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Nursing Research & Evidence-Based Practice

central line associated bloodstream infections (CLABSIs

Nursing Research & Evidence-Based Practice NUR 561


In researching the topic of central line associated bloodstream infections (CLABSIs), writer completed an online search for relevant articles to the topic. Articles selected were a quantitative and a qualitative article on CLABSI and prevention of CLABSI. This paper is based on the five-peer reviewed article on CLABSIs and CLABSIs prevention. CLABSI is considered a blood stream infection which is confirmed primarily by laboratory work (Sacks et al., 2014). CLABSI is a bloodstream infection that happens to the patient who has central line within 48 hours of insertion and is not related to an infection from another site (CDC, 2016). In general, CLABSI happens when there is a possibility of not correctly inserting the central venous line (CVL) or not monitoring or supervising the site after the insertion and not adhering to CLABSI protocol. It is one of the major blood stream infection with the increased morbidity and mortality rates of 10 to 20 % (Morrison, 2012). It cost a lot of money to the U.S. healthcare system and thousands of deaths in America, yet it is preventable healthcare associated infections just by implementing CLABSI bundle (CDC, 2016).

PICOT Question

The Evidence Based Practice research PICOT Question to be addressed: Does having a CLABSI prevention/elimination team who are dedicated to supervise entire central line insertion in Intensive Care Unit (ICU) and CLABSI bundle protocol as opposed to bedside ICU nurse be responsible to implement the CLABSI-related preventive measures for the purpose of reducing the risk of CLABSI?

P- Patients admitted in ICU

I- Having a CLABSI team to supervise the central line insertion

C- Bedside ICU nurses responsible to maintain and prevent CLABSI

O- Decreased rate of CLABSIs

T- During ICU stay

Keywords: Compliance, CLABSI bundles, Guidelines, CLABSI prevention, CLABSI

Literature Review

According to the article by Furuya et al., (2016), CLABSI is a condition that can be prevented. The intention of this study was to assess the compliance with the central line insertion bundle overall in US. The research method involved cross-sectional design involving National sample of adult ICUs participating in National Healthcare Safety Network (NHSN) surveillance (Furuya et al., 2016). The overall study involved 984 adult ICUs in 632 hospital (Furuya et al., 2016). The results of the study showed that only 69 percent of the US hospitals reported compliance with the set regulations to prevent CLABSI. It is therefore evident that compliance to the stipulated guidelines is not strictly followed. According to Furuya et al., compliance is the most effective method of preventing CLABSI. Most of the healthcare organization and healthcare centers are aware regarding the guidelines recognized by the World Health Organization (WHO) and Center of disease Control to presents the central line associated blood steam infections in ICU’s settings. This article by Furuya et al. (2016), is based on a qualitative study which is focused on the mutli-center research on the prevention and elimination of the CLABSI. This articles also focuses on why some of the hospital are more diligent on preventing the CLABSI than other despite the guidelines provided by national mandates. Research was conducted in 250 hospitals with the mean CLABSI rate of 2.1 per 1000 CVL (Furuya et al., 2016). Among them only 49 % reported to have a written CLABSI bundle policy (Furuya et al., 2016). Even on those who monitored compliance, only 38 % were highly compliant with the CLABSI bundle (Furuya et al., 2016). In this research, first the hospital’s infection preventionist was questioned by phone and then in person interviewed was conducted. On this research there was a use of snowball sampling to conduct the phone interview, in person interviews. The phone interview and in person interview was conducted on the epidemiologists, Physicians, unit managers, nurses in the ICU’s unit. After the interview it was identified that most of the organization had the common challenges to implement the CLABSI protocol in their organizations. There were basically four common challenges which were discussed by all the healthcare organization. The four challenges were the politics, culture, structure, and emotions. Politics meaning the relationship among the employee on the unit, culture as a values and beliefs which were shared by the employee, structure meaning some factors which are affecting the quality improvements projects, and lastly emotions as the level of commitment and passion shared on the unit (Furuya et al., 2016). After analyzing the article, it has been noted that those hospital who had a higher score on the culture and emotion were also the ones who were more committed and passionate about fostering change, improving implementation,  and collaborating more quality improvement projects. On the other hand, those hospital who did not score high on the four challenges were also found to be not having favorable environment for change.  The proposed study will close a gap in knowledge as it identifies that for effective implementation and collaboration of CLABSIs’ prevention plan, plan dissemination was deciphered as a prodigious step. From this article it has been found that the effect of implementing the CLABSI bundle protocol and educating nurses has a significant impact on reducing the CLABSI and associated infection as the p value was 0.015 (P = 0.015), incidence rate ratio [IRR] 0.77, 95% confidence interval and  (β = -1.029, p = 0.015).As we know that the p value less then .05 is significant and that we reject the null hypothesis of stating that there is no difference. The result indicated that there was a significant difference in reduction of CLABSI infection when the CLABSI bundles protocol were implemented and education were provided to the ICU employees on CLABSI. As a plan disseminating for the quality improvement was to meet the guidelines evidence-based practice research and implementing a Vascular Care Team (VCT) to monitor the CLABSI bundle protocol. Normally time frame for these kinds of projects will be three months. On a timely basis meeting were conducted between nurses and CLABSI team to monitor the progress towards prevention of the CLABSI.

