 80, 1227.

Craig, K. M. (2002). Examining Hate-Motivated Aggression: A Review Of The Social Psychological Literature On Hate Crimes As A Distinct Form Of Aggression. Aggression And Violent Behavior, 7(1), 85-101.

Dunbar, E. (2006). Race, Gender, And Sexual Orientation In Hate Crime Victimization: Identity Politics Or Identity Risk?. Violence And Victims, 21(3), 323-337.

Ferber, A. L. (Ed.). (2004). Home-Grown Hate: Gender And Organized Racism. Psychology Press.

Gerstenfeld, P. B. (2017). Hate Crimes: Causes, Controls, And Controversies. Sage Publications.

Haider-Markel, D. P. (2008). The Politics Of Social Regulatory Policy: State And Federal Hate Crime Policy And Implementation Effort. Political Research Quarterly, 51(1), 69-88.

Herek, G. M., Cogan, J. C., & Gillis, J. R. (2002). Victim Experiences In Hate Crimes Based On Sexual Orientation. Journal Of Social Issues, 58(2), 319-339.

Iganski, P. (2001). Hate Crimes Hurt More. American Behavioral Scientist, 45(4), 626-638.

Jackson, R. L., & Heckman, S. M. (2002). Perceptions Of White Identity And White Liability: An Analysis Of White Student Responses To A College Campus Racial Hate Crime. Journal Of Communication, 52(2), 434-450.

Jenness, V., & Grattet, R. (2001). Making Hate A Crime: From Social Movement To Law Enforcement. Russell Sage Foundation.

King, R. D., Messner, S. F., & Baller, R. D. (2009). Contemporary Hate Crimes, Law Enforcement, And The Legacy Of Racial Violence. American Sociological Review, 74(2), 291-315.

Levin, J., & MacDevitt, J. (2013). Hate crimes: The rising tide of bigotry and bloodshed. Springer.

McPhail, B. A. (2002). Gender-bias hate crimes: A review. Trauma, Violence, & Abuse, 3(2), 125-143.

Morsch, J. (2001). The problem of motive in hate crimes: The argument against presumptions of racial motivation. J. Crim. L. & Criminology, 82, 659.

Perry, B. (2002). In the name of hate: Understanding hate crimes. Routledge.

Petrosino, C. (1999). Connecting the past to the future: Hate crime in America. Journal of Contemporary Criminal Justice, 15(1), 22-47.

Shively, M., & Abt Associates, Inc. (2005). Study of literature and legislation on hate crime in America: Final report. Washington, DC: National Institute of Justice.

Welch, M. (2006). Scapegoats of September 11th: Hate crimes & state crimes in the war on terror. Rutgers University Press.

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Herman Bailey

Joint Royal Colleges: Enhancing Medical Learning

by Herman Bailey | Jul 22, 2023 | Essays | 0 comments

Committee Members

Dr Charles Deakin (Chair) Royal College of Anaesthetists

Medical Director, South Central Ambulance Service

JRCALC

Dr Tom Clarke Chair, JRCALC

Consultant Anaesthetist

Dr Jerry Nolan Chairman, Resuscitation Council (UK)

Consultant Anaesthetist

Dr David Zideman Chair, British Association for Immediate Care (BASICS)

Consultant Anaesthetist

Dr Carl Gwinnutt Consultant Anaesthetist

Dr Fionna Moore Medical Director, London Ambulance Service

Consultant in Emergency Medicine

JRCALC

Dr Michael Ward Royal College of Anaesthetists

Formerly Medical Director, Oxfordshire Ambulance Service

JRCALC

Mr Carl Keeble Operational Paramedic, East Midlands Ambulance Service Member BPA Governing Council

JRCALC

Dr Wim Blancke Royal College of Anaesthetists

JRCALC

Mr Roland Furber Chief Executive, College of Paramedics

JRCALC

Prof Malcolm Woollard Professor in Pre-hospital & Emergency Care, Coventry University

Executive summary
Introduction.
Intubation by paramedics. Risk:benefit analysis.
Training requirements for tracheal intubation.
Supraglottic airway devices.
Other issues with tracheal intubation
Discussion
References

Executive Summary

Paramedic tracheal intubation has been practiced in the UK for more than 20 years and is currently a core skill for paramedics. Growing evidence suggests that tracheal intubation is not the optimal method of airway management by paramedics and may be detrimental to patient outcome. There is also evidence that the current initial training of 25 intubations performed in-hospital is inadequate and that the lack of ongoing intubation practice may compound this further. Supraglottic airway devices (SADs; e.g. laryngeal mask airway), that were not available when extended training and paramedic intubation was first introduced, are now in use in many ambulance services and are a suitable alternative pre-hospital airway device for paramedics.

SUMMARY AND RECOMMENDATIONS

There is a paucity of evidence to suggest that tracheal intubation without the use of drugs is of patient benefit or improves outcome. The weight of evidence suggests that pre-hospital intubation without the use of drugs can worsen patient outcome.

The group believes that tracheal intubation without the use of drugs has little value in pre-hospital practice.

The current format of paramedic training is inadequate for training pre-hospital intubation. Improving training for all paramedics (and other similar providers) is not considered feasible, both for operational reasons and difficulties in delivering the training. The majority of those managing patients’ airways in the pre-hospital setting should be trained to insert a supraglottic airway device instead of a tracheal tube. Tracheal intubation should be developed as a specialist skill for selected providers and should include the provision of drug-assisted intubation. Very significant improvements in initial and ongoing training and education would be required to develop this as an autonomous specialist skill.

Supraglottic airway devices have been shown to be safe and effective devices in elective and emergency hospital procedures. Their use in airway management in pre-hospital care is increasing and evidence suggests that they are suitable alternatives to tracheal intubation.

Training in the use of supraglottic airway devices is already mandatory for UK paramedic registration. Ambulance trusts should be encouraged to adopt and use these devices as an alternative to tracheal intubation.

Where ventilation proves impossible, particularly when there is a history of possible choking, and other manual techniques have failed, laryngoscopy may be used to attempt to remove any foreign body. This does not require training in laryngoscopy to the same extent as that necessary for tracheal intubation and can be incorporated within the current clinical airway management training.

When pre-hospital tracheal intubation is undertaken, the following should apply:

1. A gum elastic bougie should be available routinely.

2. Correct position of the tracheal tube must be verified using both a stethoscope

and carbon dioxide detector. (Caution should be exercised when measuring and interpreting exhaled CO₂ during low cardiac output states such as cardiac arrest).

