Effect of Bicarbonate Supplement on Kidney Function

Effect of Bicarbonate Supplement on Kidney Function Bicarbonate Supplementation Slows Progression of CKD and Improves Nutritional Status Ione de Brito-Ashurst, Mira Varagunam, Martin J. Raftery, and Muhammad M. Yaqoob  Lay Abstract Chronic kidney disease (CKD) is the long-term damage of the kidney. Symptoms only start presenting when the disease is progressing towards the advanced stages. It is a disease of the elderly population, and with the UK’s ageing population, cases are likely to increase in the near future. Metabolic acidosis (MA) is a common complication of CKD and treating this has been thought to slow down the decline in kidney function. Bicarbonate supplementation has previously been used as an experimental treatment on rat models to correct the MA but results have been inconclusive. There is also a lack of long-term trials investigating the effect on humans. The results showed bicarbonate supplementation was beneficial to kidney function and nutritional status of patients, while causing minimal side effects. More clinical trials need to be performed to consolidate these findings and to look at alternative treatment regimens before being implemented into clinical practice. Background Information and Rationale for Carrying Out the Work Chronic kidney disease (CKD) is the long-term decline in kidney function. It is defined as kidney damage resulting in a GFR ≠¤ 60 mL/min/1.73m2 for more than 3 months, or kidney damage for more than 3 months with evidence of structural or functional abnormalities, with GFR not necessarily reduced (1). In advanced stages it can lead to metabolic acidosis (MA) due to a decreased tubular bicarbonate secretion, which has been known to cause protein catabolism and increased insulin resistance (2), and impaired ammonium excretion (3). The lesser stages of CKD are quite common in communities but ESRD is quite rare in populations. CKD is a disease of the elderly with around 30-40% of the population > 75 years having CKD at stages 3-5 (1). It is usually asymptomatic until the later stages of the disease and during ESDR, the only possible life supporting treatments are transplantation or dialysis (4). Obesity is associated with an increased risk of CKD by over 2.5 times (5). With obesity, type 2 diabetes and hypertension all on the rise (6-8) , there is likely to be a boom in the number of CKD cases within the next couple of decades. There is clearly a need to address this future burden on the healthcare system. Correction of MA in dialysis patients has shown to slow down protein degradation in a small number of short term clinical trials (9, 10). Studies on rat models have shown inconsistent evidence where MA has been shown to slow down progression of renal failure (11). Due to the short term nature of these studies, there has been inadequate evidence on the impact of renal function. There have been very few studies investigating the correction of MA in CKD in humans and also the lack of long term studies of the effect on pre-dialysis patients, which were the main motives for carrying out this study. Approaches to the Question and Key Results The research question raised was whether bicarbonate supplementation to patients with MA in CKD could slow its progression and improve nutritional status. A single-centre, open-label, randomised, parallel-group study was carried out to investigate this question. The inclusion and exclusion criteria were stated explicitly. 134 eligible patients were randomly assigned to either routine standard care or oral sodium bicarbonate tablets 600mg TID which was increased as necessary to maintain bicarbonate ≠¥ 23mmol/L. The treatment assignment procedure was done by an external statistician and involved block stratification, then randomisation carried out within each stratum of men, women, diabetics and non-diabetics. This method helped to balance each of the patients’ covariates and ensured adequate concealment. As a result, 67 patients were assigned to the control group and 67 patients to the treatment group. To reach a power of 90% which would allow an absolute difference of 30% to be detected, 63 patients in each group would have to be studied, but to allow for non-compliance, this was increased to 67. Calculation of statistical power ensured a large enough sample size. The 2 groups had similar baseline characteristics (Table 1) and ap art from the bicarbonate supplementation, they were both treated equally. Patients were followed up every 2 months for 2 years for the primary outcome measurements while nutritional assessments were carried out at 0, 6, 12, 18 and 24 months by a single dietician. All patients were able to be analysed with none of the patients being lost to follow up or discontinuing the intervention, however 5 withdrew before receiving the treatment. Intention to treat analysis was performed. The investigators, statisticians and the single dietician were blinded to the initial group assignment as they were directly involved in assessing the outcomes, but since the trial was open-label, it suggests that patients and external clinicians were not. The outcomes were focused on the research question and were measured in a standard way. The primary outcomes were the decline in renal function, the number of patients with rapid progression of renal failure, and the development of ESRD that required dialysis. After 12 months, the rate in decline of CrCl was lower in the treatment group at 1.88 ml/min per 1.73 m2 (95% [CI] 0.39 to 4.15 ml/min per 1.73 m2) than the control group at 5.93 ml/min per 1.73 m2 (95% confidence interval [CI] 4.19 to 7.76 ml/min per 1.73 m2) (P Secondary outcomes were measurements of changes in normalized protein nitrogen appearance (nPNA), dietary protein intake (DPI), serum albumin and mid-arm muscle circumference (MAMC) to identify the nutritional status of patients. Results showed an increase in DPI (P Likely