A Qualitative Project Proposal, Research Paper Example

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Research Paper

Abstract

The following proposal entitled “Acceptance to the Implementation of eMAR in a Critical Care Unit: A Qualitative Proposal” will be discussing the importance of the acceptance of the implementation of electronic medical administration records (eMAR) in a critical care setting in a local hospital. The research regarding the proposal will be conducted using a qualitative method in order to determine the various behavior of the participants involved in the study. The study will be comprised of fifteen nurses in the critical care unit, as a smaller participant pool is recommended for qualitative research due to the feasibility of hypothesis construction.

The study will use a grounded theory approach because the data collected from the nurses will be used to evaluate the acceptance of the implementation of eMAR as well as observations made by anonymous researcher during various times of the day and week throughout the course of the study. Along with the tested eMAR method, critical care nurses will continue using the traditional paper method of reporting medical events so patient safety and quality of care will never be compromised. This will not cause great distress because the study will be for a short timeframe and the benefits of the information gained far outweigh any extra work that may occur as a result.

Upon completion of the study, all fifteen critical care nurses will be issued a qualitative survey comprised of fifteen open-ended qualitative questions and asked to return these to a location within the hospital. The data from the survey will be analyzed and a formal report will be prepared for the hospital administration. This report will be presented to the administration and will be used to determine whether the acceptance of eMAR implementation is significant enough to begin the conversion process in other departments throughout the hospital for a completely electronic medical administration records institution.

As seen from the literature, the research indicates the benefits of eMAR are significant and far overshadow any learning curves or problems adapting to the system in general. Electronic medical administration records are known to improve the safety of patients due to decreasing the risk of medication prescribing errors, medication administration errors, harmful medication interactions, and will standardize the timing regimen of medications for those patients on a strict routine. Patients will also benefit from a higher quality of care due to the preceding factors and the healthcare facilities will benefit from decreased reporting of medication errors as well as a decrease of overall operating costs due to patients having to undergo unnecessary procedures or stay longer periods of time in the hospital because of medication errors.

In the event of implementation, there will be a two-week training period for each employee before using the system to replace the manual medical record methods. Overall, if the plan is implemented hospital wide, there will be approximately a one year phase in for the implementation of the eMAR to give employees time to adapt to the system and incorporate features of the system to be specific to the needs of the hospital. After this, random employees in each department will be issued surveys to gather feedback as to how successful this implementation was in order to know what steps might be needed, if any.

Acceptance to the Implementation of eMAR in a Critical Care Unit: A Qualitative Project Proposal

Problem Identification

Medication errors are one of the most harmful and costly errors caused by those working in hospitals and long-term care facilities today. The errors made due to prescribing or administering the wrong medication have serious direct and indirect results (Mayo & Duncan, 2004). They can cause unnecessary and harmful side effects, lengthier hospital stays that expose patients to other nosocomial infections, and increased overall expenses for the hospital and the employees responsible for the treatment of those affected individuals. The most harmful of all results is the chance of causing accidental death to a patient due to the administration of an incorrect medication. Nurses are affected directly because administration of the wrong medication can cause a license to be in jeopardy or, in some instances, be revoked by the nursing board.

According to DeYoung and associates (2009), preventable adverse drug events or medication errors are a main cause of medical injuries with patients in the hospital and a primary area of focus for quality improvement initiatives within health care institutions.

The medication identifier, eMAR system is a combination of two systems used together to ensure that administration of the medication is given according to the five rights: the right patient, drug, dosage, route of administration, and time.  When the pharmacist receives an indication that the system combination has been utilized correctly, the medication order appears in the patient’s chart. If the medications are overdue, an alert is sent electronically to the nurse indicating which medication is overdue.  Once the order is received, the nurse must use the scanning device on the patient’s identification band and the medication identifiers.  If for any reason the medication identifiers do not match, an alert is sent to the nurses’ desk computer for safety.

According to DeYoung and associates (2009), one of the medication-use processes associated with high rates of medication errors is the administration phase.  One study revealed that 44% of medication errors experienced by ICU patients occurred in the administration phase.  In another study, approximately 61% of all serious medical errors were related to a medication error during the medication ordering or administration phase of treatment.  The natural selection of using an eMAR is the best choice to decrease or eliminate medication errors in health care delivery system.