The research study by Park et al. (2017) was conducted in a community hospital which was based on the qualitative analysis of midline catheter and central line care that were provided by medical-surgical nurses. Most of the community hospitals are not equipped with the required tools or had experience with preventative measure which are needed to fight central line associated bloodstream infections (CLABSIs). In this research, the researcher has utilized the phenomenological framework and the methods of exploration was the interview process (Park et al., 2017). The study was approved by the Centers for Disease Control and Prevention institutional review board (IRB) and the New Jersey Department of Health’s IRB use in this analysis (Park et al., 2017). Consents were obtained from qualified participants. No human harm was noted on this study as it is an education study and was conducted by interviewing process. The researcher on this research study conducted 45-minute interview with the medical-surgical nurses on the medical-surgical units that has the highest rate of CLABSI. This research studies were basically focused on the nurse’s perspective at central line care. Fifteen medical surgical nurses were interviewed from the medical surgical units who had highest’s incidence of CLABSI who were working as fulltime. After the interview process various challenges emerges out. The biggest challenge was to follow the correct procedure along with CLABSI prevention. Also, nurses did not have high exposure with CLABSI and patient with CLABSI. 15 nurses identified that there is a need for education concentrating on the central line care and CLABIs prevention training. As, a teaching strategy, nurses who were seasoned and experienced related to CLABSI were brought to the community hospital to guide the nurses. As a result, plan was created which was based on the experiences nurses experience and when implemented decreased the CLABSI rate. This article focuses on the prevention of infection from the nurses prospective who were working nurse in a community hospital.  This article explores the interventions that can be implemented to prevent CLABSI. The article highlights that the condition can be prevented if healthcare organizations take the necessary preventive measures. This data collection methods involved exploring the impacts of overall intervention implemented by peer tutoring which involved 1000 days of continuous tutoring. The results of the research showed that CLABSI decreased from 6.9 infections in the pre-intervention period to 2.4 and 1.8 in the intervention (Park et al., 2017). This article focused on the CLABSI rate for 9 months pre-intervention, 6 months during the intervention and 9 months post-intervention. SPSS 22.0 was utilized to conduct the statistical analysis for this article. It has been found from this research that CLABSI rate decreased from 6.9 infections in the pre-intervention phase to 2.4 and 1.8 in the intervention period of 6 months with P value being 0.102 (p= 0.102) per 1000 catheters per 9-month period (Park et al., 2017). The researcher used the regression model to show the significant difference between the pre intervention and post intervention drop rate in CLABSI where the P value was  less than 0.001 (P < 0.001). As mentioned above P value less than 0.05 is considered to be statistically significant and shows the difference preintervention and postintervention of applying the CLABSI bundles and education provided to the nurses and we reject the null hypothesis stating there will be no difference in pre intervention of applying CLABSI bundle and post intervention of CLABSI bundles. Hence, this research showed significant increase in CLABSI when there was no peer tutoring. To close the gap in knowledge, the article highlights that without peer tutoring interventions, the rate of CLABSI infections can increased again. From this article it has been noted that in order to prevent the CLABSI, healthcare organization need to concentrate on clinical reasoning and preventative actions. This article can be used in healthcare organizations to explain the importance of peer tutoring towards the prevention of CLABSI.

The research by Blot et al. (2014) is based on systematic review and meta-analysis of the interventions taken to prevent CLABSI. The article sought to determine whether central line–associated bloodstream infections. The research method involves analysis of the previously done studies from 1995–June 2012 (Blot et al., 2014). CLABSI per 1,000 catheter-days, CLABSI per 1,000 inpatient-days, and catheter utilization rates were identified in this article. Maryland Health Care Commission (MHCC) measured the objectives and difficulties of reporting data publicly and has approved this study (Blot et al., 2014). The research was conducted in a five adult ICUs at a regional teaching hospital, that has 63 ICU beds. The CLABSI bundle was introduced to ICU which has four components: hand hygiene, sterile technique upon insertion, use of chlorohexidine wipes for skin preparations, and avoidance of the femoral vein as the access site (Blot et al., 2014). The research was conducted for 10-month period over 18,656 inpatient-days and 9,388 catheter-days (Blot et al., 2014). In this research 687 CVL insertions on 481 patients were performed (Blot et al., 2014). Consents were obtained from qualified participants and no human harm was noted on this study as it is an education study and was conducted by interviewing process. The results of the study show that CLABSI have decreased significantly over the years due the use of CLABSI bundles and education regarding CLABSI. A ratio of 95% confidence intervals proved that CLABSI can be prevented (Blot et al., 2014). Hence, from the article, quality improvement interventions are crucial in preventing CLABSI. Continuous quality improvement can be used to close the gap in knowledge on how to implement continuous quality improvement in ICU. This article by studied a visual design of information from widely-reported central line-associated blood stream infection (CLABSI) ending data for generating decisions by different target individuals, health care customers and professionals. In deciding on the best way to openly document CLABSI data results Maryland Health Care Commission (MHCC) measured the objectives and difficulties of reporting data publicly and has approved this study (Blot et al., 2014). The visual view of quantitative knowledge explains data for customers and health care professionals for creating decisions. The purpose of visual design, to systematize the information for relaying a message successfully, can be achieved by prioritizing, combining, and arranging the information appropriately. The study used formative methods with several groups to verify the choices that the researchers did to obtain the members, and they employed an extensive cross section of the intended user populations. The researchers confirmed visualizations that were accepted and publicly organized for customers and health care professionals in Maryland. This article recognizes that in order to expedite the CLABSI prevention program, a peer-reviewed research framework which assimilates evidence into practices is really crucial. This article focused on systematic review and meta-analysis examines to find out the impact of quality improvement interventions on central line-associated bloodstream infections in ICU patient. Also, the researcher used the Meta-regression which assessed the impact of CLABSI bundle interventions and high baseline rate on intervention effect. From this article it has been found that the effect of implementing the CLABSI bundle protocol and educating nurses has a significant impact on reducing the CLABSI and associated infection as the p value was .03 (P = .03). As we know that the p value less then .05 is significant and that we reject the null hypothesis of stating that there is no difference. The result indicated that there was a significant difference in reduction of CLABSI infection when the CLABSI bundles protocol were implemented and education were provided to the ICU employees on CLABSI.