Our conclusions are consistent with the recent NCEPOD report (Trauma: Who cares? NCEPOD 2007) that states “Airway management in trauma patients is often challenging. The pre-hospital response for these patients should include someone with the skill to secure the airway (including the use of rapid sequence intubation) and maintain adequate ventilation”.

Introduction

Although some ambulance personnel were practicing tracheal intubation as early as 1968, intubation skills were first widely introduced into paramedic practice in the mid 1980s and are now a core component of the paramedic curriculum. The aim of introducing this skill to the pre-hospital environment was to provide patients with what was thought at the time to be optimal airway management. Subsequently, tracheal intubation has become expounded as a ‘gold standard’ in airway care.

Intubation training has traditionally been undertaken by paramedics on hospital attachments and there was generally no difficulty in obtaining adequate practical experience in the skill. As paramedics matured professionally and evidence-based practice was introduced into ambulance care, the benefits of intubation began to be questioned. . This was reflected in the ‘Joint Recommendation from AETAG/JRCALC Airway Group’, published in November 2004.¹ More recently, the initial training requiring 25 intubations has become more difficult to provide; fewer patients undergoing general anaesthesia require tracheal intubation as the use of supraglottic airway devices (SADs) has become more widespread and concerns over patient consent raised by the Association of Anaesthetists of Great Britain and Ireland (AAGBI)² has resulted in fewer intubation opportunities in most hospitals. For paramedics who are qualified, ongoing competence has also been questioned; most paramedics undertake tracheal intubation relatively rarely, with figures ranging from an average of 2 per paramedic per annum in the former Avon Ambulance Service³ to just 1 per paramedic per annum in South Central Ambulance Service (Hampshire Division).⁴ The benefits of tracheal intubation, particularly in light of recent evidence,^{5 6} the difficulties in training in this procedure and the recent availability of other SADs necessitate a review of this area of practice.

JRCALC is mandated to recommend the most effective, evidence-based treatment for patients requiring emergency and urgent care. JRCALC has recommended that this area of clinical practice is examined in more detail to produce guidance and recommendations for future practice and requested that a group is formed to undertake this review.

This group has therefore been formed from experts in the field of pre-hospital airway management to examine current practice, review evidence of the effectiveness of pre-hospital paramedic tracheal intubation, discuss the adequacy of current training arrangements and report their findings and recommendations to the JRCALC Committee.

Although the initial remit was to review paramedic airway management, it was recognised that ambulance Trusts use the services of other professional groups such as nurses and doctors. It is also recognised that some doctors are able to deliver drug-assisted airway management on scene. Although this document discusses paramedic practice, the conclusions are applicable to other pre-hospital care professionals who are trained to similar or lesser standards as paramedics. The review specifically does not address issues relating to drug-assisted intubation which in the UK is currently undertaken only by doctors and is currently being reviewed by a working party from the Association of Anaesthetists of Great Britain and Ireland (AAGBI).

Intubation by paramedics: risk:benefit analysis

Intubation for cardiopulmonary resuscitation

Tracheal intubation has long been regarded as a fundamental and essential component of cardiopulmonary resuscitation (CPR). It has been assumed that tracheal intubation improves the chances of survival from cardiac arrest. There are no robust scientific data to support this belief and there are several reasons why attempted intubation can be harmful, particularly when undertaken by inexperienced individuals.⁷ The Ontario Pre-hospital Advanced Life Support (OPALS) study documented no improved survival to hospital discharge when the skills of intubation and cardiac drug administration were added to an optimised Basic Life Support-Automated External defibrillator (BLS-AED) system.⁸

The potential benefits of placing a cuffed tube in the trachea during CPR include:

Enabling effective ventilation, particularly when lung and/or chest compliance is poor.
Minimising gastric inflation and therefore the risk of regurgitation.
Protection against pulmonary aspiration of gastric contents.
Enabling ventilation while continuing chest compressions uninterrupted. This increases the number of compressions delivered in each minute. ⁹

It is known that the oesophageal sphincter pressure decreases rapidly from 20 to 5 cmH₂0 immediately after cardiac arrest and this predisposes to regurgitation of gastric contents.¹⁰ Regurgitation is documented in about one third of out-of-hospital cardiac arrests and in two thirds of these cases it occurs before arrival of ambulance personnel.¹¹ Pulmonary aspiration after cardiac arrest has been documented in 20% survivors¹² although the impact on outcome is unknown. The chances of successful intubation and the risk of complications are highly dependent on the skill of the individual undertaking the procedure. Several studies indicate that in inexperienced hands the success rate is as low as 50% and complication rates are unacceptably high.^{13 14} This is largely because tracheal intubation does not ‘fail safe’. The risks of attempting tracheal intubation include:

Hypoxaemia, especially during prolonged attempts without oxygen supplements, and hypercarbia, when time perception by the rescuer is poor.
Harmful, physiological stress to the patient, in particular when performing laryngoscopy.
Unrecognised oesophageal intubation: 2.9 – 16.7% in cardiac arrest studies ^14-18
Unrecognised main stem bronchial intubation¹⁹
Unrecognised dislodgement
Interruption of chest compressions during the procedure
Trauma to the oro-pharyngeal tissues.

In the apnoeic patient, unrecognised oesophageal intubation is almost certainly fatal. In an emergency medical services (EMS) system with significant rates of unrecognised oesophageal intubation, correctly placed tracheal tubes would have to improve outcome for many other patients in order to offset these disasters. Such a benefit for tracheal intubation in cardiac arrest is very unlikely.⁸

The only prospective randomised trial of pre-hospital tracheal intubation versus management of the airway with a bag-valve-mask (BVM) has been undertaken in children.¹⁹ This showed no overall benefit for tracheal intubation and in a subgroup of children with primary respiratory arrest, the outcome was worse in the tracheal intubation group.