The problem with the use of eMAR is the implementation phase and learning curve amongst nurses who have never used an electronic system before. Many nurses do not like change and many nurses do not understand the reasons behind the importance of eMAR implementation across the entire spectrum of critical care because perhaps those nurses have not had an error in medication administration thus far.

Product Objective

This paper will provide an in depth discussion about the problem of medication errors in the critical care setting and its adverse effects on patients. The research thus far has indicated the use of eMAR in critical care settings will decrease medication errors. The objective of this project is to gain feedback via qualitative analysis from a group of nurses in the ICU (critical care unit) in order to understand better how to proceed with the implementation of using eMAR in the entire hospital. This feedback will provide information, both positive and negative, from an employee perspective and will hopefully make hospital wide implementation an easier task.

Statement of purpose

This purpose of this proposal is to conduct a qualitative study examining the acceptance of the adoption of eMAR among a group of 15 critical care nurses in the ICU.  According to Burns and Grove (2009), qualitative research is used to detect a target level of behavior and the reasons that drive it. A qualitative study is usually focused on a small group of people to guide and ensure the construction of a hypothesis.  A qualitative study’s results are considered descriptive rather than predictive.  Grounded theory research is applicable to this study because it is a qualitative research approach that is a discovery of theory from data.  Grounded theory focuses on an area of the study and gathering data from a variety of different methods, such as interviews and observation of critical care nurses attitudes toward the use of eMAR.

The proposal focuses on the acceptance of the adoption of eMAR among critical care nurses.  The electronic medication administration record (eMAR) is a significant component to the patient’s medical chart and is a major part of a nurse’s workload and responsibility in the hospital setting because medication administration is a significant process associated with safe patient care.  According to Poon et al (2010), bar-code eMAR technology incorporates several technologies into the workflow of the nursing staff to ensure that the correct medication is administered at the correct time to the correct patient.

The objective of this study is the acceptance of the adoption of eMAR among critical care nurses as part of their daily use in the ICU to help with the reduction of medication errors. The acceptance of the adoption of eMAR among critical care nurses plays a significant role in the success of reduction in medication mistakes.  Nurses play an essential role in providing safe, effective, and quality care to patients in the critical care unit.

Possible complications

Unfortunately, the acceptance of the adoption of eMAR among critical care nurses has its challenges.  Many nurses will resist the thought of learning a new system that some believe is unnecessary due to their ability to monitor and administer medications manually. Also, many nurses will be resistant to the thought of change in general. Resistance to change is common with nurses in the health care delivery system.  Nurses’ resistance stems from the fact of learning a new system that is time- consuming and difficult.  Some older critical care nurses who are not knowledgeable about computers may have difficulty adjusting to the new system and the workflow processes of eMAR.  This could cause a disruption of the nurses’ daily routine and practices, which will cause resistance to the change as well.

Learning a new system and the use of eMAR can cause more nurses to have an increase in workload and responsibilities.  This can result to more stress to some nurses who are resistant to any change.  However, the efficacy of eMAR use in the critical care unit plays a significant role in preventing medication errors and enhancing medication administration accuracy. It’s implementation would be highly beneficial to the overall care of patients and would bring more security in their positions due to the decrease in chances of medication errors.

Solution Description

The use of eMAR and nurses’adoption of the system plays a critical role in the health care delivery system.  Nurses were interviewed regarding eMAR and their attitude concerning its use.  Grounded theory can be used for this type of study.  According to Polit and Beck (2004), grounded theory has become an important research method for the study of nursing phenomena.

According to Poon et al. (2010), the use of eMAR substantially reduced the rate of errors in order transcription and in medication administration as well as potential adverse drug events.  Acceptance of electronic health records is particularly important in the ICU because eMAR is used to review and document medication administration, timing, and comments about the administration(M. W. & S. S, 2012).  According to DeYoung, VanderKooi, & Barletta (2009), the implementation of bar-code medication administration significantly reduced the number of wrong administration time errors in an adult medical ICU.

The acceptance of the adoption of eMAR among critical care nurses is gradual for each nurse.  If there is something implemented and it is an easy process to learn, normally there is little negative feedback from personnel. However, nurses become frustrated with technology when it is slow, imperfect, or generally does not fit into their normal workflow process (Murphy, 2011). Each nurse has to adapt to the new system at his or her own pace and having nursing staff trained in its use who are willing to be used as support personnel will help in the transition of the use of eMAR in the critical care unit. The use of eMAR in the critical care unit will significantly decrease medication errors and enhance medication administration accuracy.