According to the article by Chopra et al. the main objective was to research on effective evidence-based care to prevent CLABSI infections among ICU patients. The article notes that Central Venous Catheters (CVC) play a central role in preventing the infections. The method of data collection involved 34 evidence-based studies done previously to identify causes and prevention of CLABSI (Chopra et al., 2013). Moreover, review was conducted in accordance with the protocol proposed by the Federal University of São Paulo. 1,485 studies were initially selected but only 34 studies were considered necessary for this study (Chopra et al., 2013). The results from the study showed that interventions such as hand hygiene and maximal barrier precautions are effective in preventing CLABSI among ICU patients. Therefore, the article concludes that that commitment of stuff plays a crucial role in preventing CLABSI. This article is can be used to seal the gap by teaching members of the staff how to commit themselves in preventing CLABSI. This article by Chopra et al. (2013) is a crossover randomized prospective pilot study of central venous catheter (CVC) team intervention in comparison to standard care. Consents were obtained from qualified participants and no human harm was noted on this study as it is an education study and was conducted by interviewing process. In most cases, treatment for children suffering from cancer includes chemotherapy that is delivered via CVC. Although the CVC is a reliable source for delivering chemotherapy, it increases the risk of bloodstream infections (BSIs). The study takes place in a children’s hospital with the focus on two inpatient oncology units with 41 patients in the experiential unit and 41 in the control unit. The study compares patients who receive CVC blood draw bundle by nurses on the CVC team experimental interventions versus standard care from a bedside nurse. In the six-month study, a significant difference was seen in the CVC team and standard care by the bedside nurse related to risk of BSIs. In determining the effectiveness of the CVC team, a larger cohort group is needed.  While the use of CVC is pervasive, most studies related to CLABSIs are done in the adult population. This article provides data related to CLABSIs in the pediatric population. A vascular team needs to be created to monitor the CLABSI protocol and to calculate the data of CLABSI. The vascular team will be conducting he seminar, meetings, and creation of the EBP bundles for the elimination of CLABSI. A vascular team should be created to monitor the CLABSI protocol and to calculate the data of CLABSI. The vascular team will be conducting he seminar, meetings, and creation of the EBP bundles for the elimination of CLABSI. Vascular team was providing PowerPoint presentation, webinar, websites and handouts regarding the prevention of CLABSI to educate nurses and empower them on CLABSI bundle protocol. In this research the pre intervention and post intervention of education and CLABSI bundles drastically decreased the rate of CLABSI from 3.9 per 1,000 catheter days to 1.0 per 1,000 catheter days. Also, in this research study the P value was 0.000 which is less than 0.5 and is considered to be statistically significant as the (P< 0.001).

According to the article by Sacks et al. (2014), a central line-associated bloodstream infection (CLABSI) develops within 48 hours of the line placement. This article is based on the research done to investigate pathogens associated with CLABSI. The research method involved analysis done from October 2011 to September 2012, with the intention of identifying the infectious causing agents associated with CLABSI. This article investigated the effect of the effect of implementing a checklist for the placement of central venous lines (CVL). Participants were  assigned to the checklist group either control or experimental in a 1:2 ratio (Sacks et al., 2014). In this research the frequency of CLABSI was compared in control and experimental groups. In this study total of 4416 CVL were inserted; 1518 were from checklist group and 2898 participants were in the control group (Sacks et al., 2014).This article explains that the use of checklist during CVL placement has caused lowered incidence of CLABSI frequency. Consents were obtained from qualified participants. There was no human harm noted as the education conducted was online and screenings were performed during routine exams. The results of the study showed that majority of infections were caused by staphylococci 34.1 percent, enterococci16 percent, and Staphylococcus aureus, 9.9 percent (Sacks et al., 2014). The article concludes that the action taken by healthcare organizations to prevent CLABSI like use of antibiotics, echinocandins and parenteral vancomycin which is an antibiotic intervention. The knowledge from the article is useful to medical practitioners working in ICU. The recommendations provided can prevent CLABSI. The study by  (Sacks et al., 2014). was based on a two-year case matched controlled retrospective study of central line associated bloodstream infection (CLABSI) in an urban trauma service. The population consisted of 6014 admissions to the trauma service. The case reviewed 105 case-matched controlled groups who did not suffer from CLABSI. There were 35 CLABSI catheters that were identified, 25 out of 35 documented breaks in sterile technique, and 16 catheters were placed in intensive care unit (ICU). CLABSIs were associated with documented break in sterile technique placed in the ICU setting. Practitioners were encouraged to increase awareness and education to adhere to strict sterile precautions. An emphasis was put on the use of CLABSI bundle and education on CLBASI prevention. Research was approved by the Department of Intensive Care Medicine at the University Medical Center Hamburg–Eppendorf, Hamburg, Germany. Independent variable: Catheterize patients, dependent variables: CLABSI infections (Sacks et al., 2014). The researcher in this article have utilized the SPSS 22.0 has a data analysis method which is mostly used for quantitative data. The researcher noted that the rate of CLABSI per catheter days reduced 19/3,784 to 3/1,870 after implementation and collaboration of the CLABSI protocol Bundle. It was also noted that the p value was 0.02, which is statistically significant value. P value in this research study was less then .05, (p=0.02), p <0.05). With the CLABSI bundle and education intervention, CLABSI rate decreased from 3.9 per 1,000 catheter days to 1.0 per 1,000 catheter days. Also, in this research study the P value was 0.000 which is less than 0.5 and is considered to be statistically significant as the (P= 0.02),and (b = −0.505, χ2 (1) = 4.20) (Sacks et al., 2014). We can conclude that we can reject the null hypothesis and state that there was significant difference noted when CLABSI bundle was applies towards the prevention of the CLABSI. In conclusion, most of the CLABSI identified in the trauma service were related to break in the sterile technique. It is most frequent in the ICU setting. The adherence to proper sterile technique guidelines while placing catheter can help to reduce CLABSI and patient mortality. Also, the CLABSI bundles has been found very effective by various health organizations. As identified in this article, appropriate implementation of the bundle reduces the rate of infections by 38%.


As we all know, there are several comprehensive studies and research done on CLABSI and prevention of CLABSI. The main purpose of this research study is to establish the effect of working as a team on the quest to improve the patient’s safety and prevention of infection in ICU patient. It has been found from different article review that the best way to prevent CLABSI is by developing models, educating bedside nurses, attending seminar, attending continue education based on CLABSI and CLABSI protocol guidelines. The models have to be based on the Evidence Based Research (CDC, 2016).  Knowledge is defined as power (Morrison, 2012). Attending PowerPoint presentation, attending seminar based on the CLABSI and prevention, and keeping communication open on significance of CLABSI prevention was the best way of prevention of CLABSI.  As to test knowledge a competency test should also be conducted on the bedside nurses for competency and knowledge.