Impact of Research Outcome The fact that there was both a slowdown of the decline in kidney function and a reduction in the number of patients progressing to ESRD is clinically beneficial. However, the confidence interval for the treatment group is quite large (0.39 to 4.15 ml/min per 1.73 m2) and the upper limit is close to overlapping with the confidence interval of the control group at the lower limit (4.19 to 7.76 ml/min per 1.73 m2) for the rate in decline of CrCl. Statistically, the treatment may only offer a marginal improvement over the control, but the bicarbonate supplementation clearly does offer some benefit to stage 4 CKD patients. There are also significant nutritional benefits to CKD patients. Poor nutrition leads to protein energy wasting (PEW) and a low serum albumin which increase morbidity and mortality in dialysis patients (12), but this can be easily reduced with bicarbonate supplementation. The patients studied in this trial are not 100% representative of the population. This trial had to exclude 30 out of 184 potential subjects due to eligibility criteria. The exclusion criteria included morbid obesity, congestive heart failure, chronic sepsis, malignant diseases, cognitive impairment or uncontrolled hypertension so findings will not apply to patients that fall into these categories, however the findings will be important for the majority of patients with CKD. The trial was only a single centre study on patients at the Royal London Hospital in the East End of London. The demographic in this area of London is likely to vary from demographics in other parts of London and the UK. I think all the outcomes of interest to the patient were considered before the trial. Side effects of worsening hypertension and oedema that required an increase in therapy and loop diuretics respectively were minimal (Table 3). Blood pressures rose and oedema worsened more in the treatment group but these were not statistically significant (P=0.17 and P=0.5). The single main issue was that 6.5% of subjects experienced a bad taste taking the tablet of the sodium bicarbonate, which was then switched to a powder form. In the long term I think this trial will form the basis of a future change in clinical practice. The change will not be immediate as this is the first RCT on pre-ESRD patients with MA and more clinical trials need to be carried out in this area, with a subsequent systematic review and meta-analysis. Overall, the bicarbonate supplementation does offer an advantage over standard treatment, and the fact that bicarbonate itself is simple and very cheap to source and produce with minimal side effects also works in its favour. Future Work and Conclusion There are some changes I would make to the trial. The confidence interval for the treatment group is quite large (0.39 to 4.15 ml/min per 1.73 m2) and the upper limit is close to overlapping with the confidence interval of the control group at the lower limit (4.19 to 7.76 ml/min per 1.73 m2) for the rate in decline of CrCl. So statistically, the treatment may only offer a marginal improvement over the control. In order to achieve a more precise CI, a larger sample size could be used, and a multi-centre trial could be conducted so that the findings can be applied to a wider population. I think the accuracy of the outcomes would also benefit from the use of a placebo and double-blinding. This study focused only on patients in stage 4 CKD. While these patients are likely to experience MA, it may also be beneficial to study the effect on patients in stage 3 CKD. Patients especially in stage 3b CKD (GFR 30-44 mL/min) are at risk of slipping into the stage 4 category and bicarbonate supplementation has potential to act as a preventative treatment. The serum bicarbonate level in the treatment group was maintained at 23 mmol/L or greater. There was no upper limit for the bicarbonate level and considering that the normal range of serum bicarbonate is 22-28 mmol/L, we can see that the trial looked at the lower end of the reference range. I think a future clinical trial should look at the effect of bicarbonate supplementation on stage 4 CKD patients when serum bicarbonate is controlled within a middle range of 24-26 mmol/L and at the upper end range of 26-28 mmol/L. It is encouraging to see that there have been more RCTs investigating the positive outcomes of bicarbonate supplementation on CKD (13-15), however further investigations still need to be carried out to reach an optimal and definitive treatment plan. References 1.Barratt J, Topham PD, Harris KPG. Nephrology. Oxford: Oxford University Press; 2009. 2.Kopple JD, Kalantar-Zadeh K, Mehrotra R. Risks of chronic metabolic acidosis in patients with chronic kidney disease. Kidney Int Suppl. 2005(95):S21-7. 3.Bailey JL. Metabolic acidosis: an unrecognized cause of morbidity in the patient with chronic kidney disease. Kidney Int Suppl. 2005(96):S15-23. 4.Smart NA, Dieberg G, Ladhani M, Titus T. Early referral to specialist nephrology services for preventing the progression to endà ¢Ã¢â€š ¬Ã‚ stage kidney disease. 2009. 5.MacLaughlin HL, Hall WL, Sanders TA, Macdougall IC. Risk for chronic kidney disease increases with obesity: Health Survey for England 2010. Public Health Nutr2010. p. 1-6. 6.Klahr S, Morrissey J. Progression of chronic renal disease. Am J Kidney Dis. 2003;41(3 Suppl 1):S3-7. 7.Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010;87(1):4-14. 8.Guh DP, Zhang W, Bansback N, Amarsi Z, Birmingham CL, Anis AH. The incidence of co-morbidities related to obesity and overweight: A systematic review and meta-analysis. BMC Public Health. 2009;9(1):88. 9.Graham KA, Reaich D, Channon SM, Downie S, Goodship TH. Correction of acidosis in hemodialysis decreases whole-body protein degradation. J Am Soc Nephrol. 1997;8(4):632-7. 10.Williams AJ, Dittmer ID, McArley A, Clarke J. High bicarbonate dialysate in haemodialysis patients: effects on acidosis and nutritional status. Nephrol Dial Transplant. 