Survey methodology

This study was conducted by using a survey containing open-ended questions pertaining to the usage and implementation of eMAR in the ICU. It also contained questions regarding the nurses’ feelings pertaining to ease of use, disadvantages to the new technology, and a miscellaneous section for any other comments the nurses felt were important to relay. The survey was given to 15 nurses in the ICU, which comprised every nurse on every shift. The surveys were kept anonymous in order to avoid bias and ensure a greater amount of validity for the study. All nurses were asked to fill out the survey and place the completed surveys in a box in the break room by a certain date. In addition to the surveys, observations were made during each shift so the researcher could get a better understanding of attitudes relating to the nurses’ use of the eMAR and the learning curve associated with it. These observations also helped with the interpretation of the surveys as it provided more insight into the reasons behind various negative or positive responses.

Research Support

Many articles have been written attesting to the importance of eMAR usage throughout hospitals as a means of keeping standardized records of medication distribution as well as assuring the safety of those medications being distributed to the correct patients in the correct manner according to the five rights. Several studies have also been performed globally as a way to further adapt eMAR to the current needs of hospitals and structure the technology to be more user friendly and have an easier learning curve to help with the hospital wide implementation process as this has been a complaint in various institutions.

St. Luke’s Hospital is one of the hospitals in the United States that has found significant improvements to overall patient care and streamlined workload as a result of the eMAR implementation. They reported many improvements, the most significant being the reduction of errors in the administration of medication. Also reported was an increase in overall patient safety and more accurate reporting. This is a significant issue facing hospitals due to nursing licensure and unnecessary hospital procedures or lengthier stays due to employee error.

There was also an improvement in communication between departments as well as an improvement in information sharing and process integration as a whole. This particular improvement will go far in helping patients’ wait times for procedures and, for those patients in the critical care unit, getting the medications to patients on time as they are essential. There was also a noticeable improvement with caregiver-patient interaction at the bedside. This could possibly be due to the nurse actually having to go through extra steps in order to administer the medication. Overall, the nurses and everyone employed at St. Luke’s had a positive experience after the initial implementation of the eMAR (Yates, 2007).

When considering a switch to an electronic method, one must consider this is going to be the centerpiece of a nurse’s work. But with the advent of greater and more reliable technology, we now have the potential to increase the safety of patients, improve their care, and even change the basic way healthcare is delivered (Moreland, Gallagher, Bena, Morrison, & Albert, 2012). The eMAR is going to be the most important tool a nurse will use on a daily basis. It must be structured to where it is beneficial to nurses and understandable to those without years of prior computer knowledge. In the article by Moreland, Gallagher, Bena, Morrison, & Albert (2012), there was an overall positive response to the implementation of eMAR in the hospital, especially with nursing personnel. They did, however, complain about the time factor. It is more time consuming and some things are not as easily accessible. Those issues are going to surface, no matter what the technology.

When weighing positives and negatives, though, the positives in using eMAR to help with the safety, efficacy, and standardization of patient medication distribution are going to far outweigh the negatives because one error could potentially be the life of one human and that would be a tragedy. In the Moreland and associates (2012) article, the nurses in the ICU had the lengthiest time accepting the new method of delivery. A possibility for this could be because they are treating patients who need a number of medications and if a new system is more time consuming, it will be even more so for them. That is going to be expected, but in the long term will actually be more beneficial as they learn the system and are better able to administer care to those patients.

Harding and Petrick (2008) believe adverse events can be proactively handled and medication errors are the number one error all nurses will make in the course of their careers. They are going to administer medications time after time and at some point a mistake is likely to happen. If they are proactive and implement some sort of technology such as eMAR into the workplace, this could be significant in reducing errors and would actually relieve the overall stress on nurses after the initial learning phase was completed.

The authors also state that in actuality there are many instances where medication errors are not reported because they are not ‘important’, most likely due to the fact the patient did not have an adverse reaction or no other association costs were incurred by the hospital. The stress level on those nurses who had the unreported events was still high because it was an error and they made the error. Incorporating eMAR into the hospital unit would help with that because it would be one less worry for a nurse who is overworked and multitasking for twelve to sixteen hours (Moreland, Gallagher, Bena, Morrison, & Albert, 2012).

