Current Care Guidelines for Cardiopulmonary Resuscitation : Implementation, skills and attitudes

Background: The national resuscitation guidelines were published in Finland in 2002 and are based on international guidelines published in 2000. The main goal of the national guidelines, available on the Internet free of charge, is early defibrillation by nurses in an institutional setting. Aim: To study possible changes in cardiopulmonary resuscitation (CPR) practices, especially concerning early defibrillation, nurses and students attitudes of guideline implementation and nurses and students ability to implement the guideline recommendations in clinical practices after publication of the Current Care (CC) guidelines for CPR 2002. Material and methods: CPR practices in Finnish health centres; especially concerning rapid defibrillation programmes, as well as the implementation of CC guidelines for CPR was studied in a mail survey to chief physicians of every health centre in Finland (Study I). The CPR skills using an automated external defibrillator (AED) were compared in a study including Objective stuctured clinical examination (OSCE) of resuscitation skills of nurses and nursing students in Finnish and Swedish hospital and institution (Studies II, III). Attitudes towards CPR-D and CPR guidelines among medical and nursing students and secondary hospital nurses were studied in surveys (Studies IV, V). The nurses receiving different CPR training were compared in a randomized trial including OSCE of CPR skills of nurses in Finnish Hospital (Study VI). Results: Two years after the publication, 40.7% of Finnish health centres used national resuscitation guidelines. The proportion of health centres having at least one AED (66%) and principle of nurse-performed defibrillation without the presence of a physician (42%) had increased. The CPR-D training was estimated to be insufficient regarding basic life support and advanced life support in the majority of health centres (Study I). CPR-D skills of nurses and nursing students in two specific Swedish and Finnish hospitals and institutions (Study II and III) were generally inadequate. The nurses performed better than the students and the Swedish nurses surpassed the Finnish ones. Geriatric nurses receiving traditional CPR-D training performed better than those receiving an Internet-based course but both groups failed to defibrillate within 60 s. Thus, the performance was not satisfactory even two weeks after traditional training (Study VI). Unlike the medical students, the nursing students did not feel competent to perform procedures recommended in the cardiopulmonary resuscitation guidelines including the defibrillation. However, the majority of nursing students felt confident about their ability to perform basic life support. The perceived ability to defibrillate correlated significantly with a positive attitude towards nurse-performed defibrillation and negatively with fear of damaging the patient s heart by defibrillation (Study IV). After the educational intervention, the nurses found their level of CPR-D capability more sufficient than before and felt more confident about their ability to perform defibrillation themselves. A negative attitude toward defibrillation correlated with perceived negative organisational attitudes toward cardiopulmonary resuscitation guidelines. After CPR-D education in the hospital, the majority (64%) of nurses hesitated to perform defibrillation because of anxiety and 27 % hesitated because of fear of injuring the patient. Also a negative personal attitude towards guidelines increased markedly after education (Study V). Conclusions: Although a significant change had occurred in resuscitation practices in primary health care after publication of national cardiopulmonary resuscitation guidelines the participants CPR-D skills were not adequate according to the CPR guidelines. The current way of teaching is unlikely to result in participants being able to perform adequate and rapid CPR-D. More information and more frequent training are needed to diminish anxiety concerning defibrillation. Negative beliefs and attitudes toward defibrillation affect the nursing students and nurses attitudes toward cardiopulmonary resuscitation guidelines. CPR-D education increased the participants self-confidence concerning CPR-D skills but it did not reduce their anxiety. AEDs have replaced the manual defibrillators in most institutions, but in spite of the modern devices the anxiety still exists. Basic education does not provide nursing students with adequate CPR-D skills. Thus, frequent training in the workplace has vital importance. This multi-professional program supported by the administration might provide better CPR-D skills. Distance learning alone cannot substitute for traditional small-group learning, tutored hands-on training is needed to learn practical CPR-D skills. Standardized testing would probably help controlling the quality of learning. Training of group-working skills might improve CPR performance.

The Problem of Implementation and its Relation to the Philosophy of Cognitive Science

According to certain arguments, computation is observer-relative either in the sense that many physical systems implement many computations (Hilary Putnam), or in the sense that almost all physical systems implement all computations (John Searle). If sound, these arguments have a potentially devastating consequence for the computational theory of mind: if arbitrary physical systems can be seen to implement arbitrary computations, the notion of computation seems to lose all explanatory power as far as brains and minds are concerned. David Chalmers and B. Jack Copeland have attempted to counter these relativist arguments by placing certain constraints on the definition of implementation. In this thesis, I examine their proposals and find both wanting in some respects. During the course of this examination, I give a formal definition of the class of combinatorial-state automata , upon which Chalmers s account of implementation is based. I show that this definition implies two theorems (one an observation due to Curtis Brown) concerning the computational power of combinatorial-state automata, theorems which speak against founding the theory of implementation upon this formalism. Toward the end of the thesis, I sketch a definition of the implementation of Turing machines in dynamical systems, and offer this as an alternative to Chalmers s and Copeland s accounts of implementation. I demonstrate that the definition does not imply Searle s claim for the universal implementation of computations. However, the definition may support claims that are weaker than Searle s, yet still troubling to the computationalist. There remains a kernel of relativity in implementation at any rate, since the interpretation of physical systems seems itself to be an observer-relative matter, to some degree at least. This observation helps clarify the role the notion of computation can play in cognitive science. Specifically, I will argue that the notion should be conceived as an instrumental rather than as a fundamental or foundational one.