1997;12(12):2633-7. 11.Jara A, Felsenfeld AJ, Bover J, Kleeman CR. Chronic metabolic acidosis in azotemic rats on a high-phosphate diet halts the progression of renal disease. Kidney Int. 2000;58(3):1023-32. 12.Lowrie EG, Lew NL. Death risk in hemodialysis patients: the predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis. 1990;15(5):458-82. 13.Kovesdy CP. Metabolic acidosis and kidney disease: does bicarbonate therapy slow the progression of CKD? 2012. 14.Abramowitz MK, Melamed ML, Bauer C, Raff AC, Hostetter TH. Effects of oral sodium bicarbonate in patients with CKD. Clin J Am Soc Nephrol. 2013;8(5):714-20. 15.Gaggl M, Cejka D, Plischke M, Heinze G, Fraunschiel M, Schmidt A, et al. Effect of oral sodium bicarbonate supplementation on progression of chronic kidney disease in patients with chronic metabolic acidosis: study protocol for a randomized controlled trial (SoBic-Study). Trials. 2013;14:196.

Elephant Man :: essays papers

Elephant Man The Elephant Man, written by Bernard Pomerance, is a play about identity. It is a play about a man who is deformed, but constantly trying to live life as an ordinary person. The play begins with John Merrick, also known as the Elephant Man, performing in a carnival freak show in order to make a minute amount of money for living expenses. In Scene VI, Even on the Niger and Ceylon, Not This, Treves brings in Miss Sandwich to become Merricks nurse. He explains to her that he has been let down so far by the other nurses he has introduced to Merrick. He prepares her for the sight of Merrick so that she will not react harshly when she sees him. Ironically she says, â€Å"Appearances do not daunt me.† Treves then offers her the opportunity to see Merrick for the first time and bring him his lunch. When laying eyes on Merrick, she becomes frazzled and bolts from the room, throwing the lunch tray into Treves arms. When Treves goes to speak to Miss Sandwich she states that no one will do the job. This scene contributes to the other scenes of the play because it is a prime example of how people react when meeting Merrick. Merrick struggles with trying to fit in mostly because of his low self-esteem as a result of the cruel reactions of people. People do not give him a chance and get to know him well enough to see the kind and gentle personality traits of John Merrick, all they see is his physical deformities and that alone scares them away. As the play goes on, people begin to look past his deformities and see that he is a true genuine person who has feelings like themselves. Merrick is given the chance to raise his self-esteem when he meets Mrs. Kendal. She is an actress who walks in with a smile on her face and is capable of sustaining the smile. She talks to him as if he is a human being and not a freak. She introduces many members of the elite class to John Merrick and they all react just as she did, looking beyond physical characteristics to the person he is inside.

Marks And Spencer Plc Commerce Essay

Get downing in UK as a penny shop in 1880s, Michael Marks and Top Spencer started the company we know today as Marks and Spencer plc. Simon Marks, the boy of Michael Marks took over the running of the concern and introduced the nucleus principals of the concern. The nucleus principals, which remained unchanged for most of their history, included the usage of simple monetary value policies, first-class quality of merchandises under the â€Å" St. Michael † trade name name, promoting and working with the providers straight to guarantee their procedures were modern and of the highest criterions and better the concern in efficiency and besides by organizing close relationships between the employees and the clients. By runing with a centralized distribution system and holding control over the full procedure, enabled to them have the same quality and make consistent shop experiences. This besides meant that the local shops were unable to run into the demands, as the directors were restricted in their powers. The powers seemed to be concentrated to the CEOs, who were besides the chair of the board of members. Sir Richard Greenbury, known for his strong sentiment and about allergic reaction to bad intelligence ran the company from 1988 to 1999. The jobs started in 1998, when the portion monetary values were hit badly, and the company was get bying with lifting costs due to the their trust on expensive providers in Britain ( while it seemed every other rival was outsourcing to Asia ) , increased competition in the market sections they were present and the traditional bureaucratic direction. After his surrender, the new CEO Peter Salsbury did small and lasted merely a twelvemonth, before being succeeded by Luc Vandervelde in 2000. Until his going in 2004, he made important alterations such as a new construct of â€Å" shop in shop † , recognition card fecilities, trueness plans, â€Å" Simple Food † trade name and the â€Å" Per Una † joint venture. However he excessively held the place of both the CEO and the chair. These alterations little consequence in the stock market, and many companies, who were their rivals were seeking to take over the company. Their commands were fought away and besides meant the debut of a new caput, Rose Stuart. Rose, made several more alterations, the most celebrated being the 11-point strategic program based their nucleus values of quality, service, trust and value for money. He made several cuts to halt blowing money, better efficiency and besides doing ascents in the shops. The public presentation was good, and in 2008, Ross officially took over the function of chair ( he was already the CEO ) , and despite being controversial. 