Country Research Essay Example | Topics and Well Written Essays - 500 words

Country Research - Essay Example Amaterasu is considered their chief deity with the emperor and empress as the successors who must lead ceremonies for the welfare of the people. Buddhism is another main religion practiced by many Japanese. Buddhism set the standard where salvation is achieved when believers give up their worldly desires and without too much thought of themselves. Japanese likewise have faith in myths. They claim that Izanami, the female goddess retired into the underworld as a result of the birth of god of Fire. Izanagi, the male god created the storm god, Susano. The myth of the tallest mountain is yet another that they maintain. Mount Fuji became the highest mountain in Japan because she destroyed Mount Haku after it was known that it has the tallest peak (Piggot, 1969). Interestingly, there are many rituals practiced by Japanese. Family ritual practices involve bathing themselves in a small square tub. The tub is used by every member of the family where it requires scrubbing and soaping outside t he tub before dipping. Bowing when meeting someone and departing them is observed to show respect. When entering a house, outside shoes should be removed as a sign of cleanliness. Family eats with chopstick and talking is restricted.

MODERN ORGANISATIONAL CONTEXT Essay Example | Topics and Well Written Essays - 1750 words

MODERN ORGANISATIONAL CONTEXT - Essay Example Moreover, I feel that the increase in the credit facilities coupled with decreasing interest broadened the market for the firm, as more people could not easily afford a car. As per Barney and Hesterly (2005), in addition to that, the working population has increased as more women have entered the working sector and many are working and studying simultaneously. This has increased the purchasing power of the customers and sales have increased because of it. However, I feel with the increasing working population, the demand has increased along with the competition (Gourlay, 2001, pp. 27-46). As per Ahrens (2010) this means that consumers have more choice and have become much more demanding. Moreover, in countries like India for instance the middle class expands every year by 30-40 million people, which in turn means more people now demand cars in these countries. Today, moreover, the consumers are being offered car loans on easy instalments, which make a positive impact on the sales of Toyota. Additionally, explain Berzon and Khan (2010), the prices of raw materials and petrol have increased which affects the price and thus the sales of Toyota products. These economic conditions play an important role in the increase of sales on Toyota. These conditions have of course affected the strategies of Toyota. With the economic crunch especially in the USA, the firm was proactive and aimed to increase its sales in developing China and India where the crunch was less prominent. The global strategy adopted by the firm worked positively. Additionally. When the economic conditions in the USA lowered the purchasing power of the consumers, the firm changed its strategy and started production of smaller and cheaper cars. Lastly, Jensen (2010) explains that with the increasing prices of the raw material, the firm resorted to the hybrid variety of cars, which reduced the prices increasing the sales. Thus I feel that Toyota altered its strategies very smartly as per the changing ec onomic conditions with the result that even with a global economic crunch, the firm had little effect on its sales (Kane, 2010). Berzon and Khan (2010) explain that the social aspects include the changing trends, the smarter consumer in terms of being more knowledgeable regarding product information. Kane (2010) adds that the customer can now use the internet to know about the number of Toyota recalls in any part of the world, the latest technology available, the new models, price comparisons, product features and much more. The consumer has become more knowledgeable and thus firms cannot fool them with smart and deceptive advertising. Also, Gourlay (2001, pp. 27-46) add that the consumers are becoming more demanding with globalisation, as there are many more products available in the global market. The consumer has now become more fashionable and seeks comfort. Thus Toyota needs to cater to both these social aspects. Ahrens (2010) adds that tradition, culture and the customers in t he respective markets have to be studied before the firm can design a car. Jensen (2010) explains that for instance, in India, the drivers are right hand drivers, thus the cars have to be designed differently for the market. In the US there are more left-hand drivers. Kane (2010) adds that colour preference, design and accessory preference varies from market to market and thus the firms have to cater differently to them. This means that Toyota has to change its traditional lean

2_Economics for Sustainability Essay Example | Topics and Well Written Essays - 3250 words

2_Economics for Sustainability - Essay Example Hundreds of millions of individuals might suffer water shortages, hunger and coastal flooding as a result of global warming. Scientists warn that if the world does not aggressively control climate change, the consequences will be disastrous. Carbon dioxide and other greenhouse gases are collecting in the atmosphere resembling a thickening blanket. The blanket traps the heat from the sun, thereby causing the earth to warm up (Houghton 2004, p. 30). Although temperatures vary naturally, over the past five decades, the average worldwide temperature has augmented at the fastest rate witnessed in history. Greenhouse gases emissions to the atmosphere emanates from the human activities. It is approximated that ninety percent of greenhouse gases emissions are human produced. Greenhouse gases such as methane, nitrous oxide, and carbon dioxide have caused much of the observed increase in world’s temperatures. Failure to lower level of greenhouse gases emissions, especially carbon dioxide, will destroy the global economy (Maslin 2007, p. 15). As Weart (2008, p. 37) notes, life on Earth relies on energy emanating from the sun. Approximately half the light getting into the globe’s atmosphere passes via the clouds and air to the surface. The light is absorbed and subsequently radiated upward in the form of infrared heat. Approximately ninety percent of this heat is subsequently absorbed by the conservatory gases and emitted back towards the earth’s surface, which is warmed to a life supporting average of fifteen degrees Celsius. A layer of greenhouse gases principally water vapour and smaller amounts of methane, carbon dioxide and nitrous oxide act as a thermal blanket for the planet. The thermal blanket absorbs heat and warms the Earth surface. Scientists have come to an agreement that the primary cause of the recent trends in global warming entails expansion of the greenhouse effect by

Week 4 Essay Example | Topics and Well Written Essays - 250 words