Intubation for trauma

Training in tracheal intubation and skill retention is increasingly problematic. Supraglottic airway devices are now used in up to 80% of anaesthetics in the United Kingdom and this reduces the number of opportunities for paramedics to intubate patients. One study of anaesthesia residents showed that a 90% in-hospital intubation success rate was achieved only after 57 intubation attempts;²⁰ furthermore, intubation is much easier under the conditions of elective anaesthesia than it is in the pre-hospital setting. Among paramedics, intubation success rate has been shown to correlate with the intubation experience of individual paramedics and not with their length of service.²¹ Some studies have documented much higher intubation success rates by paramedics but these have generally been retrospective or via self-reporting.^{22 23} Use of end tidal CO₂ monitoring will reduce the incidence of unrecognised oesophageal intubation,²⁴ but during cardiac arrest, CO₂ may not be detected even if the tracheal tube is placed correctly.²⁵

Data to support paramedic intubation of trauma patients are also scarce. One retrospective study from San Diego concluded that pre-hospital intubation of patients with severe head injury improves survival.²⁶ However, given that these patients were intubated without drugs, the reported survival rate is remarkably high. Furthermore, there was no correction for case mix and there was no mention of how many attempted, but failed, intubations occurred – these would be included in the no intubation group. In contrast, there was just one survivor out of 492 pre-hospital trauma patients who were intubated without drugs by paramedic or doctors working with the London helicopter emergency medical service (HEMS).²⁷ The only other published research showing improved survival after paramedic intubation was a small Finnish study involving head-injured children.²⁸ More recently, a prospective study of rapid sequence induction in 243 severe brain-injured patients by the San Diego group reported that, compared with historical non-intubated matched controls, mortality was significantly higher (33.0% versus 24.2%) in those who were intubated.²⁹ Paramedics intubated after giving midazolam and suxamethonium, and after confirmation of correct tube placement gave rocuronium. Using this technique, intubation still failed in 13% of patients. One third of the study group turned out to have a minor concussion or no head injury. In another study involving a subgroup of 54 patients from the same cohort, 57% became hypoxaemic (SpO₂ < 90%) during the intubation attempt.³⁰ The same investigators have shown that hypoxaemia and hyperventilation (identified by end-tidal CO₂ monitoring) are associated with increased mortality.³¹ A recent review of pre-hospital tracheal intubation concluded that not only was there no evidence of benefit, but that there was increasing evidence of harm.⁵

Alternative airway devices continue to improve and some of the more recently introduced supraglottic airway devices may enable oxygenation and ventilation without the risks associated with tracheal intubation. In particular, insertion is independent of factors used to predict or score difficult tracheal intubation.^{32 33} These issues apply to any professional group that is not experienced in tracheal intubation – not just paramedics.

Training requirements for tracheal intubation

How much training is necessary to become competent in tracheal intubation?

Current IHCD standards require trainee paramedics to achieve 25 intubations during hospital training, of which five must be unassisted. To the best of our knowledge, this figure was chosen because it was considered to be a reasonable number to provide paramedic training, rather than a number based on a scientific assessment of learning curves for intubation.

The attainment of 25 tracheal intubations cannot be taken as assurance of subsequent ability. The use of a logbook to record tracheal intubation has been challenged because it “…gives no clear idea of skill or of progress and merely records ‘exposure’ to a skill or technique.”³⁴ Setting of a numerical standard also does not guarantee competence of any given skill and in a group of individuals, there will always be variation in the rate of skill acquisition with some individuals requiring more training than others.³⁵

Some recent studies have attempted to define the number of attempts needed to perform a given procedure in order to be competent. The learning curve for anaesthetic trainees learning tracheal intubation with two new tracheal tubes has been reported (Fig.1). The estimate of learning half-life (half the total number of procedures necessary to be performed in order to be competent at a given procedure) was 15 intubations, irrespective of the type of tube used³⁶.Similar results were reported in a study examining first-year anaesthetic residents where it was found that 57 attempts at tracheal intubation were required to achieve a 90% success rate (Figure 2).^{20 36} More recently, an abstract detailing training requirements for tracheal intubation, reported that 32 intubations were necessary for a 75% success rate and 53 for a 90% success rate.³⁷ These figures are similar to those reported in the two earlier studies.²⁰ ³⁶

Fig 1: Intubation time vs serial number of the intubation for the 62 cases in which intubation was successful at the first attempt.  = Oxford tube,  = Portex tube.³⁶

Fig 2: Rate of success for tracheal intubation vs number of performed procedures for first-year anaesthetic residents.²⁰

It is clear from these studies that for the majority of those training in tracheal intubation, the 25 attempts at tracheal intubation currently recommended is unlikely to be adequate to attain competence. To reach a 90% success rate with the first intubation attempt, an average laryngoscopist needs at least 57 intubation attempts.²⁰By applying the results of these three studies^{20 36 37} to current paramedic training, we estimate that under ideal intubation conditions, the average paramedic is likely to achieve an intubation success rate of 70 – 75% at best; with little scope for further improvement in skills performance in practice after initial training.

Skill fade

There are few studies on skill fade in relation to tracheal intubation. Skill fade is faster with more complex tasks. It is therefore likely that skill fade with tracheal intubation occurs at a greater rate than that with more simple airway skills, such as SAD insertion. Skill fade is accelerated by lack of ongoing practical experience. The average paramedic intubates an average of just 1-2 patients per annum.^{3 4} There is a significant correlation between the number of patients intubated each year by a paramedic and intubation success rate (p <.001, R = 0.32).^{38 39} In medical students given practical instruction in tracheal intubation and re-assessed at 6 months, there was a significant decline in performance, as shown by an increase in failure rate, increase in attempts at intubation, increased time to achieve intubation and increased dental trauma.⁴⁰

With incomplete initial training and the subsequently limited opportunity to practice tracheal intubation skills, tracheal intubation performance is likely to be sub-optimal in paramedics trained within the current infrastructure and practice.

Opportunities for Training

Current paramedic training involves the intubation of 25 patients during the trainee’s hospital attachment. It is widely recognised that this is becoming more of a challenge because airway management during general anaesthesia is moving away from tracheal intubation and therefore providing fewer opportunities. Medicolegal considerations and the recent statement from the AAGBI² about consent for paramedics to practice clinical airway management have also contributed to the decline in practical opportunities for tracheal intubation.

Some of the basic intubation skills and knowledge can be acquired using simulation with a manikin. Although simulators are improving all the time, they are not a complete substitute for the training required on real patients. Refresher courses including manikin training may help skill retention.