Another positive feature of an eMAR is the ability to alert nurses to problems, such as two different versions of the same medication being prescribed to the same patient or a possible drug interaction from a combination of various prescribed medications (Trossman, 2006). While it should be noted that nothing can replace a nurse’s judgement and knowledge pertaining to medication administration and interactions, with staffing and working conditions being the way they presently are in critical care units today, it would be helpful to have a system to alert nurses to possible problems and this could serve as a double check feature for safety protocol.

Although nurses are trained extensively on pharmaceutical interactions and assessing patients for adverse reactions, they have many other duties and will frequently be called away from one duty to attend to something else. For those nurses who are having negative responses to the implementation of an eMAR, perhaps the mention of this safety benefit might be of great value to some of them. It could improve the overall quality of care delivered to all patients and help make the nurse’s feel more confident about second guessing their decisions if there is no other peer around to ask (Trossman, 2006).

Although most of the articles focused on the positive aspects of eMAR implementation and usage, one article by Caesar and Hutchinson (2006), actually gave a detailed breakdown of complaints from nursing personnel and the solutions given to them from hospital support staff during the changeover process. There was the normal ‘beginners’ frustration with the annoyance, as almost every employee will experience with a new system. These were things such as accidently bypassing warning screens, allowing shortcuts, having trouble locating certain action keys, and double charting. The company manufacturing the software actually stepped in during the implementation process to help with these problems and the others that will follow.

The solutions offered were taken and after this occurred, nurses were more positive in their attitudes and understood the importance of having eMAR in the hospital for the safety and security of patient care. They complained of having to stand to use the carts for medications and charting. This was corrected by using occupational therapists to instruct the nurses on the proper posture and ergonomically friendly ways to work in order to correct the problem. Another complaint was the inability to scan bar codes on medication packages. This was remedied by remodeling the bar-coding system in the pharmacy department. A complaint was made about cords on the laptops being too short to use, thus having to move them on and off the cart and causing breakage. This was remedied by a simple replacement with longer cords. As the article implies, no method is going to be one hundred percent perfect, but the attitudes of the nurses after these problems were corrected improved substantially and the implementation of eMAR was a success (Caesar & Hutchinson, 2006).

Shedenhelm and associates (2008), agree the implementation of eMAR has obvious benefits for everyone. They list some of these as being improved communication, improved access to data, and clinical documentation that can actually lead to better clinical outcomes and an overall quality of service. The hospital in this particular article chose to give a two-week implementation period in which to train its nurses on the eMAR before going ‘live’ with the system. In addition to this, there was a two-week period after the implementation of the system in which support staff would be available to assist with any problems. Unfortunately, some of the nurses did not understand the system as quickly as others and some did not embrace the change. This actually caused several problems with the implementation. Many of the nurses were documenting patient data inappropriately and many felt overwhelmed by the impact of it all. The administration took a step back and reevaluated the process. They made changes and gave those having problems with the system extra time to learn the information. They incorporated staff on different units, especially those such as critical care, to assist with the barrage of questions so that patient safety would not be compromised. Feedback was actually requested from the employees and taken into consideration. This is important because if a staff in the critical care unit does not embrace a change eventually, there could be problems ahead. Fortunately, all wrinkles were taken care of and the implementation continued. Once the nurses learned the system they actually preferred it to the old system of manually entering data. The sheer fact of mistake avoidance made it worth the extra effort to learn something new if it would give the nurses a peace of mind and help with their job in the long term (Shedenhelm, Hernke, Gusa, & Twedell, 2008).

It has also been suggested that the benefits of eMAR, when used to its full capabilities, will eventually become the lifetime narrative of a patient’s medical history. This would indeed help clinicians, and especially nurses, with patients who have chronic conditions because there are many medications to take and many possible interactions to consider (Lodyga, Fredericks, Ross, & Kondellas, 2011). Hospitals could provide much better and safer care to patients as well as providing more cost effective care if a patient’s medical record ‘followed’ him or her around. This obviously is not in use presently and will most likely not happen in the near future, but when speaking of safety concerns, medication errors, stressful work environment, and understaffed institutions it would make sense to have an eMAR on a patient for that patient’s lifetime history to help with the diagnosis and treatment of whatever the patient encountered. This would be of significant help for those patients in ICU with problems such as COPD, or end stage renal failure that are prescribed numerous drugs and have developed hypersensitivities or allergies to many of them. Nurses would have an even better safety blanket around them and a little less stress in their daily routine.