Week 4 - Essay Example Although the changes will affect my personal life in an apparent negative way, it will save on my money and also on the local water supply as a whole. Concerning the local water supply, my strategy would be to reduce the amount of water delivered to my homestead and this would also imply a reduction of electricity cost for the local supplier. As a general strategy of water saving for the whole region, I would suggest the recycling of water. This might appear as a hard nut to crack but the water that goes to waste on a daily basis is even more than we could ever imagine. For instance, the water used to wash dishes could be used to water the kitchen garden. However, there are cons and pros of this method. Starting with cons, it should be said that this method requires use of washing buckets instead of washing sink to make it easier to retrieve the water. There is no doubt it is a big nuisance. Also, the method will require more than just throwing the water on the garden. Moreover, it is required to sieve the water of unnecessary material before using it for watering. Taking the total household use as 272 gallons, considering each gallon to be about 8.3 lbs in weight, then carrying the water home from a distant source would mean carrying about 2257.6 lbs per day per person. This is incredible but it happens every day in the developing countries. This difference, which is quite big, can be attributed to water wastage like that in the bathroom. It can also happen due to the use of machines not designed within the concepts of water saving

Understand how to set up a home based childcare service Essay Example for Free

Understand how to set up a home based childcare service Essay This was the name of the green paper produced in response to the laming inquiry into the death of Victoria Climbie in 2000. It went on to form the basis of the 2004 children’s act. The paper lists five outcomes which were identified in consultation with children and young people; Being healthy; enjoying good physical and mental health and living a healthy lifestyle staying safe; being protected from harm and neglect. Enjoying and achieving ; getting the most out of life and developing the skills for adulthood making a positive contribution; being involved with the community and society and not engaging in anti-social or offending behaviour economic well- being; not being prevented by economic disadvantage from achieving their full potential in life. Children’s act 2004 This act sets out the processes for integrating services to children in England and wales, requiring local authorities and their partners to co-operate in promoting the welfare and wellbeing of children.it created the post of children’s commissioner for England and introduced the requirement for local authorities to have a director of children’s services. Children’s act 1989 First acknowledgement in UK law of children’s rights, none as ‘the needs of the child are paramount`. Education act 1993   Secretary of state are required to publish a code of practise for children with special educational needs parents of children under 2 years have the right to ask for the child to be formally assessed. Data protection act 1998 It protects sensitive personal information being published without a person’s consent. where children are involved consent has to be given by a parent or guardian. Food safety (general food hygiene) regulations 1995 Local authorities require registered child-minder’s are to register with their local environmental health department and obtain the following  document. ‘safer food, better business for childminders` Special educational needs and disability act 2001 This act protects persons from discrimination on the grounds of a disability, and it requires that reasonable adjustments must be made to services, provisions and/or premises so that disabled persons do not suffer significant disadvantages compared to non-disabled persons. Children are covered by this legislation as they are persons in the eyes of the law. Role of regulatory bodies Regulatory bodies in the UK are Ofsted (England) The fundamental role of these regulatory bodies is to ensure that all children receive the best possible care in all settings a child attends away from their home. The systems they have in place will also reassure parents, guardians and carers who have to be able to entrust their child to an organisation or individual to look after. They will make sure you meet the welfare requirement’s and learning and development requirement’s as set out in the early years statutory framework for the early years foundation stage, Are a suitable person to provide care for children and can promote an environment where children are well cared for, are safe and their learning and development is catered for. The regulatory bodies have processes and systems to control home based childcare in the following ways. Registration – This covers checks on you, other adults who live with you and the premises where you plan to carry out your business. Inspection This is when inspectors carry out checks on the service you offer and on you once you are registered they produce a report which is then available on the websites of the regulatory bodies and must be offered to parents. Investigation – Following a complaint or concern, an inspector may carry out an investigation into your childcare service to make sure that you are meeting and complying with the welfare requirements. This is in addition to an inspection. Enforcement – If you do not meet the welfare requirements  or standards of your country, the regulatory body can take action against you.in England there are five general welfare requirements. Safeguarding and promoting children’s welfare Suitable people Suitable premises, environment and equipment Organisation Documentation. 1.2 Develop policies and procedures for; * Accidents, illness and emergencies The safety of your child is paramount and I will take every measure I can to protect your child from hurting themselves. However, sometimes accidents do happen. I have written the following procedure on how I will deal with such a situation: *I will comfort the child and reassure them. *I will assess the extent of their injuries and if necessary call for medical support/ambulance. *I will give any first aid procedures that are necessary. I have been trained to carry out to these procedures and have required certificate. *Once the child is more settled I will contact you as soon as possible to inform you of the accident, and if necessary I will ask you to return to care for your child / meet me at the hospital. After every accident, however minor I will: *Complete a report in my accident book. *Ask you to sign the report. If the incident requires any medical treatment then I will: *Inform Ofsted *Inform my Insurance Company. *Contact the NCMA for additional advice/support. It is important that you keep me informed regarding your child’s condition following an accident and if you have sought medical advice. Back up registered childminder:_____________________________ Known responsible adult:________________________ *Behaviour Biting can be an uncomfortable subject for parents of both the biter and the child who is bitten. I hope that this policy will explain how I deal with biting in my home. Please do discuss any concerns you may have regarding this issue with me. If your child is known to bite I would prefer to know in advance. Children bite for a variety of reasons. This may be because they are teething, frustrated, exploring using their mouth, asserting their independence and wanting to gain control, maybe of a toy or they could be stressed. It may also be because they want to gain attention. I will work with you and your child to establish when and