2009 proved to be a twelvemonth of slow growing for the company, and this caused relationships between the board and the investors to go rancid. Ross, announced his connotations to step down as the CEO, nevertheless he would retain the place of Chair until 2011.Theory and constructsThe instance survey is based around alteration direction and the schemes involved. Every company faces alterations, and must do them to run into the demands of the concern. Many factors can convey about this alteration and influence it. The writers ( Witcher & A ; Chau 2010 ) depict one such model as the PESTEL model. It consists of: Political affairs such as the influence from the authorities, Economic factors that are caused due to affairs related to cost incurred, Social factors which are the alterations that are related to the alterations in the society, Technological factors which involve alterations in the engineerings that are invented and proficient alterations made in procedures, Environmental factors which are caused by environmental events or considerations of environmental impact, and in conclusion Legal factors which are alterations in the legal institutes and models. Harmonizing to the writer ( Henry 2008 ) the alteration influences can besides be described by the â€Å" Porter ‘s five forces model † , which can demo the success or failure of a merchandise or service. The five forces are: menace to new entrants, the bargaining power of the purchasers, the bargaining power of the providers, the menace of replacement merchandises and services and in conclusion the strength of the competition among the rivals in the market. These forces can be examined to measure the whether the company will be able to vie in the market, and put its resources. These factors have all influenced M & A ; S plc to do alterations. To do these alterations nevertheless a proper direction is required. The company can take many paths to recognize the alterations, and many attacks can be taken to implement the alterations. These are detailed in the subdivisions that follow.Aims of the assignmentThe aims of the assignment are to: Analyse the strategic paths taken by the company. Identifying the nucleus competences of M & A ; S plc. Analyze and discourse the types of alteration direction used in M & A ; S plc.II. Beginnings of competitory advantages of M & A ; S and routes takenCompetitive advantages of M & A ; S plcDegree centigrades: UsersuserDesktop ew.PNG Figure: Strategic Clock The archer scheme clock is used to do an analysis of the place of a company with its rivals. From the writers ( Needle 2010 ) and ( Thomson & A ; Baden-Fuller 2010 ) we understand that, the â€Å" Strategic Clock † is set against two factors, the â€Å" Perceived Value of the merchandise to the consumer † and the â€Å" Price † . It came from an earlier stiff theoretical account, by Michael Porter, which was seen as deficient. Companies can be analyzed utilizing this theoretical account, falling non merely in a peculiar section, but taking a assorted way. In the clock we can see, the low priced, low added value, which is focal point on supplying basic merchandises and minimal pricing. From at that place, we see the low priced, which is for companies supplying merchandises that are cheaper discrepancies of similar merchandises offered by their rivals. The intercrossed way is taken to set supply both a distinction factor and a low monetary value factor, which is me rely possible with high volume gross revenues. The distinction way is for merchandises which are offered merely to supply distinction, and the focussed distinction way allows the company to bear down higher by offering different, advanced and merchandises which are merely available from them. On the other side of the clock we see that hazardous, monopoly pricing and loss of market portion, which are all bad for the company, unless under extreme fortunes where the company has a monopoly over the merchandise. These schemes combine to organize of import factors to see in order for bettering the place of the company in the market. The paths taken by Marks and Spencer are based on the loanblend and distinction of its merchandises to acquire a competitory advantage in the market. These allow the company to be: Loanblend: The Company provides merchandises which are merchandises in a sensible cost, but due to its repute and the long history of attending to inside informations, the company is able to portray a higher sensed value for the merchandise. For this ground they are able to construct a trueness from the clients. Differentiation: In this path the company is supplying the client with a higher sensed value for the merchandises. They increase the borders of the merchandises and have been making so for some clip, basking higher net income borders. This distinction is based on the many factors harmonizing to ( Obitz 2009 ) such as image distinction which allows for the trade name image to distinguish their merchandises in the market utilizing the company ‘s image. Support distinction is where the company provides the clients with convenient and advanced services such as shopping hours, price reductions, shop layout etc. Quality Differentiation is where the company differentiates its merchandises based on the quality. This has been achieved by proper trading which is controlled by the company, the attending to inside informations of the demands of the merchandises and invention. And in conclusion the design distinction where the importance is to maintain it different and advanced in the marke t.CompetencesThe nucleus competences of M & A ; S plc can be identified as: The trade name is known for quality. This is one of the chief competences, which provide them with extra value from their rivals. From the early yearss, the company has been able to concentrate and command the quality of the merchandises it sells in the shops, from design, production and distribution. This allows for the merchandises at their shops to be of the highest quality and design. The merchandises of the company are known for their value for money. Although they are more expensive than their rivals, they are able to maintain the monetary values at a degree that