As for a successful implementation of an eMAR is to understand that everything is going to be a work in progress. It is important to have time to understand the basic functions and not feel rushed. This will only add to the stress factor nurses encounter every day in their jobs. Most institutions that have implemented eMAR have been pleased with its inception and would not have done things differently, except for possibly giving employees more time to train or providing additional staff for support on those units with extra needs, such as critical care units (Whitham & Davis, 2007). A positive attitude from the leader or charge nurse is important to have as the other employees are going to get much of their attitude from that person. Change is inevitable, but necessary to remain abreast of the newest technology in order to give patients the best in terms of safety, quality, and care. Cost effectiveness is important also when administrations are inspecting each department and most departments are operating below what their staffing needs already should be (Whitham & Davis, 2007).

Implementation Plan

Implementation of eMAR in the critical care unit of the hospital took place over the course of two months. This was strictly on a research basis and the results were to be used to assess whether or not the hospital would benefit from an institutional implementation as well as how cost effective this would be over time. Four eMAR carts were purchased for this evaluation on a lease option and two specialists were included (one each for day and night shifts) to assist with proper training of personnel. Each nurse was instructed in the mechanics of the machine, all of the basic functions, the proper way to input patient data, the correct sequence in which to chart information, and how to relay messages to and from the pharmacy in order to ensure orders were being delivered accurately. In addition to this, a manual method was also being used concurrently as it had been in the past so that no patient’s safety would be compromised.

The plan was observed on a daily basis at various intervals throughout the day by researchers whom did not make themselves known to the nurses or patients. This was to ensure no bias in the study and to have the most accurate reports possible. All results were recorded on a chart and notes were made, as needed, pertaining to events that might have transpired during the observations. The eMAR method was evaluated for the

two-month period and afterward things returned to the way they previously were.

Overall, this was a feasible plan for qualitative research purposes because the original method of patient charting and medication administration was not interrupted; therefore, no harm was brought to any patient due to the study. Only one unit was involved in the study, so there were only 15 employees involved in the training and this did not cause a problem in the budget for the hospital because of the work schedule in the unit. The survey questions were distributed after the entire process was completed.

Evaluation Plan

As mentioned earlier in this paper, 15 nurses were surveyed as part of this project. The surveys were passed out after the two-month period of testing the eMAR procedure and the nurses were asked to complete the surveys and place in a box in the break room. The surveys were qualitative in nature due to the fact they were open-ended questions and, along with the observations, used the grounded theory to assess whether the implementation of eMAR would be a good choice for this hospital based on the assessment of the critical care unit (ICU).

The nurses were asked six questions pertaining to their use of the eMAR devices and all of them responded to the questions. A copy of the questions is attached to the end of this document. From the entire group, 12 of the 15 nurses believed the eMAR would provide better safety to patients as far as the distribution of medications was concerned after the initial learning process was completed. Three nurses believed the system was extremely difficult to master and two nurses believed the system was quite time consuming. However, all five of these nurses were in agreement with the rest of the group that the eMAR would be a safer way of administration and provision of care for their patients, especially those on multiple medications with various time regimens.

Six nurses believed the ‘red flag’ function was the most important feature to the eMAR because it helped them in double-checking to avoid drug interactions. One nurse listed on her survey that many times she would be pulled away from rationing out her medications for a patient and would return ten minutes later to continue with her task. The red flag function would be of great benefit if she were at the end of her shift and especially tired because it might help avoid a tragic error.

Decision Making

The results, along with the observations taken by researchers, were typed and presented to hospital administration. This, along with a literature review of various studies and other articles advocating the use of eMAR in hospitals across the country, was used in the determination by hospital administration as to whether or not to implement the eMAR throughout the institution. Based on the initial findings, it was suggested by a member of the administration that the eMAR be incorporated into one unit of the hospital at a time, beginning with the critical care unit as they already had a basic working knowledge of the process.