Supraglottic Airway Devices

The first successful and widely used supraglottic airway device (SAD) was invented in 1981 by Archie Brain, a consultant anaesthetist at the Royal London Hospital. His aim was to produce an airway for use in anaesthesia that was more practical than a face mask but less invasive than a tracheal tube, obtaining a continuous clear airway, closer to the natural anatomical and physiological pathway than via a tracheal tube, with the subsequent added benefit of providing a tracheal intubation aid.⁴¹ The first paper describing its use was published in 1983⁴² and the device became commercially available in 1988. Since its introduction, it is now estimated that there are more than 3000 publications relating to this device and it has been used on more than 200 million occasions worldwide. The device was originally designed as a reusable airway for use in anaesthetised patients breathing spontaneously and although this remains its main application, it has an important role in several other situations, for example resuscitation,⁴³ and is used increasingly by non-medical healthcare professionals.⁴⁴

Since 1988, the LMA has evolved into a number of different forms that are suitable for a variety of circumstances:

A reinforced version to enable the tube to be flexed without the risk of kinking
The intubating laryngeal mask (ILM) that once inserted acts as a conduit to enable the insertion of a tracheal tube without the need for direct laryngoscopy
The ProSeal (PLMA), with an additional posterior cuff to improve the seal around the glottis and facilitate positive pressure ventilation; and an extra oesophageal drain tube which can guide correct positioning of the device.⁴⁵
Disposable versions of the classic LMA, the PLMA (LMA Supreme) and the ILM to reduce the risk of cross infection.

Once the original patent expired, other manufacturers were quick to produce similar devices. Not all of these have been successful, but there are now several disposable (or single use) devices available, all with slight design variations compared with the original, the latter now referred to as the classic LMA (cLMA). Brain’s device has also stimulated a wide range of interest in the production of alternative devices to provide a secure means of managing the airway without the need for laryngoscopy. All of these devices are now grouped together as SADs, although some are designed to function if placed either above or below the glottis. The following devices are available:

Glottic aperture seal (GO2)
Pharyngeal airway xpress (PAX)
Cobra Perilaryngeal Airway (CobraPLA)
Laryngeal tube (LT, LT-D,LTS, and LTS-D)
Airway management device (AMD)
Elisha Airway Device
Combitube®
Easytube
Streamlined Liner of the Pharynx Airway (SLIPA)
I-gel

Despite their designation as SADs, these devices vary considerably in their design and function. Consequently, it is increasingly difficult to determine the advantages and disadvantages of the different designs. Furthermore the situation is made more difficult by published trials in which there is no consistency in approach. There are currently:

Trials in anaesthetised patients
Insertion by anaesthetists, nurses, medical students, paramedics and fire-fighters
Trials in manikins
Trials in different makes of manikins
Trials of insertion in cadavers
Use with spontaneous and controlled ventilation
Trials comparing dissimilar devices
Varying numbers in trials
Anecdotal evidence of use of devices

All of this makes comparisons and recommendations about devices, or the circumstances in which different devices may be useful, almost impossible. It must also be remembered that none of these devices have anything like the accumulated experience of usage associated with the LMA.

A summary of the current predicament is expressed succinctly by Cook: “New developments in supraglottic airways may offer benefits over the current preferred devices. Considerable further research in this area is justified. This might include an examination of the appropriateness of training in tracheal intubation to those who rarely use it.”⁴⁴

Other issues with tracheal intubation

Several other issues need to be considered when discussing optimal pre-hospital airway management. This section also discusses the use of devices to aid intubation and to confirm tube placement.

Securing the airway

As highlighted in the previous statement of JRCALC,¹ the primary aim should not be the use of a particular airway device, but to ensure a secure and effective airway, oxygenation and ventilation for the patient.

Several paramedic studies have shown that airway devices not requiring direct visualisation of the vocal cords are more successful in securing the airway. A simulator-based study comparing paramedic insertion of a Combitube^® and tracheal tube (TT) found the time to airway placement was less for the Combitube^® than the TT (median difference 26.5s, p=0.002).⁴⁶ A clinical study comparing paramedic LMA insertion with tracheal intubation found LMA insertion to be more likely to succeed compared with tracheal intubation. Furthermore, LMA insertion was successful in 80% of failed intubations.⁴⁷

Other considerations when choosing an advanced airway management device are the limited number of practitioners present (typically 2-3) at an out-of-hospital cardiac arrest in the UK. In theory, the use of an appropriately secure airway device with an automatic ventilator should release one practitioner to undertake other duties. Airway devices can be difficult to secure reliably: the airway may be dislodged when the patient is moved causing loss of the seal with the larynx or, in the case of a tracheal tube, oesophageal intubation. Hence, meticulous supervision of the airway has to be safeguarded at all times.

Risk of supraglottic airway device cuff leak during chest compressions

The European Resuscitation Guidelines 2005 state that: “Intubation attempts will require interruption of chest compressions, but once an advanced airway is in place chest compression will not require interruption for ventilation.”⁴⁸ The lower sealing pressures of SADs compared with tracheal tubes may result in a leak when attempting ventilation without interrupting chest compressions and this may cause gastric inflation and regurgitation. The frequency and scale of this problem is unknown.

Oropharyngeal leak pressure varies between SADs. Mean +/- SD oropharyngeal leak pressure is significantly higher with the SoftSeal LMA (21+/-6 cmH₂O) compared with the cLMA (17+/-7 cmH₂O) and LMA Unique (16+/-6 cmH₂O).⁴⁹ The laryngeal tube (LT) may provide an even better seal than laryngeal mask devices; LT airway leak pressures of 26.3 +/- 7.3 cm H₂O compared with 19.2 +/- 8.6 cm H₂O (P < 0.001) for the LMA.⁵⁰

Eight studies (858 comparisons) report significantly higher seal pressures

with PLMA than cLMA, with median PLMA and cLMA seal pressures approximately 30 cm H₂O and 20 cm H₂O respectively. In 20% of cases PLMA seal exceeds 40 cmH₂O.

Since its introduction the PLMA has also successfully been used for ventilation of morbidly obese patients (BMI >40, or >35 kg.m^-2 in the presence of obesity-related comorbidity).⁵¹

Airway security

Although the risk of aspiration is considered to be higher with LMAs than TTs, there is no specific evidence to support this assumption. A review of hospital cases published in 2004 identified just 23 published cases.⁵² These were all cases from hospital settings: the relative risk of aspiration in the pre-hospital environment is unknown.