why they are biting. I will observe the child closely to see if certain conditions or situations trigger the behavior and then work with them to try and avoid the incidents occurring. This may involve altering the child’s routine, giving them more one to one attention, purchasing additional resources so sharing is not such a major issue or if it is because a child is teething provide suitable teething resources. I will ensure that if a child is bitten that they are comforted and given lots of attention. I will ensure that any first aid is applied correctly if required and the incident will be recorded in my book and parents asked to sign it. If your child bites then I will remove them from the situation. I will explain to them, according to their age and understanding that biting is unacceptable behavior. For younger child this may be by my tone of voice and facial expressions rather than lots of words. It may be necessary for me to exclude the child from an activity and use ‘time out’ until they are calm enough to return. I will also encourage the child to apologize to the child they have bitten and work with them to develop strategies to help them deal with the reasons. Many children go through a stage of biting, please don’t be alarmed it doesn’t last forever! Please sign and date to say you have read and understand Managing Behavior Policy Promoting positive behavior is very important and I do this by: *Giving lots of praise for good behavior *Giving the children individual attention so they feel valued *Setting a good example, being a good role model *Listening to what the children have to say *Rewarding good behavior (choosing next activity etc) *Giving children stickers for good behavior, sharing etc. I help the children understand my house rules, which are realistic and I am consistent in the enforcing of them. I do not give out confusing signals, Saying No means No! I am aware of the different reasons why children misbehave and will endeavour to keep to routines so that your child feels safe and is not over tired or hungry. However all children will misbehave at sometime. I have developed several different strategies on how to deal with a child misbehaving and use different ones depending on the age/stage of ability of the child and the situation: *Distraction. Remove the child from the situation and give them an alternative activity. *Ignore. Depending on the situation I may ignore the bad behavior as I feel it is being done to get a reaction. *Discuss with Child. If the child is able to understand I will discuss their behavior and try and get them to appreciate the consequences of their actions on others. I inform them that it is their behavior I do not like, not them. *Time Out. Removing the child from the activity and sitting them quietly for a few minutes. I will never smack, shake or hurt your child. I will not humiliate your child. If a child misbehaves I will let you know by either writing it in their contact book or by ringing you later after collection. Some children can become upset if the incident is retold in front of them. I will also inform you of how the matter was dealt with. If you have any concerns regarding the managing of your child’s behavior, please do not hesitate to contact me. It is important that we work together on managing behavior in order not to confuse your child. Please sign and date to say you have read and understand *safeguarding My responsibility as a childminder is to ensure the safety and welfare of children in my care. I have received training on safeguarding children issues and am aware of the signs and symptoms of abuse, physical, emotional and sexual, and those of neglect. If I have any reason to suspect a problem I will seek advice from the Child Protection Team and / or discuss with the parent. If I have reason to believe that any child in my care is being  abused in any way I will follow the local safeguarding children board procedures and report the matter to the Social Services. Under these circumstances I will not be able to keep information relating to your child confidential, but will need to share it with Ofsted, Social Services and the Police if requested. Please sign and date to say you have read and understand Equal opportunities I give all children in my care the opportunity to reach their full potential. Sometimes this means adapting an activity to the child’s ability and stage of development, providing additional resources or giving one child more attention and support than others during a particular activity or routine. All children in my care are given the opportunity to play with all the toys (subject to health and safety with children under 3 years of age). No toys are just for girls or just for boys. I try to ensure my toys reflect positive images of children and people from different cultures and with different abilities. No child in my care will be discriminated against in anyway, whether for their skin colour, culture, gender, ability or religion. I will challenge any remarks that I feel are inappropriate. I encourage the children in my care to learn more about their own culture and to find out about the culture and religions of other children. We do in this in a fun way through sharing book s, cooking and eating food from around the world. I encourage the children to develop a healthy respect of each other’s differences and to value everyone as an individual. I encourage Parents to share with us any festivals, special occasions or artefacts, which may enhance the children’s learning and understanding. Please sign and date to say you have read and understand All these policies will be implemented by letting the parents no on signing the contract and experience along the way as working as a professional child-minder. 1.3 Explain the importance of confidentiality and data protection. It is important to maintain confidentiality in order to build a relationship of trust between the parent and child-minder. It is important that they can trust you with their personal data and have peace of mind that  you will respect data they have provided. A child –minder is looking after the parent’s most precious thing in their life their child, therefore a relationship of trust and a mutual respect is incredibly important. One sure way of losing this trust is to disrespect the importance of the data to which you are provided. If you cannot be trusted with personal information it may become difficult for a parent to trust you with their child. It is also important to maintain confidentiality to protect the children the children in your care as well as their families, sharing information with the consent of the parent can be of great benefit as long as every party involved is working for the best interest of the child. In the interest of safety the sharing of information could save a child’s life for example medical issues or allergies. Sharing of information can also support learning as a setting can build a solid base for teaching based on a child’s likes and dislikes. If there is an issue at home that affects the child’s behaviour or progress for instance a family death sharing of information can help all involved understand the situation and deal with it appropriately. The main priority should be the interest of the child and this is where it is important to have up to date record, respectfully handled and shared responsibly with parent’s permission.