Blot, K., Bergs, J., Vogelaers, D., Blot, S., & Vandijck, D. (2014). Prevention of central line–      associated bloodstream infections through quality improvement interventions: a                                  systematic review and meta-analysis. Clinical Infectious Diseases59(1), 96-105.

CDC National and State Healthcare-Associated Infections Progress Report, (March 2014), retrieved from

Chopra, V., Olmsted, R.N., Krein, S.L., Safdar, N., & Saint, S. (2013). Prevention of central line-            associated bloodstream infections: Brief update review in making health care safer II: An             updated critical analysis of the evidence for patient safety practices. Rockville (MD):

 Agency for Healthcare Research and Quality (US), No. 211(10).  doi: 10.1007/s11606-    011-1935-y.

Furuya, E. Y., Dick, A. W., Herzig, C. T., Pogorzelska-Maziarz, M., Larson, E. L., & Stone, P.                W. (2016). Central line–associated bloodstream infection reduction and bundle                                   compliance in intensive care units: a national study. infection control & hospital                                   epidemiology37(7), 805-810.

Morrison, T. (2012). Qualitative analysis of central and midline care in the medical/surgical

setting. Clinical Nurse Specialist, 26(6), 323-328.

Park, S. W., Ko, S., An, H. S., Bang, J. H., & Chung, W. Y. (2017). Implementation of central                 line-associated bloodstream infection prevention bundles in a surgical intensive care unit                     using peer tutoring. Antimicrobial Resistance & Infection Control6(1), 103.

Sacks, G. D., Diggs, B. S., Hadjizacharia, P., Green, D., Salim, A., & Malinoski, D. J. (2014).

Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle. The American Journal of Surgery, 207(6), 817-823.


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Cultural Difference Between the US And China

Nowadays, it is hardly to pick up a newspaper and read without some articles which related to expansion of business to China. Nike was known as Blue Ribbon Sports which founded at the year of 1964. After that, a name Nike is used to replace the Blue Ribbon Sports at the year of 1978, because it represents Greek goddess of Victory. However, all of the Nike brand footwear and apparel are produced outside of United States. The main headquarter of Nike Incorporation is located at Beaverton, Oregon. The footwear and apparel are manufactured in China since it is the low-cost country source. China is preferred which due to some reasons as shown in following paragraphjdfjdfjdf.

First and foremost, China has a huge market base for investing. As according to the International Monetary Fund’s research, the China’s total population had rose from 1.29 billion to 1.36 billion at the years of 2003 and 2013 respectively. Thus, it shows that this is an advantage to manufacture Nike’s footwear and apparel at China without worry no customer will purchase it. Company will not make a loss if even only target on part of the population, and target based on the demographic which includes, age, gender, family, occupation, and races. The International Journal of Business and Management has been stated, main target markets of Nike are young people around 20 to 30 years old and middle-age people which in the range of 30 to 50 years old. Furthermore, young people can be classified low and middle income social class, whereas the middle-age people which comes from middle and high income social class. In China, Nike Incorporation is able to target high percentage population of young and middle-age people meaning success rate is higher than other country. Its success rate is proved by the 2010 census which has the fact about nearly 750 million people which is equal to two-thirds of China’s population is under age of 35. Their spending are much higher compare with other segmentation.

Moreover, manufacturing in China can enjoy cost benefit as compared to United States. This is due to Nike Incorporation having a comparative advantage which related to labor cost of China is more affordable than the labor cost in United States and Asia countries and can produced more quality product with the well- developed infrastructure. Let’s think on the side of Nike, the productivity and quality are almost the same however only require to pay a lower amount of wages. In addition, this money can be used for other purpose such as advertisement or Corporate Social Responsibility which help to build positive reputation for company. Since the factory located near to target customer, thus Nike Incorporation able to deliver the footwear or apparel on time, as a result, needs of target customers are satisfied quickly which in turn of increasing the loyalty from them. However, if the situation is like that, the customers need to wait a longer period for the merchandise, they will tend to switch to other competitor such as Reebok or Adidas, it is such a huge loss to Nike Incorporation, thus it can be in termed of cost benefit. Target on existing is much cheaper than target on a new segmentation.

Furthermore, economy condition of China is superior; it undergoes the rapid growth, and now is ranked as the world’s third largest economy. It still can undergo with the Gross Domestic Product (GDP) 9 percent when there is a world financial crisis in the year of 2008. In last year, there are around 8 percent of GDP. This reduced the worry and chance of getting loss because the consumers still want to purchase shoes even in recession period. The most important point is use a suitable marketing strategy and advertisement.

Last but not least, geographical location of the factory in China is much more strategic. Reduction of lead time since lot of component can get over there without export from United States to China. Or else, can have a good bargain from the supplier. Besides that, product can be marketed more rapidly than the competitor in order to gain the market share.


Entering into a foreign market is like discovering new territory for business owners. Foreign countries have different laws, economies, business strategies and currency. Cultural differences can also significantly influence a company’s success. So, analyze the relevant gains and shortcomings of entering into foreign countryis essential for any entrepreneur intent to expand into foreign markets. There are several great advantages of China.First, economy condition of China is superior which has a more developed and balanced industry than many developing countries, a result of China’s much faster growth rate in manufacturing since the 1950s. In 1980, when India and China were more or less equal in Gross Domestic Product (GDP) per capita, China already enjoyed a powerful advantage in manufacturing. (Au Loong-Yu, 2007) As economy condition of China is stable and the GDP is growing, it enables the foreign company, Nike who entering into China market growing as well. China has a great economic growth rate is due to the availability of natural resources allows Nike who operate their business in China to produce their product efficiently and effectively.

bvhjjjnmnmSecondly, it cannot be denied that China is a huge country with a population of 1.3 billion (Jeffery, H. 2008) which greatly magnifies the advantages of effective growth and sophisticated manufacturing in China. It produces the benefit of economy of scale. The 2009 China Business Report released by the American Chamber of Commerce in Shanghai shows that U.S. enterprises view China as their major investment destination country due to its huge domestic market. (People’s Daily Online, 2010) Once again, huge domestic market in china also boasts billions of potential consumers for everything from pharmaceuticals to footwear, cars, and clothing. In short, Nike can develop huge and lucrative customer base by entering to China market since China has huge population. Furthermore, this can potentially boosts Nike’s sales and revenue, gains a larger profit margin, and allows Nike to realize economies of scale. This can prove from a research with shows that during the 2011 fiscal year, Nike Greater China’s earnings before interest and tax were USD777 million, a year-on-year increase of 22%. (, 2011)