Although other advanced airway management devices may reduce the risk of aspiration, devices with oesophageal cuffs, such as the Combitube^®, are associated with a small but important incidence of oesophageal laceration or rupture.⁵³

The LMA may be dislodged more easily than a tracheal tube, but leak pressure for both the PLMA and the cLMA is increased by cervical flexion and rotation.⁵⁴

The LMA can also cause trauma on insertion, and the risk of this occurring depends on the type of LMA. A study of novice doctors, each undertaking five attempts with three different LMA types in anaesthetised patients reported that a sore throat was experienced by 14% of patients in LMA Unique group, versus 41% and 42% in the LMA Classic and SoftSeal groups respectively. The SoftSeal LMA was most frequently associated with blood on the mask (32%) compared with the LMA Unique (9%) and LMA Classic (6%).⁵¹

Tracheal tube as a route for drug delivery

Tracheal intubation enables the direct introduction of suction catheters into the trachea and bronchial tree. This is unreliable with supraglottic airway devices. Tracheal intubation also enables resuscitation drugs to be injected directly into the trachea when intravenous access is impossible. Absorption of drugs is unreliable when given by this route and this intervention is unlikely to impact on the outcome of cardiac arrest.^55-57

Use of intubation aids: the intubating bougie

The bougie is commonly available in hospital to assist with difficult intubation and its use increases intubation success rates when intubation is difficult.⁵⁸ ⁵⁹ Despite being recommended to support pre-hospital intubation,⁶⁰ few ambulance services train and equip their paramedics with bougies.⁶¹ Intubation in the pre-hospital setting is particularly challenging and it is logical to recommend that a bougie is used routinely.

Availability of devices for confirming tracheal tube placement

Confirmation of correct tracheal tube placement by physical examination alone is unreliable: some studies document unrecognised oesophageal intubation rates of 10%⁶² – 25%.⁶³ Exhaled CO₂ or oesophageal detection devices can be used to identify correct tube position. Confirmation of tracheal tube placement using capnometry is a mandatory minimum monitoring standard in UK anaesthetic and emergency departments. However, this is less reliable if the cardiac output is low or absent such as during cardiac arrest.⁶⁴ The use of the oesophageal detector device (ODD) is an alternative technique but is less reliable and does not provide continuous monitoring as does capnometry.⁶⁵ A survey in 2004 showed that virtually no UK ambulance service used either device routinely.⁶¹

Hospital vs pre-hospital practice

Hospital minimum standards for the practice of intubation⁶⁶ are not currently requirements for the pre-hospital environment where risks are higher. The lack of capnometry increases the risk of unrecognised oesophageal intubation. The lack of availability and training in the use of simple intubation aids such as the intubating bougie increases the number of failed intubations.

The minimum monitoring standards required in hospital should be applied to pre-hospital intubation and simple intubation adjuncts must be used to increase the safety and success of pre-hospital procedures.

Discussion

The group’s aim was to critically evaluate the need for tracheal intubation as a core skill in ambulance practice and to make recommendations about the optimal pre-hospital airway management by UK ambulance services. This was primarily in relation to paramedic practice, but encompassing all those who undertake pre-hospital tracheal intubation without the assistance of anaesthetic drugs. The evidence for the benefit, or not, of pre-hospital intubation without the use of anaesthetic drugs was reviewed and debated in detail, as were the associated topics relating to current training in this procedure and availability of alternative airway devices. A systematic review of pre-hospital airway management was not undertaken as part of this exercise because it was considered that the recent reviews and expertise within the group covered all the main publications in this area and the costs and delay associated with performing a systematic review would have been significant.

The Committee was in general agreement that there is little evidence that pre-hospital intubation without the use of anaesthetic drugs improves outcome in seriously ill or injured patients. Although some studies are of limited quality, the balance of evidence suggests that paramedic intubation may be associated with a worse outcome than basic airway management using the bag- mask device. The reasons for this are not entirely clear, but may be related to difficulties in securing the airway, resulting in significant hypoxaemia during the attempts at intubation.

Intubation is a complex motor skill that requires adequate initial training and sufficient ongoing experience to maintain competency. Current paramedic training was reviewed against the limited evidence for training requirements. Most studies have demonstrated that in order to be competent in the procedure, initial training requires the successful placement of 50-60 tracheal tubes, compared with the 25 that is currently required. There were also concerns expressed that most paramedics do not have sufficient ongoing intubation experience to remain competent in the procedure.

Simple intubation adjuncts (e.g. intubating bougie) are not used by most UK ambulance services and these have been shown to improve tracheal intubation success rates in hospital airway management. Their use in pre-hospital tracheal intubation is recommended. Additionally, pre-hospital capnometry should be mandatory for tracheal intubation in order to minimise the incidence of unrecognised oesophageal intubation. This would bring pre-hospital practice in line with minimum monitoring standards for hospital practice.

Alternatives to tracheal intubation were discussed. Supraglottic airway devices have many advantages over tracheal intubation, particularly in relation to training and maintenance of practical skills. They also do not risk unrecognised oesophageal intubation. Their use in the pre-hospital setting is limited, but growing, and LMAs are now a standard airway device in use by many UK ambulance services.

The Committee concluded that pre-hospital tracheal intubation, as currently practiced by paramedics, could not be endorsed. What evidence there is, suggests that this procedure is more likely to be harmful than beneficial.

The way forward was discussed. It was considered impractical to recommend that all paramedics were trained to an adequate intubation standard and maintain these standards after qualifying. Although these standards have yet to be defined, they are likely to be to a significantly higher standard than that currently practiced and would have parallels with the initial training of doctors entering anaesthesia as a speciality. Training would also necessitate the removal of paramedics from front-line practice for considerable periods, which may not be endorsed by ambulance trusts with significant performance pressures. We agree with the recent NCEPOD report that recommended that the pre-hospital response for trauma patients should include someone with the skill to secure the airway, (including the use of rapid sequence induction and tracheal intubation).⁶⁷ The way in which this is delivered would be the responsibility of each ambulance trust. If ambulance trusts were to permit tracheal intubation as a specialist skill for some providers, these individuals should receive enough training to become competent in the provision of drug-assisted intubation. Very significant improvements in initial and ongoing training and education would be required to develop this as an autonomous specialist skill. This may be best achieved through a physician-based system, although this would require a more long-term approach.

For the majority of paramedics, this Committee recommends that tracheal intubation should be withdrawn and greater emphasis placed on airway management using an appropriate supraglottic airway device (SAD). (The importance of training to a high degree of proficiency in basic airway management skills should not be overlooked during training). Several SADs are in clinical use. It is not the scope of this review to recommend specific SADs and ambulance trusts should discuss the options with their local Clinical Advisory Groups. More pre-hospital research is urgently needed to understand the factors influencing morbidity and mortality in relation to airway management and establish the optimal device(s) with which the airway should be secured.

Where ventilation proves impossible, particularly when there is a history of possible choking, and other manual techniques have failed, laryngoscopy may be used to attempt to remove any foreign body. This does not require training in laryngoscopy to the same level of competence as that necessary for tracheal intubation and can be incorporated with current clinical airway management training.