Cultural Differences In Interpersonal Relationships English Language Essay

Cultural Differences In Interpersonal Relationships English Language Essay What is your friendship style. It is probably different for each one of you and you all have your own friendship style as well. Friendship consist of mutual liking, trust, respect, tolerance, and often even love and acceptance under any conditions. They are established usually on the basis of similarities or common ground between the individuals. Friendship in real life may involve intimate touching between individuals. We can be a friend no matter what reasons. It does not matter where we from, which countries. Therefore, I would want to discuss about the difference between friendship styles with cultural background especially, cultural differences in interpersonal relationships. Many foreigner comers to the United States mention that people from US do not know what true friendship is. Americans seem very friendly at first time, but the friendships do not forward to another step. Americans are usually very friendly and kind to people eventhough they are not really close with, and they also being more generous in what others talk about than people are from many other countries. Because of this, it can be make someone to confuse who comes from a country where people are deserved first. It may seem like some difficulty to other people who from many other countries. 2 Case descriptions Steve and Yarer first met in their chemistry class at an American university. Yarer was a student from Jordan. He was excited to get to know an American; he wanted to learn more about American culture and hoped that he and Steve would become good friends. At first, Steve seemed very friendly. He always greeted Yarer warmly before class. Sometimes he offered to study with Yarer. He even invited Yarer to eat lunch with him. But after the semester was over, Steve seemed more distant. The two former classmates didnt see each other very much at school. One day Yarer decided to call Steve. Steve didnt seem very interested in talking to him. Yarer was hurt by Steves change of attitude. Steve said we were friends, Yarer complained. And I said friends forever. What was wrong in the relationship between Yarer and Steve? Are Americans fickle? Why did Yarer feel confused? Because he is an outsider to American culture, he doesnt understand the way Americans view friendship. Americans use the word friend in a very general way. They may call both acquaintances and close companions Friends. Americans have school friends, work friends, sports friends and neighbourhood friends. These friendships are based on common interests. When the shared activity ends, the friendship may fade. 3 Analysis and solutions of the case 3.1 Problems and underlying cultural differences As you can see this case, there is one big problem. Steve and Yarer they did not understand their cultural background. Understanding ones cultural background is not easy and simple. However, if you want to make effort to make a friend, you should know about his or her cultural differences. What is the most important point to considered an appropriate topic to discuss about with your friends from many other countires. Many international students said that they do not know how to make a good conversation with Americans and suffered from make a friend in US, because of a lack of understanding ones cultural factors like background information. People from different cultures have different organizations of interpersonal relationships and they have different expectations of people in the same category. As you know, Steve is from US. He seemed very friendly at first time, but it did not go for long relationship. So Yarer disappointed about Steves behave and he confused why Steve changed. From this case, we can find out what is American friendship style like. According to Cornell University international student and scholars office department, they mentioned that what is American friendship like. The American pattern shows typical Americans friendships are like they initially kind at first time because they do not really put any meaning to word friend. For instance, in US, word friend mean anything like many kinds of friend. There could be work friend, study friend, gym friend and so on. Therefore you do not have to put a big meaning to be a friend. Just try to get use to their friendship style because we all have other kinds of friendship style depends on what countries we are from. 3.2 Solutions and recommendations Your friendship and the way you look at friendships will be influenced by your culture. In cultures around the earth we observe friendship defined by the way people interact with each other, how they display their affection toward close and loving friends. But the word friend has different meanings in different countries. The misunderstanding about friend during intercultural communication sometimes may hurt ones feeling and cause in bad effects as well. Many international newcomers or students feel very disappointed that they do not know Americans well. Here are some advices: Even though you wish that Americans will invite you to come over and hang it out to get to know each other, do not take it seriously. They may not put any meaning of it. Just try to take it as a refuse to your request. Take the first step as make you to get close with them. Do not be frustrated to ask about certain thing that you need to know. talk with them with interesting topics. Such as talk about your country, cultural background and etc. They will interest to those topics because differences between culture factors always sounds fun. -Approach to them with your own friendship style. Do not frustrated to talk to them and shared your thinking. They will welcome what you think about them and care about them as well. If you want to be a good friend, just show them your true heart. It will bring out a trustworthy friendship to you If you think too much to make friend from many other countries, it will not forward to another steps to move on. You should act with confidence. And do not forget you should try to know other peoples cultural background. Also, you need to understand and respect their cultural background. 4 Conclusion The meaning of friendship may give everyone to interest but it also sort of difficult to describe. Communication style differences can also bring out misunderstandings about the other persons intentions and purpose. A main point to having successful intercultural relationship is establishing an effective relational culture. It is true that understanding ones cultural background is sort of difficult however; we should put our effort to make a good relationship with people from many other countries. If you want to maintain a good friendship with others, you should respect others first and approach to them with your true heart. People from many other countries may have different friendships between you have so we should prepare to comprehend others cultural fact and background information. Like any other friendship, intercultural friendships still hold a lot of uniqueness. In fact, friendship rules are individually negotiated so that no two friendships are alike. We create our own relat ional culture that determines whether we will be successful. 5 Literature http://www.silvaultramindsystem.com: The Silva Methods latest and most up to date program for training your intuition http://www.china-nafsa.aief-usa.org/chpter3.pdf http://www.friendship.com.au/ http://www.helium.com/knowledge/143177-what-is-friendship

Challenges Faced Rural Healthcare Facilities Health And Social Care Essay