Monetary Policy Implementation in the Interbank Market

The liquidity crisis that swept through the financial markets in 2007 triggered multi-billion losses and forced buyouts of some large banks. The resulting credit crunch is sometimes compared to the great recession in the early twentieth century. But the crisis also serves as a reminder of the significance of the interbank market and of proper central bank policy in this market. This thesis deals with implementation of monetary policy in the interbank market and examines how central bank tools affect commercial banks' decisions. I answer the following questions: • What is the relationship between the policy setup and interbank interest rate volatility? (averaging reserve requirement reduces the volatility) • What can explain a weak relationship between market liquidity and the interest rate? (high reserve requirement buffer) • What determines banks' decisions on when to satisfy the reserve requirement? (market frictions) • How did the liquidity crisis that began in 2007 affect interbank market behaviour? (resulted in higher credit risk and trading frictions as well as expected liquidity shortage)

CSR in forest industry – Case study of reporting and implementation of social responsibility in three international companies

Corporate Social Responsibility (CSR) has become increasingly important topic in forest industries, and other global companies, in recent years. Globalisation, faster information delivery and demand for sustainable development have set new challenges for global companies in their business operations. Also the importance of stakeholder relations, and pressure to become more transparent has increased in the forest industries. Three dimensions of corporate responsibility economic, environmental and social, are often included in the concept of CSR. Global companies mostly claim that these dimensions are equally important. This study analyses CSR in forest industry and has focus on reporting and implementation of social responsibility in three international companies. These case-companies are Stora Enso, SCA and Sappi, and they have different geographical base, product portfolios and therefore present interesting differences about forest industry strategy and CSR. Global Reporting Initiative (GRI) has created the most known and used reporting framework in CSR reporting. GRI Guidelines have made CSR reporting a uniform function, which can also be measured between companies and different sectors. GRI Guidelines have also made it possible to record and control CSR data in the companies. In recent years the use of GRI Guidelines has increased substantially. Typically CSR reporting on economic and environmental responsibility have been systematic in the global companies and often driven by legistlation and other regulations. However the social responsibility has been less regulated and more difficult to compare. Therefore it has previously been often less focused in the CSR reporting of the global companies. The implementation and use of GRI Guidelines have also increased dialogue on social responsibility issues and stakeholder management in global companies. This study analyses the use of GRI´s framework in the forest industry companies´ CSR reporting. This is a qualitative study and the disclosure of data is empricially analysed using content analysis. Content analysis has been selected as a method for this study because it makes it possible to use different sources of information. The data of this study consists of existing academic literature of CSR, sustainability reports of thecase-companies during 2005-2009, and the semi-structured interviews with company representatives. Different sources provide the possibility to look at specific subject from more than one viewpoint. The results of the study show that all case-companies have relatively common themes in their CSR disclosure, and the differences rise mainly from their product-portfolios, and geographic base. Social impacts to local communities, in the CSR of the companies, were mainly dominated by issues concerning creating wealth to the society and impacting communities through creation of work. The comparability of the CSR reporting, and especially social indicators increased significally from 2007 onwards in all case-companies. Even though the companies claim that three dimensions of CSR economic, environmental and social are equally important economic issues and profit improvement still seem to drive most of the operations in the global companies. Many issues that are covered by laws and regulations are still essentially presented as social responsibility in CSR. However often the unwelcome issues in companies like closing operations are covered just briefly, and without adequate explanation. To make social responsibility equally important in the CSR it would demand more emphasis from all the case-companies. A lot of emphasis should be put especially on the detail and extensiveness of the social reponsibility content in the CSR.

Factors affecting perceptions of corporate social responsibility implementation: an emphasis on values

This dissertation is a broad study of factors affecting perceptions of CSR issues in multiple stakeholder realms, the main purpose being to determine the effects of the values of individuals on their perceptions regarding CSR. It examines perceptions of CSR both at the emic (observing individuals and stakeholders) and etic levels (conducting cross-cultural comparison) through a descriptive-empirical research strategy. The dissertation is based on quantitative interview data among Chinese, Finnish and US stakeholder groups of industry companies (with an emphasis on the forest industries) and consists of four published articles and two submitted manuscripts. Theoretically, this dissertation provides a valuable and unique philosophical and intellectual perspective on the contemporary study of CSR `The Harmony Approach to CSR'. Empirically, this dissertation does values assessment and CSR evaluation of a wide variety of business activities covering CSR reporting, business ethics, and three dimensions of CSR performance. From the multi-stakeholder perspective, this dissertation use survey methods to examine the perceptions and stakeholder salience in the context of CSR by describing, comparing the differences between demographic factors as well as hypothetical drivers behind perceptions. The results of study suggest that the CSR objective of a corporation's top management should be to manage the divergent and conflicting interests of multiple stakeholders, taking others than key stakeholders into account as well. The importance of values as a driver of ethical behaviour and decision-making has been generally recognized. This dissertation provides more empirical proof of this theory by highlighting the effects of values on CSR perceptions. It suggests that since the way to encourage responsible behaviour and develop CSR is to develop individual values and cultivate their virtues, it is time to invoke the critical role of moral (ethics) education. The specific studies of China and comparison between Finland and the US contribute to a common understanding of the emerging CSR issues, problems and opportunities for the future of sustainability. The similarities among these countries can enhance international cooperation, while the differences will open up opportunities and diversified solutions for CSR in local conditions.