Thirdly, it is cost effective to entering into China market. Since China’s population is more than 1.3 billion and the country boasts to have larger human resources than any other countries. As a result, China’s low product and labour costs are well known. Today, when a manufacturing industry needs labour-intensive, value-added services, Chinese suppliers and logistics service providers are capable of responding. Since Chinese labour costs a fraction of US labour, it is extremely cost effective for Nike to manufacturing its products at China rather than at its origin country. As the population increases, China will have the greatest number of professionals which enable Nike to hire Chinese professionals with lower wages as compare with US professionals because the average wage rate in China is only 2.1% that of the United States. (RIETI, 2002) Decreasing overhead through manufacturing in China is a valuable resource for Nike. Cutting costs by employing workers at a reduced rate or paying less for plant operation allows Nike to invest the additional profits into other areas of the business such as advertising to build brand awareness, thereby increasing the potential for company growth. Besides, Nike is able to more efficiently produce its product and reduce costs due to manufacturing its product in China. The average hourly manufacturing compensation for China in 2004 was about 3 percent of the average hourly compensation costs of $22.87 for production workers in the United States for the same year. (Erin Lett and Judith Banister, 2006.) This enables Nike to price its brand at a competitive rate with other companies that sell a similar product.

In the Political aspect, China is not a free-market economy in which the allocation for resources is determined only by their supply and the demand for them. Adversely, China has an authoritarian communist government which is a risk associated with doing business in China. While China is a quickly emerging economy it still is a Communist nation. China employ some of the same terms and strategies as capitalist markets, political control is everywhere.A concern for many businesses is corruption of Chinese officials and lack of legal security in Chinese courts.The shortcoming for Nike to entering into China market is there are many restriction place on them and they only have very little freedom when operate their business in China. Cultural differences are another risk for Nike to entering into China market since the culture of US people with China has a huge different. In addition, most of the foreigners are not exposed to the Chinese culture, thus they do not know what are the preferences and needs of the Chinese consumers. In addition, China encompasses a wide range of cultures, climates and peoples, so Nike will encounter a wide range of development and industrial strengths. The way of doing things can be varying even within this single country. Nike may face the difficulties in satisfying the needs of their wide-range customers in every segment due to the customers in each region will have its own specific needs that will not always overlap with other parts of the country. For example, there is a huge cultural difference between China’s northern and southern regions. Northern Chinese are vigorous and unrestrained; impetuous and straightforward. In comparison with northern Chinese, the southerners are gentle and delicate; patient; reserved. (Renita Lin, 2011)

Another risk may facing by Nike to entering into China is Chinese consumers have a strong sense of national and local pride. The Chinese consumers have a very strong national pride and they like to be associated with their nationality and country. They often prefer to deal with local, Chinese-ru

n companies rather than western enterprises. Hence, the Chinese consumers are very supportive of their local products and they may refuse to buy foreign products. Hence, Nike may face difficulties in this manner and may have a hard time trying to market their products to the Chinese consumers because their products may seem too unfamiliar and foreign. For example, China people may loyal to Warrior which is a brand of athletic shoes from china, founded in Shanghai. Warrior brand athletic shoes is the pride of China, because he Warrior trademark was identified as the most famous trademark of Shanghai city and in 1999 it was recognized as a well-known trademark throughout China. “Warrior” footwear products have won the national silver medal of quality many times. (Lianzhi Ma, 2013) Warrior brand is today one of the People’s Republic of China’s most recognisable creations. ( In short, Chinese consumer may support and prefer Warrior shoes rather than Nike shoes.

China facing a serious issue of failed to sufficiently enforce intellectual property laws. Therefore, another risk facing by Nike of doing business in China is the likelihood of facing patent violations and piracy. Idea theft is serious issues in China, and it extends far beyond DVDs and software. Not only is this a problem for companies engaged in buying and selling goods, but it can impact manufacturers who may unwittingly use counterfeit materials. However, one concern for many companies considering entry into the China market is imitation. If you’re selling a good product with well-known brands, someone in China will imitate it. So, it is useless for Nike to spent tens of millions of dollar building their brand in China, because there is a high probability for them to regularly see imitation of their products appearing throughout the country. Nike may faces the problem that others China producers will imitate their products and sell those counterfeit Nike products in much cheaper price in the market. This will cause Nike loss of market share, a drop in sales and perhaps destroys the reputation of Nike in consumer’s mind. For example, Nike brand may become a cheap brand in the eyes of a consumer who buys a shoddy counterfeit without any awareness that it is fake brand.


We found that there are some risks to go in china market, so we also recommended some point to increase the ease to go in china market. According to the analysis the risk may face by the Nike when they entering to the China is Chinese customers have a strong sense of national and local pride. In order to make the Chinese customers feel more reliable on the Nike product is through the corporate social responsibility. Recently, all of the societies are very concerning about the corporate social responsibility from the companies towards the society. Nike has start doing the corporate social responsibility since year 2000 but the amount of corporate social responsibility done by Nike incorporation is not enough to make society aware of their contribution. Corporation social responsibility is type of activity that the company contributing their effort to the environment, society and people. For example, provide scholarship for student, charity programs and plantation activities in the city. It will improve reputation of the company, generate more sales and increase consumers’ awareness towards the environment. As we know that Chinese consumers at China have a strong sense of national and local pride. So Nike incorporation can contribute more effort in China to let the consumers aware of their brand are putting some much effort to the society and to reduce the distance between Nike with the market and also reduce the local pride toward Nike. If the consumers know Nike incorporation is contributing so much to theirs society, they sure willing to try Nike’s product. Consumers are smart, will know Nike incorporation have good image in the market, they will contribute their profit to the people and society. In addition, Nike incorporation also has the manufacturing factory over China. Most of the Asia’s footwear, apparel and equipment are producing at the China manufacturer side. The products are label made in China, it will make the consumers feel more reliable on the products which are from their own country.