Challenges Faced Rural Healthcare Facilities Health And Social Care Essay Twenty-five percent of the total population in the United States are living in rural areas and compared with urban Americans and healthcare facilities in rural areas generally serve low-income, the elderly, and individuals who are less informed and armed with less knowledge concerning health care prevention measures. Moreover, rural individuals accessing healthcare in rural facilities face barriers to healthcare such as fewer doctors, hospitals and health resources in generation and face difficulty in accessing health services. Statement of the problem   Hospital closures and other market changes have adversely affected rural areas, leaving State and Federal policymakers, and others concerned about access to health care in rural America. Considerable changes in the health care delivery system over the past decade have intensified the need for new approaches to health care in rural areas. Managed care organizations, for example, may not be developed easily in rural areas, partly because of low population density. Research Questions          The primary research question in this study is the question of whether rural health care facilities overcome the ongoing challenges to provide quality medical care to their communities. Rationale of the Research The rationale of this research is based upon the following facts: 1.) Rural Healthcare and Barriers to Accessing Care: Many small rural hospitals have closed, while other health care supply of primary care physicians and other health care provider facilities are in financial straits. Unavailability of resources and transportation problems are barriers to access for rural populations. 2.). The supply of primary care practitioners and other health care providers in rural areas is decreasing. Some are leaving rural areas to join managed care organizations elsewhere. 3.) Barriers to Health Promotion and Disease Prevention. Goals for improving the Nations health over the next decade can be achieved only if rural populations are included in efforts to remove barriers to access and use of clinical preventive services. 4.) Barriers Related to Lack in Health Care Technology. Technologies including telemedicine offer promise of improved access to health care, but their most efficient and effective applications need further evaluation. 5.) Organizational Barriers of Service Provision to Vulnerable Rural Populations: Low population density in rural areas makes it inherently difficult to deliver services that target persons with special health needs. Groups at particular risk include: the elderly; the poor; people with HIV or AIDS; the homeless; mothers, children, and adolescents; racial or ethnic minorities; and persons with disabilities. 6.) Consumer choice and the rural hospital. Factors that drive changes in rural hospitals have a critical effect on consumer choice and access. Significance of the Study This study is significant in that individuals in rural areas are likely to continue to receive less healthcare as well as less effective healthcare if rural healthcare does not gain necessary knowledge, informed by research study as to what should be done to better deliver health care services to those in rural areas. This study is of significance to several groups including patients depending on rural healthcare services, the families of these patients, the rural communities at large and the insurance companies who provide insurance coverage for individuals in rural areas. Methodology The methodology of the proposed research is one of a qualitative nature in which data will be gathered through survey/questionnaires of individuals, physicians and business in the rural community at focus in the research in order to asses whether the needs of the community in terms of healthcare provision are being met. Data analysis will be both qualitative and quantitative in nature. After having administered and compiled data from the survey/questionnaires focus groups will be scheduled to gain further insight into the unmet needs of the community in health care services in needs assessment focus group discussions. Literature Review The California Healthcare Foundation, in its Rural Health Care Delivery: Connecting Communities through Technology report of December 2002 states : Challenges facing rural health care include scarcity of local medical resources and distance between patients, physicians and facilities. (Turisco and Metzger, 2002) Furthermore, it is related in this report that there are insufficient numbers of primary care practitioners in rural areas. (Turisco and Metzger, 2002; paraphrased) In the instance where a patient is forced to travel from home to another area for accessing health care services resulting is a range of difficulties including: (1) time away from work; (2) additional expenses; and (3) the complications of coordinating care in different locales. (Turisco and Metzger, 2002) This increases the chance the patient information will come up missing or incomplete and as well may result in care that is delayed or fragmented. (Turisco and Metzger, 2002) The physicians in rural areas as wel l as other health care providers experience negative impacts due to the low number of health care practitioners in rural areas as well as in the distance factor, which results in limitations on productivity, communication and ongoing education. (Turisco and Metzger, 2002) Research notes that there is more difficulty for the rural providers in communication with other providers of health care. There is much less in the way of opportunities to attend conferences and training due to the requirements of travel, which limits access to medical knowledge and research work. Lower efficiency results due to travel time involved in visiting patients in hospitals and nursing homes as well as in à ¢Ã¢â€š ¬Ã‚ ¦fewer face-to-face visits, and more time on the telephone with other providers and with patients. (Turisco and Metzger, 2002) In a recent report relating to healthcare in rural India stated is that: The number of patients is increasing exponentially each year, putting enormous pressure on healthcare delivery systems worldwide. Hospitals and specialists are concentrated in cities and are inaccessible to the rural poor. (Tata Consultancy Services and Microsoft Corporation, nd) This report relates that several physicians in India along with Tata Consultancy Services (TCS) and the largest IT company in India collaborated in the creation of WebHealthCentre.com which is stated to be: à ¢Ã¢â€š ¬Ã‚ ¦a comprehensive healthcare portal like no other. (Tata Consultancy Services and Microsoft Corporation, nd) Offered are abundant health-related reference material, online medical consultation, online appointment scheduling, and online lab results for physicians. (Tata Consultancy Services and Microsoft Corporation, nd) The WebHealthCentre.com website was stated to have been created with the Microsoft.NET Framework, Micr osoft Windows 2000 Advanced Server, Web services and Microsoft SQL Server 2000. The requirements set out by the physicians in rural areas included: Ease of use by a wide cross section of people; Cutting-edge yet cost-effective technologies; Simple log on by many different users and easy assignment of user rights; Tight security to keep medical records confidential; Structured data capture for future data mining; Scalable to handle millions of users; and Extensible to accommodate audio and video interface. (Tata Consultancy Services and Microsoft Corporation, nd) Benefits resulting from implementation of this healthcare service delivery Network include: Improved access to healthcare; Better use of doctors time; Rapid development, usability; Scalable to millions of patients; and Extensible to new technologies. (Tata Consultancy Services and Microsoft Corporation, nd) Key features of WebHealthCentre.com are