After the critical care unit was live on the system, other units such as the surgical unit, the maternal unit, and the newborn unit would follow suit, with each unit being given an initial two month training period if needed to grasp the basic functions of the system. The general patient floors would follow and the emergency department would be the final department involved in the implementation of the eMAR. It was decided this entire conversion process would take approximately one year and at the end of the year, a group would randomly be selected from each department to gather feedback on how the system was working and how to better integrate various features of the system with specific hospital needs.

Conclusion

As stated previously, the acceptance of the implementation of an eMAR among critical care nurses plays a significant role in the promotion of patient safety. The efficacy of eMAR use in the critical care unit is important to reduce medication errors and enhance the accuracy of medication administration. The use of eMAR has also promoted patient safety in critical care unit settings as well as in the entire hospital. This technology assists the nurses in preventing avoidable medication errors, adverse drug interactions, and enhances accurate medication documentation at the patient’s bedside.

References

Burns, N., & Grove, S. K. (2009). The practice of nursing research: Appraisal, synthesis, and generation of evidence (6th ed.). St. Louis, MO: Saunders Elsevier.

Caesar, B., & Hutchinson, B. (2006). Reducing medication errors by using applied technology. Nursing , 36 (8), 24-25.

DeYoung, J. L., VanderKooi, M. E., & Barletta, J. F. (2009). Effect of bar-code-assisted medication administration on medication error rates in an adult medical intensive care unit. American Journal of Health System Pharmacy, 66(12), 1110-1115. doi:10.2146/ajhp080355.

Harding, L., & Petrick, T. (2008). Nursing student medication errors: A retrospective review. Journal of Nursing Education , 41 (1), 43-47.

Lodyga, M., Fredericks, M., Ross, M., & Kondellas, B. (2011). Electronic Medical

Records (EMR): Call for empathy in the patient-clinician relationship within a technological milieu: Implications for professional nursing practice. Electronic Journal of Health Informatics , 6 (3), e23.

Mayo, A. M., & Duncan, D. (2004). Nurse perceptions of medication errors: What we need to know for patient safety.  Journal of Nursing Care Quality, 19(3), 209-217.

Moreland, P., Gallagher, S., Bena, J., Morrison, S., & Albert, N. (2012). Nursing satisfaction of implementation of electronic medication administration record. CIN: Computers, Informatics, Nursing , 30 (2), 97-103.

Murphy, J. (2011). Leading from the Future: Leadership Makes a Difference during Electronic Health Record Implementation. Frontiers of Health Services Management, 28(1), 25+ W., & S. S. (2012). ICU nurses show increasing acceptance of electronic health records. AHRQ Research activities, (379), 14. Retrieved from EBSCOhost.

Polit, D. F., & Beck, C. T. (2004). Nursing research: Principles and methods (7th ed.).

Philadephia: Lippincott Williams & Wilkins.

Poon, E., Keohane, C., Yoon, C., Ditmore, M., Bane, A., Levtzion-Korach, O., Moniz,

T., Rothschild, J.M., Kachalia, A. B., Hayes, J., Churchill, W. W., Lipsitz, S., Whittemore, A. D., Bates, D. W., &Gandhi, T. K. (2010). Effect of bar-code technology on the safety of medication administration. The New England Journal of Medicine, 362(18), 1698-1707. Retrieved from EBSCOhost.

Shedenhelm, H., Hernke, D., Gusa, D., & Twedell, D. (2008, July). EMR implementation and ongoing education. Nursing Management , 51-53.

Trossman, S. (2006, Sept/Oct). Preventing errors: IOM report offers strategies throughout the medication process. The American Nurse , 14-15.

Whitham, J., & Davis, S. (2007, May/June). Effectively integrating your EMR initiative. The Physician Executive , 56-59.

Yates, C. (2007). Implementing a bar-coded bedside medication administration system. Critical Care Nursing Quarterly , 30 (2), 189-195.

Appendix A

  1. Do you feel you would be more effective at providing care to patients if an electronic medical record was used instead of a manual method? Why?
  2. What initial problems did you have during the testing phase of the eMAR?
  3. What do you feel was the most important attribute to the eMAR over the manual method?
  4. Do you believe the eMAR to be a safer way of administering medications than any other previous method? Why?
  5. What would you change about the eMAR?
  6. What other comments do you have about the eMAR or its abilities?
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