Secondly, the cultural difference between US and China is the risk for Nike to entering into China market. Nike incorporation can find out the uniqueness of the China culture and needs. China is a potential market for Nike incorporation it is because China has a huge number of populations in the world. China’s background is totally different with western country. So the easier and safety way to understand more about the China preferences and needs is hire local people as their consultant. Consultant will directly let us know about the taste of the local people. They also will provide information for company about the culture differences between western country and China. This will also reduce the strong local pride inside the customer mind, because as you do more research and understand the cultural of them, they will feel the relationship between the company was more closer to them. This way will help company save cost and time to understand the needs of the local people. Then Nike just can design the products which can suit for their taste. For example, Nike can introduce or emphasize on red series colour of Nike’s product before Chinese New Year Festival. As we know that, red colour symbolize for Chinese is good luck. Nike incorporation also can add the characteristics of Chinese as part of design. This type of design not only can attract young teenagers, adult also will like it. Chinese is the race always takes care of their religious and traditional. In order to understand more about the culture references, Nike also can through conduct survey or questionnaires in the public places. From the survey we can know the favorites style of different level customers and what the consumers desire to have on their sportswear and equipment. The analyses of the survey will make the Nike product closer to their culture.

Thirdly, Nike incorporation can also have a product line extension strategy to extend their product to be more variety. A product line extension strategy can help Nike incorporation to boosts their profit through the sale of different product and it also can reduce the risk in one of the product had failed there are numerous other products to compensate for the loss. Nike can doing this to increase the target markets and any other segment that Nike had not targeted and also provide many other choices to satisfy the needs of wide-range customer in every segment that the customer will have their own specific needs. Nike incorporation mostly designs footwear for athletic purpose. In my opinion, a large percentage of sales that Nike incorporation may gain are from the sales of footwear, apparel, accessories for casual and leisure purposes. So, Nike incorporation can increase their product in a variety of way. Nike incorporation must clearly understand and analyze on some aspect, which are the needs, physiology, design preference and trend of choices of all target market. Secondly, Nike incorporation may also extend their products and also have more choices for their target markets by offering a variety of products like Nike racket, all kinds of balls, watches, eyewear, and so on. Nike incorporation may also provide every type of sports equipment such as soccer, football, basketball, tennis, golf, all kinds of sport to the market. Nike incorporation may also have their products through children’s clothing, school supplies, electronic media devices, and other items that under NIKE brand name. The more Products in the market, can lend to the higher choices to the customers, higher satisfaction and expectation to a customer, higher recognize of the brand name of the company to a customer, higher market share in the market, as long as maximize the company’s profit.

On the other hand, from the analysis we get to know Nike facing difficulties in satisfying the needs of their wide range customers. So, Nike incorporation can expand the customize product to be more variety and services to more areas. Nike’s customize product services is which the interest customers can create their own preferences and colour on their own footwear, apparel or equipment. We seldom can get this type service in the market. Nike’s customize product only available at US, Japan, Europe and China only and the customize product factory is located at US. They may be can locate their customize product manufacturing plant at China. It can help the China’s customers save the shipping cost and they are able get theirs products in a shorter time. They may expand the delivery services products area so more of the interest customers can make their order through online. If the customize product manufacturing locate in China is not only beneficial to the China’s customers even Asia customers also can gain the advantage same with the China’s customers. Asia seldom get this type of customize sportswear services yet. This unique idea can help Nike’s incorporation generate more profit and attract more teenagers who like to seek for unique clothing and footwear to try on their products. Even though Nike is providing chances to customers can customize their shoe which is different from others. But, they only provide limited selection of the pattern, design and colour for customers. So, customers may be can’t really enjoy to play with the style of what they want they shoe to be. Nike incorporation can improve their customize services system to be more advance to help customers own theirs desire products. They can provide different type of surface quality of shoe which can satisfy different needs of customers. Nike incorporation also can design variety shape of the shoulder bag since main target market of Nike incorporation are the young teenagers. Even the height of the shoe also can let the customers to choose it.

tdgfhgjkLast but not least, to reduce the patent violation and piracy, Nike incorporation can also have some method to reduce such as a well-planned inventory management strategy. Inventory control is the supervision of supply, storage and accessibility of item in order to ensure an adequate supply without excessive oversupply and also ensure the accuracy of sending goods to the sellers. A well-planned inventory management can reduce the chance of imitation from other and clearly identified the authority of sellers selling their products and also increase the credibility to the customers. As a seller, it is your job to ensure that the products that require by customer are in the stock and also not a counterfeit product, if not, you will lose your loyalty customer and it will definitely affect the sales of your company. So Nike can also add product identification inside every product that they made. Nike should make a symbol or anything in their products that only unique to Nike incorporation. Nike must also ensure that their products are only selling in their own retail shop but not all shop lot in the street. Nike should also manage product waste and also damaged inventory because counterfeiters will always get from scrap yards, waste repositories or reclamation centers. With implement these strategies to reduce the violation and piracy, it can let the customers easy define of every product, increase the credibility from the customers, increase the satisfaction from the customer, increase the trust to the company and also maximize company profits.


After we have done all the analysis, we know that Nike may face many challenges while expand their business to China such as political, environmental, economic, social and technological forces. There are gains and shortcomings in expand their business to China. However, we still suggest that Nike should enter into China because we found that there are many advantages for Nike expand to China.

As a final point, Nike should improve on their strategies as different country has different culture. Nike should also put more effort to China market since there have huge population and high growth rate. In order to get more market share in future, Nike should improve with more varieties to suit global cons

umers’ unlimited needs and wants. Moreover, different country may have different needs and wants, therefore Nike must have a full research on its target market needs and wants before enter into China.

From this overall research we done, we are confident that Nike will be successful in entering into low-cost country such as China by using those strategies that we suggested.

In a nutshell, using an appropriate expansion strategy is very important for Nike enters into low-cost countries and it cannot be ignored.

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Compare and Contrast the UK and the US Health Care Systems

The UK and the US health care services are great examples of publicly funded and privately funded health care systems respectively. By assessing and analysing key findings from a microeconomic standpoint, we can see significant difference between the two approaches to health care provision.