A small but significant number of patients with partially or completely obstructed airways cannot be managed without the use of drug-assisted techniques. Trauma patients and those with obstructed airways not manageable with basic airway adjuncts or a SAD may need to be treated by a practitioner competent in pre-hospital rapid sequence induction of anaesthesia and intubation, for which there is currently little provision in the UK. The recent NCEPOD review of trauma management ⁶⁷ found that 13.7% of patients with major trauma arriving by ambulance did so with a partially or completely obstructed airway, suggesting that current paramedic training does not equip them with sufficient skills and tools to manage these patients adequately. In 28.6% cases, patients were not intubated when reviewers believed that it should have been attempted. The report concluded that “…if pre-hospital intubation is to be part of pre-hospital trauma management then it needs to be in the context of a physician-based pre-hospital care system.” This may be one option that ambulance Trusts should consider in delivering appropriately trained providers to care for those with difficult airways, “…to ensure that they are seen at the right time, in the right place and by staff with the most appropriate skills.”⁶⁸

The Committee concluded that paramedic tracheal intubation can no longer be recommended as a mandatory component of paramedic practice and should not be continued to be practiced in its current format. If pre-hospital tracheal intubation is to be undertaken, it requires considerably more education and training than that currently provided for paramedics or the use of physicians with appropriate training in advanced airway skills. SADs are suitable alternatives to tracheal intubation. SADs should be introduced into all ambulance services and ambulance trusts should ensure that both paramedics and technicians receive adequate initial and ongoing training in the use of these devices.

The timescale for the introduction of any changes in paramedic practice should be decided at a local level. Changes to training and practice in both tracheal intubation and SAD use will need to be reviewed by individual ambulance services to decide the most appropriate way forward.

References

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Herman Bailey

Decoding the Allegorical Elements in Poe’s ‘The Haunted Palace’

by Herman Bailey | Jul 13, 2023 | Essays | 0 comments

Introduction

The haunted palace by Edgar Poe is one of the finest poems of all times. The poem is associated and said to be derived from the poem the fall of the House of Usher. The poem is filled with mystery. The poem is an account of the both sorrow and happiness. The poem is metaphorical of the writer’s troubled life. At the beginning of the poem it is easy to read the thoughts of the palace of the human ruler) but as time progresses the palace gets cloudy and difficult to read. The poem’s most dominant theme is allegory; allegory means that the story or the poem has two meanings. Most of the times there is the surface meaning that is obvious to the readers as they read the poem (Wilbur 105). Then there is the deeper meaning that is symbolism in the poem. This paper shall discuss the theme of allegory in the Haunted Palace by Edgar Poe; the paper shall use quotes and examples from the poem to explain the allegory theme further.

Conclusion

From its title, the haunted palace is an allegory poem that has more than one meaning. The title describes a palace a beautiful place that is haunted. In the beginning of the poem Poe describes the palace exterior outlook praising its beauty. The windows in the palace are the eyes of the human ruler; the door is the mouth and the spirits that hover in the palace re the thoughts that cross the human mind. The human mind is full of wisdom and sane at the beginning of the poem. Towards the end of the poem the palace is no longer praised instead it is described as a frightening palace visited only by the frightened travelers. The windows are no longer bright and luminous they are now covered in blood. The blood shot eyes describe the troubles that the human ruler is going through.

Works Cited

Poe, E. “The Haunted Palace”. The Works of Edgar Allan Poe, 1903.

Wilbur, Richard. “The House of Poe,” collected in Poe: A Collection of Critical Essays, edited by Robert Regan. Englewood Cliffs, NJ: Prentice-Hall, Inc., 1967: 104–105.

5/5 - (11 votes)

Herman Bailey

Navigating Generational Differences in the Workplace

by Herman Bailey | Jul 13, 2023 | Essays | 0 comments

Introduction

There are several reasons for the transformation that humankind has witnessed in the work environment; however, the most significant cause of change is the advancement in technology, whose fueling by social factors has brought tremendous outcomes as well. A keen analysis of history provides evidence that only two groups constituted the workplace in the recent past. Notably, the two groups were the ‘know-it-all’ and the ‘old-timers’. The old-timers universally referred to the traditionalists and the individuals who were about to retire, not forgetting the people who fixed their thoughts in the old historical schooling. On the other hand, the know-it-all referred to the youngsters believed to be the intruders of big ideas and enthusiastically destined to move higher the hierarchical administration stepladder (Allahyari, 2000). A reflection of the workplace in the contemporary world portrays a completely different and complicated setup with a mixture of a wide range of factors influencing the classification of workers (Asch, 2001). Surprisingly, the categorization of workers drastically and considerably evolved over a short duration to come up with the current five generations that work together for the success of the management in charge. The five generations include the employees born before 1945 (the traditional generation), those born between 1946 and 1964 (the baby boomers), workers born between 1965 and 1980 (the generation X), those born between 1981 and 1995 (the generation Y), and finally a set of employees born in 1995 and beyond (the Linkster Generation). According to (Council of Europe, 1985), there are main historical incidences and events, cultural phenomena, and social trends that influence each of the listed generations. Such forces transform the thought about all things from perceptions and expectations concerning the provisions of the workplace and the behaviors of the workers to the organization’s work ethic and loyalty.

Generational Distinctiveness

A study by (Allahyari, 2000) on the general factors and characteristics of the five working generations identified unique generational features that influence working styles, communication styles, and team conduct. Assuredly, understanding the distinction or contrast between the groupings of the generational workers can be very fundamental in avoiding conflicts in the work environment (Council of Europe, 1985).

Generational Groups and their Differences

The Traditional Generation

The traditional grouping consists of the sort of internal marketing and the interactive marketing. The service triangle is premised that when organizations attend to their employees born before 1945, and characteristically referred to as the ‘depression babies’. This category of staff members is highly influenced by World War II and the ‘Great Depression’. The workers seem to be having quality traits that distinguish them from other generational categories of employees; for instance, they comparatively respect the authority, they are loyal, stubbornly autonomous, dependable, produce excellent work, and have advanced interpersonal and communication skills (Council of Europe, 1985).

The Baby Boomers

The set of generational employees consists of persons born between 1946 and 1964, and generally known as the ‘Woodstock generation.’ Unique events influence and define the group, which include the postwar social change, the 60’s, and the great Vietnam War. They as well have exceptional and imitable characteristics, for example, outstanding solidarity skills, well educated, query management, and authority, and they thrive superbly on assignments that stimulate adrenaline (Parent, 2013).