stated to include the following: Online, real-time medical consultation with remote healthcare professionals. PC or mobile-phone access to regional directories for hospitals, specialists, blood banks, medical appliance suppliers, and welfare agencies. An online appointment scheduler that enables patients to make appointments with participating physicians. An online lab report tool that helps diagnostic centers automate the process of uploading lab reports to the Web. Access to test results through mobile devices. Online access to electronic health records. Medical image upload services. Online sonogram viewing. A medical student resource center. Healthcare job listings. Online shopping for healthcare supplies. (Tata Consultancy Services and Microsoft Corporation, nd) The Agency for Healthcare Research and Quality (AHRQ) held an expert panel meeting to provide guidance on its new health information technology on July 23-24 2003. The focus of AHRQ is the implementation and evaluation of technologies, which have been shown to be effective in small and rural communities. Secondly, the AHRQ has set its focus upon supporting advancement in the HIT field through implementation and evaluation support for innovation in technologies for use in diverse health care settings. (Expert Panel Meeting: Health Information Technology: Meeting Summary, 2003) The Meeting Summary reports that two general themes emerged from the discussion which are those of: (1) Bringing people together; and (2) Providing technical assistance. (Expert Panel Meeting: Health Information Technology: Meeting Summary, 2003) Activities recommended for achieving their goals are those as follows: Support demonstration projects that involve HIT implementation and will lead to the creation of learning networks comprised of providers from various types of rural health care organizations. Create learning communities that span geography; collect and analyze the outcomes associated with participation. Once factors that facilitate learning communities and HIT implementation have been identified, engage CMS and other purchasers to define an appropriate reimbursement strategy. Incorporate evidence-based primary care guidelines with rural relevance into technological templates. Clinicians are likely to accept clinical guidelines offered by the Federal Government at no cost. Support local capacity development for HIT, including barrier analysis, education and other activities. Provide sustained technical assistance (Expert Panel Meeting: Health Information Technology: Meeting Summary, 2003) Evaluation of the process in rural and small communities includes: (1) scope of the project; (2) goals; (3) critical success factors; and (4) technical assistance. (Expert Panel Meeting: Health Information Technology: Meeting Summary, 2003) Community grants have been focused on the provision of personal digital assistant (PDA) systems in assisting with the decision support role. The initiative is stated to include: (1) development of toolkits; (2) leveraging known tools; (3) developing capacity; and (4) disseminating best practices. (Expert Panel Meeting: Health Information Technology: Meeting Summary, 2003) Ormond, Wallin, and Goldenson report in the work entitled: Supporting the Rural Health Care Safety Net (2000) state: The policy and market-driven changes in the health care sector taking place across country are not confined to metropolitan areas. Rural communities are experiencing changes impelled by many of the same forces that are affecting urban areas. However, due to the demographical differences and other facts existent only in rural life the health care system can be differentiated from those in urban areas in various ways. According to Ormond, Wallin, and Goldenson, it is that difference that highlights the importance of giving consideration explicitly to the impact of competitive forces and public policy developments on rural health care systems and the patients and communities they serve. (2000) The changes that are occurring in the health care sectors are resulting in many providers being threatened in both rural and urban areas however, health care provider failures in a rural area is likely to a much greater impact as compared to health care provider failure in urban areas. Because alternative sources of care in the community or within reasonable proximity are scarce, each provider likely plays a critical part in maintaining access to health care in the community. For this reason, in most rural communities all providers should be considered part of the health care safety net if not directly through their care for vulnerable populations, then indirectly through their contribution to the stability of the communitys health care infrastructure. (Ormond, Wallin, and Goldenson, 2000) The study reported by Ormond, Wallin and Goldenson is based on case studies in rural communities in the states of Alabama, Minnesota, Mississippi, Texas, and Washington selected in representation of à ¢Ã¢â€š ¬Ã‚ ¦a broad range of pressures facing rural providers. (2000) A debate is stated to exist in terms of limited services models for hospitals who fear that more insure d patients or those who are wealthier will be reluctant to use this facilities. Challenges to full-service facilities in rural areas include recruitment and retention of health care professionals and of ensuring the financial viability of local hospitals. (Ormond, Wallin, and Goldenson, 2000) Also related is the fact that health care providers are very reluctant to locate in communities without a hospitalà ¢Ã¢â€š ¬Ã‚ ¦ while simultaneously when there is not a strong physician practice in an area, hospitals find it difficult to attract patients. (Ormond, Wallin, and Goldenson, 2000) Constraints upon a rural hospital of either a full or limited service hospital include its rural location. The population required to support given service, such as a hospital or particular physician practice is spread over a much greater area. Low volume can mean high average costs, a factor that rural health officials feel is not always taken into account in reimbursement. (Ormond, Wallin, and Goldenso n, 2000) Demographical and socioeconomic differences in rural areas places demands upon health care system providers in terms of the need for treatment for more elderly people which are those more likely to have chronic health care needs. (Ormond, Wallin, and Goldenson, 2000) Furthermore, due to the lack of access to mass and major media in rural areas, the individuals residing in these areas are much less likely than those in urban areas to be aware of the availability of health care and public programs. Insurance coverage in rural areas is also a factor because rural areas have higher self-employment than urban areas, and specifically relating to farming operations making it very likely the employer-sponsored insurance in minimal. Of those who are insured in rural areas, it is likely that many of these are under insured with high premiums and low benefits as compared to those insured in urban areas. The social structure of rural communities may make the stigma attached to particip ation in public programs greater, particularly in the case of Medicaid. (Ormond, Wallin, and Goldenson, 2000) The range of services offered in rural hospitals is limited by the size of the area it serves as compared to the population within that area. Many of the hospitals in the study reported by Ormond, Wallin and Goldenson relied on a local primary care physician for core servicesà ¢Ã¢â€š ¬Ã‚ ¦but augmented his or her capabilities by making arrangements with other, nonlocal providers. The core services each hospital offers depend primarily on the capabilities of their physicians. (2000) In order that a hospital be able to support