First, the role of government interventions in the provision of healthcare is to balance the demand and supply of the services; as well as prevent market failures in the form of monopoly, price fixing, and exploitation. Insurance system is also introduced to avoid information asymmetry in the market. We then look into the UK health care service and see that a public funded system will attempt to discourage market failures by avoiding information asymmetry, negative externalities and regional monopolies. However, the National Health Service (NHS) suffers from allocation and productive inefficiencies. The US system benefits from a competitive market model, this having higher levels of economic efficiency, innovation and quality of service. On the other hand, the US model is often criticised for not offering equal welfare to society, in addition, it leads to waste and the dominance of insurance companies. Finally, we will assess the role of a regulator when ensuring efficiency and competitiveness as well as discouraging market failures; whereas the role of a market form will ensure better allocative efficiency in healthcare provision.


In the UK, the NHS has existed for over fifty years and offers health care that is free at the point of delivery for everyone. This service is funded by taxpayers for the benefit of those same taxpayers. However, the option remains available for people to purchase private health insurance if they so choose.

In the US, the majority of citizens have health insurance that is related to employment or purchases directly. The federal government only ensures public access to emergency services, regardless of an individual’s ability to pay. They also have publicly funded health care programs that cater to the elderly, the disabled and the poor.

These are two significant examples of the two different approaches to health care provision: publicly and privately funded. In this report, we are going to look into the microeconomic aspects of the two models by assessing and analysing:Healthcare-System-UK-US

  1. Health care features as policy interventions in the market
  2. The microeconomic advantages and disadvantages of the UK system
  3. The microeconomic advantages and disadvantages of the US system
  4. The role of the regulators and markets in the provision of health care

Key Findings

Health care features as policy interventions in the market

In the majority of advanced societies, access to basic and emergency health care is considered an irrefutable moral right, regardless of gender, age or creed. But through what means should a government decide it has the right to control any health care system via administration and policy? Both systems contain state owned entities which provide free health services, funded by the taxpayer, although the limitations on state services differ greatly, defining the private and public services. By its very nature, a state owned entity requires policy interventions in its administration, in order to decide what services each government chooses to provide.

As a nationalised service, both UK and US government run monopolies on health care on some level. At the same time, medical institutions such as hospitals may create localised monopolies since no other alternative may offer their services and economies of scale incentivise ‘the emergence of one large hospital in an area rather than a large number of small hospitals’. By definition, monopolies create economic inefficiencies through social loss such that a monopoly firm may retain higher profits from their personal gain. Where health care exists as a privately provided system, the same regulations and policies that are inflicted on all free enterprise may be used. Such policies exist to ensure perfect competition where possible, to prevent the formation of cartels or price fixing, and to limit the exploitation and advantages given to any natural monopoly.

With free service, demand for health care from the common citizen is at its practical maximum. The role of government is to supply this demand to the best of its ability. Such, it can be seen that the government itself has a demand for a level of health care which creates an equilibrium against what the production firms can supply. Policy intervention is therefore required to choose the appropriate level of demand the government wishes to obtain, given the cost of supply, the health demands of the people and the level of funding from taxes.

As the demand for health care is not a constant for any individual consumer, since accidents are unpredictable, a system of insurance has been adopted in many markets, whereby a prepayment to a firm is made, such that when demand for medical care is required, all costs are covered by the firm. The free health market funded by taxes may act as a proxy to an insurance system since taxes are paid regularly in exchange for returns via public services. With any insurance system, problems may arise if contracts are improperly defined or information is asymmetric, such that consumers are refused service if they are not adequately covered, or are unaware of the full extent of their insurance coverage. A policy and regulatory body may be necessary in order to ensure fair contracts are held without exploitation.

healthcare-in-canada-uk-usThe economic advantages and disadvantages of the UK system


Health care is a complex, unique good and everybody demand it but it faces problems if it is distributed through a free-market system and not a state-funded system. Market failure can occur for many reasons and the problem of asymmetric information is one of these. This is when producers and consumers within a market have access to different levels of information, whereas a characteristic of a completely competitive market is when all economic agents have access to all information. This is the case between doctors and patients as patients have minimal information (individuals cannot treat themselves). They expect doctors to act in their best interests but this may not happen in a free market. A doctor working for a company motivated by profit may act in the best economical interests of the company when deciding how to treat a patient.

Other causes of market failure include externalities and the forming of regional monopolies. These problems do not exist in a state-funded health care system and neither do insurance related problems.

‘The main aim of the NHS is to provide a comprehensive, high quality service available on the basis of clinical need and not ability to pay’. It is also a huge job provider, increases the productivity of the economy by keeping the workforce healthy (including preventative treatments like vaccinations) and increases real GDP by raising life expectancy and therefore lengthening the average working life (Riley, 2006).

The NHS also benefits extensively from economies of scale because of its size and is good value ‘at a total cost of around 6% of the GDP’, compared with 16% of the GDP for the US (Team project guidelines).


Since profit is not the main incentive behind the NHS, and prices do not play the same role as in a free market system, inefficiencies exist. The power of a competitive market suggests that the correct quantity and quality of health care would be provided at minimal cost to meet consumer demand. This would not be the case for the NHS. The distribution of resources would not produce a Pareto efficient outcome.

Demand for health care simply outstrips supply and demand will continue to grow because of ‘changes in the age structure, increasing real incomes, improvements in medical technology’ (Office of Health Economics, 2009). As the population of the UK ages, the larger number of older people will put a greater strain on the NHS, increasing real incomes cause people to raise their standards and medical developments simply increase the number of conditions that can be treated. Government expenditure on health care will therefore need to increase or health care will have to be rationed to a greater extent.

The economics advantage and disadvantage of the US system


Health care in the US is provided by many separate legal entities both in the private sector and public sector. This is a contestable market (or free market system) where anyone, any unions, any groups, regardless public or private, can provide health care. Hence, it increases the competitive level of health care provision to consumers, increasing economic efficiency. In addition, contestable markets also rule out the chance of monopoly rule and in doing so, prevents deadweight loss to the customers. In order to stay in the market, each entity needs to maximize quality of products (insurance, drugs price, medical fees) and minimize the costs. The contestability system opens up many opportunities for businesses which allow more research about drugs and health technology which will help cost saving in medicine. Furthermore, the US has some of the best medical research systems such as the Harvard Medical School, Mayo Clinic and the Cleveland Clinic.