is justified by the quality they provide. This can be important when competition with rivals who provide lower cost merchandises. The trade name of the company has been present in the market for a long clip. Therefore it is good known by about everyone. Due to this, they can vie with new trade names that are non so good known in the market, and hence demands to pass more money in advertisement. The company ‘s direction has ever been a closely knit clump. The work civilization at the company, being closely related to the clients can intend that the client service is better. This is of import to supplying the clients with a great shop experience. Other rivals might non be able to supply the same degree of client satisfaction. The company has been spread outing and is present in many states, with many shops. The shops are able to supply entree to many clients. This is an advantage for the company, in contrast with some of their rivals who do n't hold such a immense planetary range.III. Type of alteration employed by M & A ; SChange direction is an of import portion of any organisation. ( Harrington 2006 ) argues that, clients demand betterment and alteration in merchandises invariably, maintaining up to which requires the changeless focal point of any company to guarantee they run into these demands in an effectual and efficient manner. In add-on to this, the gait of alteration is increasing as the population of the universe is increasing. While points out that there are two ways in which alteration can be done. There are different types of alteration. The writer ( Martin 2003 ) point out these alterations as: Incremental Change: This type of alteration is when the company makes alterations as the demand for them rises. The demand comes from the consumers and is met in a uninterrupted manner. To enable this sort of alteration it is of import for the people involved to do accurate Hells about the types and graduated table of the alteration that is required and meets all the demands. Measure Change: This type of alteration effects the full organisation, and involves doing important alterations in one or many countries within the organisation at one spell. The alterations have a Domino consequence, which means that alteration made in one portion normally causes alterations to other parts of the organisation. For illustration, the company can present a wholly new merchandise or service in the market, which would intend a important alteration from its yesteryear. Transformational alteration: This involves the complete alteration of one concern procedure or the full concern as a whole. This is a radical alteration, which means a wholly different set of individuality and process. The alteration is deep and involves everyone in the company. An illustration of this type of alteration is a amalgamation between two companies that provide the same services, to organize a new company ( like in the recent instance of two Bankss in Oman, unifying into one ) . The alterations made in M & A ; S have been fundamentally incremental. Throughout their history, they have been doing alterations on a regular footing as the demand presented itself. For illustration, when the demand in the market appeared for betterment in engineering use such as recognition cards, the company made those alterations. Even more, when the company was confronting challenges and concern from the investors, the top direction was changed to let them to run into the demands as a company. In times of alterations in the market, and client demand for better merchandises, the company introduced the trueness card strategies, recognition card strategies and such. It would non be incorrect to state that they have failed to even run into the incremental alteration demands. However, they have besides made some measure alterations. During the term of Philip Green as CEO, the company closed down many shop, acquired Per Una trade name, cancelled many nutrient merchandises, and restricted their direction to do it more efficient. These were important alterations that were introduced to better the company and caused the first growing in gross revenues since two old ages prior. The company has yet to do transformational alterations, and they are right in making so. One of the cardinal competences of the company is its trade name value, which has been a symbol of quality and invention. Changing this would do a important strain to its fiscal stableness and besides do it to be at a disadvantage in the competitory market.IV. DecisionM & A ; S plc has had to do important alterations in their history. Organizations have to do strategic alterations due to the many factors that can be defined utilizing models such as PESTEL and Porter ‘s five forces. These alterations have to be managed decently to be effectual. As such, companies take waies, as M & A ; S did, to supplying their merchandises and being competitory in the market. Furthermore they have made these alterations in an incremental and few in a transformational mode to run into the demands of the consumers. We have been able to analyse and understand strategic alteration direction. Change is necessary for any concern, and of import for any organisation to win.V. MentionsHarrington, HJ 2006, Change Management Excellence: The Art of Excelling in Change Management, Paton Press. Henry, A 2008, Understanding Strategic Management, Oxford University Press. Martin, V 2003, Leading Change in Health and Social Care, 1st edn, Routledge. Needle, D 2010, Business in Context: An Introduction to Business and Its Environment, 5th edn, South Western Educational Publishing. Obitz, C 2009, Supermarket distinction in the UK: A theoretical and empirical probe, Diplomica Verlag. Thomson, N & A ; Baden-Fuller, C 2010, Basic Strategy in Context: European text and instances, 1st edn, John Wiley & A ; Sons. Witcher, BJ & A ; Chau, VS 2010, Strategic Management: Principles and Practice, CL Business Press.