The generation X

The workers classified under this category are persons born between 1965 and 1980. People know as the ‘Latchkey Generation’ and jokingly refer to them as the products or creation of separated and divorced parents. Their traits are distinguishable to people who are not part of the workforce for reasons that; they focus on family matters, they are independent, do not tolerate bureaucracy, are socially responsible, are hardworking, as well as critical in all mannerisms about the workplace (Schell, 1994).

The generation Y

The group is composed of workers born between 1981 and 1995. Universally, they are common in the public domain as the ‘entitled generation’; what’s more, evidence suggests that their affectionate and devoted parents, as well as the technology, play a tremendous responsibility in driving and influencing them toward work. Their uniqueness is unquestionable as they are loyal, highly socialized, socially accountable, technologically able, and often need to balance between work and life (Schell, 1994).

The Linkster Generation

This is the last set of employee generational categorization at the workplace and includes all individuals born in the year 1995 and beyond. They are uniquely distinguished from the other groups by the name ‘the Facebook crowd’. The media that has saturated the world presently highly influences them, more specifically the social media. This group is technologically autonomous and has close ties to parents; consequently, it easily tolerates substitute lifestyle, engages in green causes, and heavily link itself to societal activism (Brayne, 2010).

Managing and Working With Diverse Generational Groups

Working or managing divergent generational groups may not be an easy task in a workplace environment, and there are proposed tips offered to resolve conflicts between the different generational groupings if they so happen. Since the groups are dissimilar in their characteristics and interests, it would be tedious and complicated to manage a set of workers composed of the entire mix. Nevertheless, the following tips would guide a manager in developing relevant skills of performing the task without much hassle.

Understanding of Work Styles

Unfortunately, the baby boomers and the traditional generation dislike passionately the idea of being micromanaged. On the contrary, Generation Y and the Linksters yearn for particular, detailed instructions concerning how things should work, and are used to hanging around authorities (the United States, 2009).

Regarding Generational Principles or Values

Ideally, every generation has a distinctive set of principles or values that they dearly protect; nonetheless, if conflicts happen in a working environment mixing the groupings, then it would be a threat to the values put in place. A good example is that of the baby boomers who value working in teams, engaging in cooperation, and buying-in. Another instance involves generation X’s desire to make independent decisions and moving on, if possible, singly.

Sharing of Perceptions

If a conflict erupts between workers of two or more generational groupings, sharing their perceptions can help them learn or gain knowledge a great deal. A person of the traditional generation may be the lacking of manners and formality of the generation Y’s individual as disgusting and unpleasant. At the same time, the generation Y persons may have a feeling of repulsion and revolt if the older workers fail to respect their input and opinions (the United States, 2009).

Finding a Generational Suitable Fix

Douglas (2002) supposes that it is very hard to change or transform the experiences of people’s lives; however, it is possible to function with a sort of expectations and attitudes that arise or result. For example, a boomer with extensive knowledge might see a person of Generation Y face frustrations while performing a task due to lack or deficiency of experience; as such, the boomer can turn into a mentor due to his sense of prerogative.

Finding or seeking Commonality

Persons in the traditional generation and generation Y value stability and security while the traditional group and the boomers are often resistant to change. Nevertheless, both sets of generations value development and training. Generation Y and Generation X workers value very much flexibility at the workplace, as well as the balance between work and life. Linksters and boomers, on the other hand, are often contented with substitute lifestyles and diversity. Lastly, Linksters and the generation Y are proficient in technological matters and show commitment to socially accountable policies.

Learning from One Another

It is indisputable that every generational group has valuable and principled lessons that can transform and teach the subsequent. For example, the boomers and the traditional generation are rich in tricks and full of knowledge regarding their employment that any young employee would desire to have. On the other hand, Generation X workers are famous for their meditation and fairness abilities, while the generation Y employees are wizards on matters of technology. The Linksters, on the contrary, are specialized on issues regarding marketing, business trends, and future workplace (Szporer, 2012).

Converging Trends that have constructed the Five Generational Groups of Workers

A mixture of trends has played an imperative role in creating the current five generations of a workforce. Such patterns include but do not limit to the following (Wilms, 1996):

• Persons having longer lifetimes and living actively, as such they are capable of working for a longer;

• Individuals, for example, the baby boomers, and the traditional generation being in a position not to retire because of their financial positions and capabilities;

• Persons in the groups such as the baby boomers and the traditional generation anticipating and showing a willingness to work up to old age since work has played a significant role in defining them for years;

• The baby boomers providing financial support to their millennial kids already considered adults, who regarding age are in their late twenties and even thirties;

• The duration between generations potentially becoming diminutive or very small as the rate of transformation or change augments in the fields of communication and technology usage;

• All these factors or trends work together to create one workforce of several generations

Challenges Facing a Multigenerational Workforce

Since various workplaces have multiple and different challenges in the contemporary world, it is always important that the multigenerational employees work hand in hand for the vision and strategies of the organization to be attainable. The newcomers comprising of the younger generation, the middle age group already established and holds a better part of the management responsibilities, as well as the generation of senior and older executives aging thirty to forty years in their careers, should all harmonize the working environment to minimize the possibility of conflicts. All these groups with the entirety of their generational distinctions can result in frictional relations amongst bosses and colleagues (International Labor Conference & International Labor Office, 2004). The current workplace is not different from that of the past decades, taking into consideration that all the parties of generation X, generation Y, and baby boomers co-exist in one workplace. However, as a majority of the boomers work beyond retirement age, and the technologically knowledgeable millennial individuals continue grading and joining the workforce, the bleak disparities in the principles and values, work mannerisms, and communication styles of every generation become more pronounced (Szporer, 2012).

Since the postmillennial groups are swiftly coming closer to college-age, other imminent generations might be joining the ranks soon. If so, happens, the five generations workforce will soon become another norm in the workplace. Therefore, leaders and managers should be ready to handle the anticipated challenge of incorporating fresh members of staff while at the same time respecting the experience and seniority of the older employees. As the new generational groups will be joining the workforce, an adaptation period will be necessary on either end (International Labor Conference & International Labor Office, 2004).

Challenges

Style of Communication

There are significant differences in the preference of the communication styles between the younger and the older generations. Generation Y prefers tweeting, texting messages, and sending instant messages as strategies of communicating. On the other hand, generation X and the baby boomers often prefer emails and phone calls. Distinguishably, the sort of younger workers like using abbreviations, colloquialisms, and unofficial language in communication. Older workers, in particular, instances have a habit of communicating to the senior management with much formality as they equate that formality on the communication. However, if not offered the same formality in return, they may as well interpret it as a lack of respect (the United States, 2009).