a visiting specialist program it is a requirement that the hospital have the staff that is appropriate and qualified to assist in the various specialties and physicians be able to monitor recovery, as well as the necessary space and equipment for procedures. (Ormond, Wallin, and Goldenson, 2000) The rural hospital is not in the position to provision all the services needed within the community it serves and this makes a requirement of having a referral system of a reliable nature. Stated to be a mainstay of the safety net in rural areas just as is the case in urban areas is the community health center. (Ormond, Wallin, and Goldenson, 2000) Another important provider of care in rural areas is the local health department. Another problem in rural areas is transportation for patients in that in rural areas there is oftentimes no public transportation. Internal strategies reported to be used by rural health care providers are inclusive of: à ¢Ã¢â€š ¬Ã‚ ¦increasing the stock of physicians and other health professionals, tailoring facilities and services to the needs of the community, and expanding, downsizing, or diversifying as needed. (Ormond, Wallin, and Goldenson, 2000) Other stated strategies are inclusive of cooperation among rural providers and developing links with urban providers through mergers, management contracts, and joint projects. (Ormond, Wallin, and Goldenson, 2000) Initiatives have been developed for recruitment of physician s and other health professionals who are familiar with life and medical practice in rural areas. (Ormond, Wallin, and Goldenson, 2000) Those who are recruited for practice in rural areas are likely to remain after recruitment. All five states in this study report that they provide support: à ¢Ã¢â€š ¬Ã‚ ¦for the development of rural health professionals by requiring, facilitating, or funding training opportunities in rural areas so that students become familiar with the particular demands and satisfactions of rural medical practice, or by funding education either through scholarships for aspiring providers from rural areas or through loan forgiveness for providers agreeing to locate in rural areas. (Ormond, Wallin, and Goldenson, 2000) Only the state of Washing is stated by this report to have a formal residency program. Service expansion is reported to be utilized by rural hospitals and clinics for enabling them in meeting a broader range of health care needs in their communities. (Ormond, Wallin, and Goldenson, 2000) Areas of expansion included: (1) the construction or renovation of a physician plant; (2) the addition of new medical services; and (3) diversification beyond traditional acute services. (Ormond, Wallin, and Goldenson, 2000) In fact, growth and expansion as compared to downsizing appeared to be the more common, and seemingly more successful, route. (Ormond, Wallin, and Goldenson, 2000) Expansion is also noted in outpatient services offered by hospitals and clinics. Cooperative efforts among rural providers as these health care providers collaborate in order to ensure the capability of serving their communities will continue is noted in this report stating that cooperation with other rural providers is also a mainstay of rural hospitals strategy to ward off encroachment by urban health care systems. (Ormond, Wallin, and Goldenson, 2000) The work of Rygh and Hjortdahl entitled: Continuous and Integrated Health Care Services in Rural Areas: A Literature Study makes a review of literature that examines possible methods of improving healthcare services in rural areas. Stated by these authors is the fact that: Healthcare providers in rural areas face challenges in providing coherent and integrated services. (Rygh and Hjortdahl, 2007) This study proposes a need for greatly flexibility in traditional professional roles and responsibilities, such as nurse practitioners of community pharmacists managing common conditions. (Rygh and Hjortdahl, 2007) Further stated is that the substitution of health personnel with lay health workers or paraprofessionals often in combination with interdisciplinary teams, is among measures proposed to alleviate staff shortage and overcome cultural barriers. (Rygh and Hjortdahl, 2007) Other findings of this study include that for those working in rural areas called for is flexibility of roles and responsibilities, delegation of tasks, and cultural adjustments by the healthcare practitioners. (Rygh and Hjortdahl, 2007) This study states that rural case management is greatly dependent upon a locally based case manager and that the highest ranked skills for rural case managers are: the ability to be creative in the coordination of resources, multidimensional nursing skills, excellent communication skills, high-caliber computer skills and excellent driving skills. (Rygh and Hjortdahl, 2007) Stated is that: Case management in a rural environment requires a much broader and generalist knowledge base, it covers all levels of prevention and transverses all age groups. Rural case management is a distinct specialty area of practice, with a distinct knowledge base and skills level, and nurses should be prepared at the advanced practice level. (Rygh and Hjortdahl, 2007) This study further relates that evidence exists of the success of: à ¢Ã¢â€š ¬Ã‚ ¦collaboration at the interface betw een primary and secondary sectors may improve access, continuity of care and the quality of service delivery in rural areas. (Rygh and Hjortdahl, 2007) This study defines telemedicine as Medicine practiced at a distance therefore encompassing diagnosis, treatment and medical education. (Rygh and Hjortdahl, 2007) The state of Maine is stated to have a well-functioning telemedicine services system using telemedicine in a broad array of interactive videoconferencing applications, including mental health and psychiatry, diabetes management, primary care, pediatrics, genetics and dermatology. (Rygh and Hjortdahl, 2007) According to this review telemedicine has the potential to be a tool of a valuable nature in achievement of healthcare access in rural areas although the cost-effectiveness of telemedicine has yet to be documented. (Rygh and Hjortdahl, 2007; paraphrased) The work entitled: Providing Hospice and Palliative Care in Rural Frontier Areas states that the National Rural Health Association (NRHA) à ¢Ã¢â€š ¬Ã‚ ¦believes that all Americans are entitled to an equitable level of health and well-being established through health care services, regardless of where they live. An important but often overlooked aspect of health and well-being is assurance of appropriate care and support when people are experiencing chronic, progressive illness and/or approaching the end of their lives. (Providing Hospice and Palliative Care in Rural Frontier Areas, 2005) In order to study this area of service provision the method for defining and assessing needs is stated to be through a needs assessment to include recruitment of a group of members of the community for participation in identifying the needs and creating a method of assessing results. Data is gained from various sources an may include the following: Demographics of the community; disease statistics (county health department and state vital statistics division); List of health care organizations/agencies that provide related services; A definition of unmet or under-met service needs; Identification of the unique characteristics that differentiate palliative care and/or hospice services from other services in the community; Vital statistics, including cause of death, age at death and location of death; Loss data; Community residents satisfaction with current hospice and/or palliative care services, obtained through interviews; and Community members preferences about hospice and palliative care. (Providing