Decision-Making Model Paper - Free Essay Example

Sample details Pages: 10 Words: 3037 Downloads: 3 Date added: 2017/06/26 Category Psychology Essay Type Argumentative essay Did you like this example? Decision-Making Model Paper Life is full of decisions. Some of them are trivial, like for example: should I choose this newspaper or another? Which kind of dish should I choose from the menu? Other decisions are hard to evaluate and vital, like for example: should I put my private life first or I should privilege professional aspects, should I take this new job opportunity to relocate somewhere else? Some decisions can affect many people, others only yourself. An appropriate decision making plays a major role in the success of any business management. Don’t waste time! Our writers will create an original "Decision-Making Model Paper" essay for you Create order The success of the business and projects depends on the decision making quality of the management and leadership. Making good decisions is fundamental to obtain a good performance in organization. There are some decisions that can have huge consequences, which can change the organizational roles and the company operation processes. The daily choices that organizations have to take are always subject to variations, this is a continuous process of making reactions and consequences; a circle in which each person has a role. Without an appropriate and good decision making, leaders and managers are not able to achieve projects and business objectives. Good decision making is not an easy task for a manager, because there are many potential factors that can influence the decision making process, such as environmental, cultural, economic and physiological factors. One of the main impediments and barriers related to good decision making is the lack of information, because in decision makin g if a manager takes a decision based on an improper or insufficient data this can have an impact on the success of the decision. In addition, without having a proper information, managers are not able to take correct decisions. Moreover, due to lack of time and resources, managers are usually unable to collect appropriate and sufficient elements and this obviously contributes to make bad decisions. Lacking of availability of sufficient, reliable and proper information also implies an impact on managerà ¢Ã¢â€š ¬Ã¢â€ž ¢s decision making. Another factor that may affect decision making is when managers have poor ideas. This is an impediment in a decision making situation because on the basis of poor arguments, managers will not take good decisions. Ideas play a major role in decision making, as on the basis of different ideas of a given problem managers take decisions related to the situation. In addition, if the idea is wrong the probability of succeeding is very low. For example, if a manager is looking for improving the profit, but is only focusing on cost reduction and cut expenses, this wonà ¢Ã¢â€š ¬Ã¢â€ž ¢t work as he would expect in optimizing resources utilization and improving production in order to achieve higher profit. So, without good ideas and better solutions, managersà ¢Ã¢â€š ¬Ã¢â€ž ¢ decision making is not effective for the business. The five steps of the decision making process that should be identified when facing a problem are: define the problem, generate and evaluate alternatives, decide course of action, implement the decision and evaluate the results. In this essay Ià ¢Ã¢â€š ¬Ã¢â€ž ¢m going to present two different decision-making approaches. Ià ¢Ã¢â€š ¬Ã¢â€ž ¢m also going to describe a decision that I made while working for a previous company using the five steps of the decision making process and Ià ¢Ã¢â€š ¬Ã¢â€ž ¢ m going to highlight how critical thinking had an impact on that decision. The following model is a decision-making sc hema that I applied to reach a decision. FRAMING Clarify purpose and boundaries of the decision Gather information Identify who is affected by the decision Identify who is in charge to make the decision (an individual or a group) Identify what experience or knowledge is needed to make the decision Determine what information or resources are available on decision making process topic Define by when the decision needs to be made Communicate to affected parties who is in charge for decision making and the reasons for it DECIDING Define how the decision will be approved (consensus, voting, etc.) Use appropriate tools that support data gathering (affinity diagram, how-how, interrelationship digraph, fishbone, flowcharts) Make the decision through ideas and data integration, negotiation and ideas prioritization Identify who (individual or group) will implement the decision COMMUNICATING Summarize the rationale for the decision Communicate the decision, why it was done and the reasons for it IMPLEMENTING Define the steps in implementing the decision including completion timeframes Define the method to report when something is done and who will get the report EVALUATING Identify the process for assessing impact of decision We can define critical thinking as, The general term given to a wide range of cognitive skills and intellectual dispositions needed to effectively identify, analyze, and evaluate arguments and truth claims, to discover and overcome personal prejudices and biases, to formulate and present convincing reasons in support of conclusions, and to make reasonable, intelligent decisions about what to believe and what to do. In other words, critical thinking consists in being able to look at information critically. It implies asking questions about the information presented and then analyzing the answers. It means using the answers to create new ideas, solve problems, and make decisions. Critical thinking is imperative to making sound decisions using a decision-making modelà ¢Ã¢â€š ¬Ã‚ . This was an example of a quite simple decision that I had to take in occasion of company department restructuration, while working for the previous company. Top management decided to swap and merge a few d epartments that were reporting to several managers, this was done mainly to reduce staff costs and optimize project organization flows, as few roles and departments were overlapping. I was chosen as manager for supporting