Negative Stereotypes

Some terms often attach to the thoughts of older employees immediately they think of the millennial generation. Such terms include lazy, technology, entitled, over-enthusiasm, and obsessed. Generation Y workers are not the only victims of these stereotypes since the baby boomers at times get the perception by younger employees as stubbornly set and hard to train in their ways (Douglas, 2002).

Cultural Anticipations or Expectations

As the distinctive place of work changes in keeping up with the transforming work trends and technologies, the health care, cultural factors have a strong influence on patients’ and families” decisions. Some cultural expectancies have subsequently occurred as well. The transition can be particularly harsh for the older generation of workers, who accustom to having functionality or performance deliberated by the length of time spent on taken at their working desk. On the contrary, the majority of the younger managers do not value the time spent in the office as much as they do appreciate the results that the work did produce. Also, generation Y sets higher values and expectations on a healthy balance between work and life (International Labor Conference & International Labor Office, 2004).

Recommendations for Managers

A management team and its leaders that can motivate, understand, communicate, train, as well as, retain four to five dissimilar generations at a similar time are desirable to all the owners of organizations and companies. It is not important whether an individual is in healthcare, retail, finance, or technology since the working together of various generations in harmony is becoming a mission-crucial skill. Most managers may naturally not have the skill-set of cross-generation, although if developed through practice and learning, it can result in the formulation of a comprehensive and significant leadership plan in an organization. For this reason, leaders and managers should learn more concerning generational kinetics, which will make them more competent and aware of the innovation, teamwork, and desire to drive functionality and performance (Douglas, 2002).

Conclusion

Probably, a majority of the younger workers comes from comparatively stable families where both parents are working presently or were working in the past, and, therefore, a greater premium is on a course on the balancing of work and life. The best way leaders and managers can approach the issue of the challenging multigenerational workforce are by allowing individuals to function or work in styles that they prefer and believe suit them well. As well, the entire staff, led by the management team should acknowledge and appreciate every team member, despite the consequences of their working styles. Because everyone in the working environment loves recognition and appreciation for the assignments or tasks, they execute, as well as having access to resources they require and have feedback delivered appropriately, each human in the workplace must receive the honor for the contribution they have made to the group. For significant change and progress to happen in the workforce of multigenerational groups, elements such as openness and flexibility concerning the factors of each age group are crucial. Every age group introduces their own sort of cultural norms and skills; therefore, an efficient staff should be the focal point of diverse personalities, generations, and aptitude, all converging mutually in the direction of a common goal. Assuredly, that is the merely approach an organization will make sure they are introducing new viewpoints too often familiar troubles.

References

Allahyari, R. A. (2000). Visions of charity: Volunteer workers and moral community. Berkeley, CA: University of California Press.

Asch, B. J., United States., & National Defense Research Institute (U.S.). (2001). The pay, promotion, and retention of high-quality civil service workers in the Department of Defense. Santa Monica: Rand.

Brayne, H., & Carr, H. (2010). Law for social workers. Oxford: Oxford University Press.

Council of Europe. (1985). Temporary employment businesses: General problems, specific problems relating to legal or illegal hiring out of workers across borders: report prepared by the Study Group of the 1983/1984 Co-ordinated Research Programme. Strasbourg: Council of Europe.

Douglas, M. (2002). Workers’ compensation 101. Waterford, PA: Douglas Publishers.

International Labor Conference, & International Labor Office. (2004). The situation of workers of the occupied Arab territories: Report of the director-general: appendix. Geneva: International Labour Office.

Parent, C. (2013). Sex work: Rethinking the job, respecting the workers.

Schell, O. (1994). The mandate of heaven: A new generation of entrepreneurs, dissidents, bohemians, and technocrats lays claim to China’s future. New York: Simon & Schuster

Szporer, M. (2012). Solidarity: The great workers strike of 1980. Lanham, Maryland: Lexington Books.

The United States. (2009). Making the connection: Creating pathways to career success for the next generation of workers: field hearing before the Subcommittee on Employment and Workplace Safety of the Committee on Health, Education, Labor, and Pensions, United States Senate, One Hundred Tenth Congress, first session, on examining ways to better educate and train the next generation of workers to create pathways to career success, November 28, 2007. Washington: U.S. G.P.O.

Wilms, W. W. (1996). Restoring prosperity: How workers and managers are forging a new culture of cooperation. New York: Times Business

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Advantages	Disadvantages
They are cost-friendly	• It could be viewed as discriminatory when computer illiterate candidates hear about it
In most cases, they speed recruitments and streamline administration	• A website that is not well designed may turn-off applicants who are potential.
Promotes global reach and has offered instant application.	• There will be huge numbers of applications that are not appropriate.
The use of technology assists in managing these vacancies faster and coordination of processes

Advantages	Disadvantages
• Offers discretion	• It is very costly
• Notices only the individuals who can do that particular job.	• May does not involve the shortlisting of people.
• Gives consultants a chance to know more about that organization.	• limits the number of candidates.

Advantages	Disadvantages
The costs are fixed as much as these adverts may require repetition.	It is usually a very low process of recruitment.
Most of these publications offer online packages	This method is only limited to those people who read that particular newspaper or journal.

Introduction

People Also Read

Works cited

Abstract

People Also Read

Introduction

Background to the problem

Forms of hate crimes

Drivers of hate crimes

Combating hate crimes

Conclusion

References

Committee Members

Contents

Executive Summary

People Also Read

SUMMARY AND RECOMMENDATIONS

Introduction

Intubation by paramedics: risk:benefit analysis

Intubation for trauma

Training requirements for tracheal intubation

Other issues with tracheal intubation

Discussion

References

Introduction

People Also Read

Conclusion

Works Cited

Introduction

People Also Read

Generational Distinctiveness

Generational Groups and their Differences

The Traditional Generation

The Baby Boomers

The generation X

The generation Y

The Linkster Generation

Managing and Working With Diverse Generational Groups

Understanding of Work Styles

Regarding Generational Principles or Values

Sharing of Perceptions

Finding a Generational Suitable Fix

Finding or seeking Commonality

Learning from One Another

Converging Trends that have constructed the Five Generational Groups of Workers

Challenges Facing a Multigenerational Workforce

Challenges

Style of Communication

Negative Stereotypes

Cultural Anticipations or Expectations

Recommendations for Managers

Conclusion

References