Hospice and Palliative Care in Rural Frontier Areas, 2005) Recruitment of individuals in this type study are stated to include: Community residents; Representatives from other community service providers such as a librarian, store owners, chiropractor or dentist; The president of a fraternal organization, the Rotary Club, another service club or the Chamber of Commerce; Pastors or leaders of local faith communities; Someone involved with the local food pantry or other emergency relief organization; An influential local business person such as the feed store owner; A county extension staff person active in community events and volunteer work; Someone who organizes the towns annual parade, festival or other special events; Someone who works on civic clean-up and beautification; and Representatives from other small organizations and entities in each of the countries the provider serves. (Providing Hospice and Palliative Care in Rural Frontier Areas, 2005) This study speaks of the creation of capacity building in expansion of the service provision and in meeting unmet or undermet needs in rural areas. Capacity building strategies include education and training of staff for skills development needed in broadening the services provided. Community education in establishing a broader understanding of what services and opportunities are available for care is also stated to be a strategy for capacity building as service utilization will be increased as well. Capacity building strategies as well are stated to include outreach strategies for development and sustaining partnerships and collaborations as well as in sustaining and supporting growth of expectations related to hospice and palliative care services. (Providing Hospice and Palliative Care in Rural Frontier Areas, 2005; paraphrased) Stated as practical examples of the training and education of staff and the philosophy used by rural providers in the creation and sustaining of program ca pacity are those as follows: Development and adoption of service performance parameters; Education of the board and/or local leaders in national trends such as palliative care, open access, managed care, chronic care management and the nursing shortage; Establishment of an ethics committee comprised of community members, hospital representatives, palliative care and hospice program staff, and church members to review specific ethical considerations/cases and to address projects such as advance care planning and advance directives; Importing best practices in enhancing service definition and outreach; Offering support for local and offsite continuing staff education an subsidies for staff to pursue relevant credentials; Offering support for local and offsite continuing staff education and subsidies for staff to pursue relevant credentials; Appointing full-time or substantially part-time physicians and advanced practice nurses as soon as feasible and involving these individuals in professional and community outreach; Establishment of bridge programs and/or extended palliative home care; Improved/extended utilization of volunteers in meeting caregiving requirements. For hospices, this may include volunteer participation in providing continuous care as allowed by regulations; and As needed, referrals to other organizations. (Providing Hospice and Palliative Care in Rural Frontier Areas, 2005) The work entitled: Planting the Seeds for Improving Rural Health Care relates the Chronic Care Model which portrays the essential involvement of the community, the design and function of the health care system and effective interaction between patients/families and their team of caregivers, producing optimal clinical outcomes. (2005) The following figure labeled figure 1 shows the Chronic Care Model: Figure 1 Chronic Care Model Source: Planting the Seeds for Improving Rural Health Care (2005) Components of this program include the following: Use of a rapid-cycle method for implementing quality improvements; Use of a standard set of changes for teams to implement; Sharing a vision of the ideal system of care developed by clinical experts; Monthly reporting of process and outcome measurements; Three learning sessions; A final national forum during which teams attend sessions with expert faculty to share progress, best practices, and lessons learned. (Planting the Seeds for Improving Rural Health Care, 2005) The work entitled: Practical Tips and Information Resources for Developing Collaborative Relationships Between Rural Community Health Centers (CHCs) and Rural Hospitals asks the question of Why Collaborate? and answers this question by stating that collaboration strengthens community health infrastructure; improves efficiency levels; and provides joint economic advantage. Collaboration is stated to be a process through which parties who see different aspects of a problem can explore constructively their differences and search for (and implement) solutions that go beyond their limited vision of what is possible. (Taylor-Powell, et al., 1998) There are five levels of relationships in building collaborative interorgnaizational relationships around health issues in a rural community which are: (1) networking; (2) cooperating; (3) coordination; (4) coalitions; and (5) collaboration. These five levels of relationships according to purpose, structure and process are shown in the following C ommunity Linkages- Choices and Decisions matrix. Figure 2 Community Linkages Choices and Decisions Source: Practical Tips and Information Resources for Developing Collaborative Relationships Between Rural Community Health Centers (CHCs) and Rural Hospitals (2005) The following are examples of the ways that CHCs and hospital partnerships are able to collaborate. These initiatives may also be used by any rural hospital, CHC or primary care provider: Joint training, recruitment, human resources, and clinical direction; Shared case managers; Working together on disease collaboratives; Shared medical laboratory; Partnership establishment enables organizations in qualifying for funding through grants for which they would not otherwise have been eligible to receive; and Shared electronic patient medical records systems; (Practical Tips and Information Resources for Developing Collaborative Relationships Between Rural Community Health Centers (CHCs) and Rural Hospitals (2005) This study states findings that a number of activities specific to an individual site have the potential for wider replication. Those activities are stated to be as follows: Local foundations can support rural health-related activities; namely physician recruitment and retention. Collaboration of CHCs, hospitals, nursing homes, and assisted care facilities in the same location can serve a large rural area and make efficient use of scarce resources; namely physicians. Affiliation with a large regional hospital can be a positive experience that is supportive of community-based services. Collaboration may be a vehicle for expanding benefits to CHC patients; namely as a result of the collaborative, a hospital utilizes the CHCs sliding fee scale for laboratory services provided to CHC patients. Case management for discharge planning and care coordination between the CHC, home health care agency, and the hospital can improve patient care. Electronic patient medical records systems that integrated the CHC and the hospital medical records are the key to future collaboration and the development of a comprehensive model of a health care system for the rural community. (Practical Tips and Information Resources for Developing Collaborative Relationships Between Rural Community Health Centers (CHCs) and Rural Hospitals (2005) There are important factors identified for organizing a successful collaboration which include: (1)