and à ¢Ã¢â€š ¬Ã…“redesigningà ¢Ã¢â€š ¬Ã‚  the new staff reorganization. I decided then to proceed step by step: The first one was to get acquainted with my team, the second was to involve managers of the other departments to understand if the teams were optimally organized, team activities, head counts, ongoing projects, internal problems, workflows etc. At the end of my analysis I had to revert top management with my findings on team organization, about what could be done in order to increase team efficiency and productivity, and I had to provide my hints on how to rearrange them. I decided then to use decision-making model to determine and evaluate what needed to be done, and if any organizational changes should to be done, if opt to merge departments with o thers, if hire or fire people. As part of the model framing process, I knew that I had to take the decisions alone and that this would potentially impact the company structure and business. However, I wanted to get the input also from the other managers, since they were more knowledgeable regarding the strengths of each team member and they were familiar with the dynamics, which tend to arise when working in groups. I did not want to inform, or announce, any implementation or changes too quickly to avoid any kind of shock, like having to report to a new boss or being relocated somewhere else or fired. In the deciding phase I met each individual manager for a face-to-face coffee break. I had previously prepared a list of questions that I was going to ask them, which I would cover during our conversation. I shared that my goal was to get to know each of them deeply and find out something more about their team, their feelings and thoughts about company businesses and activities. I also encouraged them to ask questions, in their turn. I questioned them about their perception concerning their position in the group, their development plans, and I requested them what they would have changed about the group if they were top managers. I spent about a week in order to be able to gather all the information through this process. I found out that the staff was organized fairly well, with a few exceptions, and the teams were working on almost the same topics (different resources from different teams were working on same topics waste of time/resources à ¢Ã¢â€š ¬Ã¢â‚¬Å" and this was happening mainly because teams were not communicating to each other, so people were not informed that they were working on the same projects). The overall outcome was anyway really good and I decided to make only two minor changes and a major one: I decided to move two teammates to different teams within the same group and to merge two teams in order to increase overall productivity and efficien cy and to establish weekly meetings among team managers to avoid any double activities and to let all of them share weekly updates and results. As part of the communication phase I referred my proposed changes to top management, that validated my decision and I shared rationale behind my organization changes with them. Changes were implemented while talking on a new project for the teams. I spoke with the impacted colleagues, communicating that I needed their specialized skill sets in their new groups. They showed to acknowledge the news well and they continued to be satisfied on their new teams. I went on keeping periodic one-to-one meetings with my staff and the other managers. During those meetings I had to assess the impact of my decisions. Another kind of decision that I had I had to take was about my career plan. I spent the last 2 years working within finance field and this has had a great impact in a lot of ways, both in my professional and private life. I have been able to create a pleasant environment with my colleagues and have appreciated my collaboration with the company. They used to say and believe that the fundamental aspect in your job activity to perceive a great passion on what you do and enjoy while doing it. I have been able to follow the advice and in fact I continue to improve myself in order to effectively perform my work. It isnà ¢Ã¢â€š ¬Ã¢â€ž ¢t easy to cope with the responsibility linked to making decisions within a company. Moreover making the right decision becomes even more painful when your own feelings are involved. Being in charge of international teams, my work implies examination and supervision of the work done by my teammates, work with different people across different continents, cultures, religions and ways of thinking. The job is not easy to do because there are people who will take it personally when you control some aspects of their work and their quality results. There are people, who answer à ¢Ã¢â€š ¬Ã…“yes, I g ot ità ¢Ã¢â€š ¬Ã‚ , even if they donà ¢Ã¢â€š ¬Ã¢â€ž ¢t understand. Being involved in a few project reviews that include wide and complex projects is a very hard situation to manage, as my role sometimes involves decisions that may not be in favor of team mates. Moreover, it is sometimes hard understand their enrollment and support to the project tasks or their participation in different project aspects. I cannot avoid being deeply concerned with the situation and with its possible consequences in other people lifeà ¢Ã¢â€š ¬Ã¢â€ž ¢s, because they have a personal direct report line and they know me. I still donà ¢Ã¢â€š ¬Ã¢â€ž ¢t manage to accept the fact that some people could do things against the company without following assigned tasks. There are of course also decisions that need a proper judgement like when choosing between personal life and your work. A practical example is when you are faced with the problem of refusing an assignment because there is a family matters to attend. It might be the case that you choose to be absent from work in order to take some time for yourself. One of the hardest decisions that I had to take in these two years was about issuing an end contract review to one of my teammates. Thus part of my responsibility is to interview new candidates that will join my team and to monitor their results. One of them has been diagnosed with a mental disease and this was a piece of information they used against her. During her apparent ship she didnà ¢Ã¢â€š ¬Ã¢â€ž ¢t show any sign of her illness. In fact I had found her an efficient and effective collaborator, thanks to of her patience, intelligence, and as well as willingness on learning and improving her knowledge in the field. After three weeks, and in reason of my recommendation, to give her access to widen her learning experience within the company operativity, the Compliance Officer decided to introduce her in the operation team as junior assistant for a period of two months. D uring her training, I was informed by her line supervisor that she experienced sudden attack of hallucination. The news took me by surprise and deeply affected me because I didnà ¢Ã¢â€š ¬Ã¢â€ž ¢t suspect such a terrible truth. Human Resources wasnà ¢Ã¢â€š ¬Ã¢â€ž ¢t acquainted at all regarding her health problem and for this reason they were unable to communicate me the results of her background inquiries. I was asked by her line manager to conduct a thorough evaluation of her case and consequently to report my findings on her status to company top management. In reason of this insufficient investigation carried out by Human Resources, I found myself in the unpleasant situation of not knowing how to proceed on her present status with our HR Dept. Of course there is a labor law that has to be taken in consideration concerning company protection. Her school reports were good like her previous professional experience, but her disease generated doubts in me about her ability to perform her daily tasks and the impact of her illness on other co-workers. The decision has to be done before the apprentice ship period ends. Through assessment, I finally decided to recommend closing her contract with the company, because of the effect of her mental disease to the general team results, or like the impact that high workload and pressure will result on her disease. I had to set aside my empathy, in order to privilege the whole company. She couldnà ¢Ã¢â€š ¬Ã¢â€ž ¢t afford too much pressure on herself, she would have suffered much more and this might not be helpful for her case. The working environment within the company is extremely competitive, thus I continually check my results and evaluate to invest in further education. I trusted the management and I set aside too much of my private life for the company but unfortunately in the end I was deceived. This disappointment made me doubt about management effectiveness to support me in any further career development. As long as I love my job and colleagues I work with, I have to consider carefully all options and evaluate other future possible alternatives. My frustrations started when I requested the management to let me lead different team operations, in order to be able to concentrate on my academic studies and simultaneously experience new challenges, since operations are a very demanding area of the financial companies undertakings. Being a business oriented person, I feel the necessity to look for more challenges and as Ià ¢Ã¢â€š ¬Ã¢â€ž ¢m already in IT management since more than 10 years it no longer provides me the challenges and motivations I need. I thus asked the management to relocate me to other areas aiming to improve my skills in other ways. Unfortunately the request was refused and I was kept in the same position. Furthermore, my supervisor, our Chief Financial Officer resigned and a good percentage of his workload was transferred to me, without even opting for a promotion. I performed his functions as additional to mine, so at the end my job was involving multi-tasking activities. In a practical thinking environment, I was expecting a career advance or promotion, but unfortunately my request was put aside for more than three months. As a consequence Ià ¢Ã¢â€š ¬Ã¢â€ž ¢m unsatisfied with my current job position and, at the present moment while experiencing a serious doubt concerning the decision whether to stay or leave the group. Management choice not to support me in impeding me to pursue my education has been a great disappointment to me. I was unhappy with the way in which the Human Resources dept. managed the situation and left me no option but to resigned and abandon the company. The decision to continue to work for the same company is very difficult for me because I loved the job and the people. The company has been my second home, but in a professional perspective. I have the impression that I am no longer in the right place because I now experience discon tentment, which would greatly affect the quality of my work if I stayed. I have taken into considerations a lot of options and alternatives for my future. I have different sensations about my resignation, because in many ways I am afraid facing the many changes that this decision may lead to after resigning. These uncertain include dealing with new companies, new working context and groups or new bosses. Moreover the fact that I might not find a suitable job immediately has given me a frustrating feeling of inadequacy and incompetence. I have been working for years and now I realize that I could be forced to stay at home with nothing to do. This prospective frightens me a lot, because I cannot stand idleness, even for a short period of time. All of these uncurtains must be solved, otherwise I wonà ¢Ã¢â€š ¬Ã¢â€ž ¢t realize that I can still get a lot of satisfaction from my business life. I am still young and there are so many open opportunities just waiting for me. Therefore, my dec ision has been taken: I am perfectly determined to accept à ¢Ã¢â€š ¬Ã…“job-hunting challengeà ¢Ã¢â€š ¬Ã‚  again. I believe in my skills and possibilities to pursue and find the à ¢Ã¢â€š ¬Ã…“dream jobà ¢Ã¢â€š ¬Ã‚  I am looking for. Consciously or unconsciously, decisions are taken daily, at work or at home. These decisions can involve and affects individuals, groups, or families. The more crucial a decision is, the more it requires thorough evaluation and critical thinking, counterbalancing the positive and negative issues it could lead too. Having a global picture is always good as it will help to become a good manager and improve the ability to make good decisions. A decision-making model is a good process to obtain optimum decisions. References: Critical Thinking (Bassham Irwin, Nardone Wallace) https://highered.mheducation.com/sites/0072879599/student_view0/chapter1/glossary.html