In an article discussing the US health care crisis, Paul Krugman and Robin Wells state that the US health system favours the wealthy especially the employer (Krugman & Wells, 2006). Whereas those with higher incomes pay medical fees using pre-tax income, some firms and wealthy people get a ‘tax-break’ in the form of access to all medical services available. For example, instead of paying the tax, some corporations pay the health insurance for their employees instead.

Furthermore, Paul and Robin also argue on the heavy reliance of the Americans on health insurance which leads to waste and the domination of the insurance companies (Krugman & Wells, 2006). As of 2008, private health insurance paid for 33.5% of the total spent on health expenditures account while out-of-pocket-payments consists of only 11.9% (Centers for Medicare & Medicaid Services, 2008). As health insurance in the US is mostly distributed by the private sector (67.5% in 2007) (Centers for Medicare & Medicaid Services, 2008), many people lack health insurance. This leads to a portion of Americans who have no jobs, have no insurance and hence they are not able to get any medical services. As of 2007, there is at least 15.3% of Americans who have no insurance (Centers for Medicare & Medicaid Services, 2008).

This system helps both the government and the consumers by creating greater savings on health services. Because the government is not the only one who provides health care, the government’s share in health care should be lower compared to economies where the government provides full services to all citizens. Also, as stated above, advances in technology that reduce cost in drugs production also benefit the public sector. In 2008, the US government only accounted for 47.3% (or $1.1 trillion) in the $2.3 trillion spent on health care services and products (Centers for Medicare & Medicaid Services, 2008).

The US health care seems to favour private business over public services. However, it also creates jobs and saves money for its customers which could lead to an increase in average disposable income.

The role of a regulator and markets in the provision of health care

Health care is a good that is, generally, under-supplied and over-priced in competitive markets. The role of the government, with regards to health care, should be to sustain supply at an optimal level that would not otherwise exist in a competitive market. Therefore, given this supply of health care provided by the government, regulators should exist to ensure the efficient operation of the NHS in the UK. Due to the lack of direct competition to the NHS, supply is only a function of costs, rather than being a function of price as well as costs, only because it is provided for free to consumers who demand it. In the US, where competitive markets determine the price and quantity of health care provided, there are high fixed costs in terms of capital and equipment and that those that supply health care engage in discriminatory prices as a result of the existence of market power (Glied, 2003). Shelly Glied notes that ‘[t]hese patterns suggested that per unit costs of health care could be reduced’ (Glied, 2003). Therefore, regulators should also act to ensure the competitiveness of the entire health care market in the US and the private health market sector in the UK.

The role of markets is to, by incentivising individuals to respond to signals in the market, achieve efficiency and equity in the health care industry (Le Grand, 1998). In order to maximise the supply of health care services, maximising efficiency should be the priority role for both the National Health Service, and the private health care providers that exist in the US and the UK. Due to the competitive nature of the market for health care in the US, maximising supply should not be the priority, otherwise you may end up with an excess of supply over demand for health care – hardly an efficient allocation of resources. Instead, ensuring effective resource allocation subject to the demand and supply for health care should be the primary role for the competitive market for health care in the US.

Imperfect competition, in the form of oligopolies and asymmetric information, in the health care industry in the US, however, causes the role of the markets to be distorted often resulting in market failures such as niche markets and market segmentation (Grembowski, Diehr, & Novak, 2000). In addition, regulators should also intervene to eliminate these market failures, where possible, in the US health care system in an attempt to maximise the provision of health care to individuals.

In summary, the role of the regulators is to encourage the production of health care and the role of the markets is to allocation resources in the most efficient manner.


The demand for health care, when it is provided at no cost to consumers, exists at a maximum level. The supply of health care, provided by the government, is determined by a number of variables, including the costs of production and the level of funding received through taxation. When health care is provided at a positive cost consumers enter into contracts with insurance providers, this creates a situation where policy intervention becomes necessary to ensure all parties enjoy the benefits of information symmetry and properly defined contracts.

The UK model benefits from a service that is provided when needed and is not based on an individual’s ability to pay. The lack of a profit-maximising incentive within the institutions providing health care results in aid provided primarily to heal the injured rather than efficient operation becoming more important than the quality of service. However, because prices play little role in incentivising agents, inefficiencies can occur in the UK system of health care provision and is the main disadvantage of the model.

The competitive market for health care in the US means that the provided level of health care is likely to be closer to the socially optimal level of provision given the demand and supply for health care. It is also a much more contestable market, with fewer monopolies, further increasing economic efficiency. However, the positive cost of health care creates the social and political issue of whether your access to health care should be a function of your disposable income.

Regulators’ role in health care markets should be to encourage the production of health care from the sub-optimal level initially provided in competitive markets, to the more efficient level. This is achieved by regulating firms’ costs and the minimization of them in order to maximize production. This is especially important in the UK market where output of health care is only a function of costs due to the lack of competition and the publicly-funded nature of the industry. The role of markets is to determine the largest provision of health care at the lowest cost possible; the most efficient allocation of resources given the demand and supply for health care. Markets and regulators work in conjunction to solve a problem with health care under competitive markets, that they are inefficiently supplied in less-than-optimal quantities.


Throughout the report, we saw the characteristics, positives as well as drawbacks from the two different healthcare systems, public and private funded. We also evaluated the importance of government interventions and the role of regulators in order to avoid market failure.

In the case of the UK system, a state-funded healthcare provision ensures equal services for all citizens and no regional monopolies. The system is also benefited from massive economy-of-scale and being an effective economical tool to keep the workforce at a healthy state. However, it suffers lack of innovation and development, leading to insufficient in quality and quantity of healthcare services in long-term. Resources allocative inefficiency and waste are also major problems for the UK market. Therefore, the role of the government and regulators here needs to be more decisive. There are different ways to minimize these disadvantages in long-term, such as:

  • Increase the retirement age: Easing up the pressure from dependant population on the healthcare and insurance system.
  • Provide more vacancies as well as training for part-time staffs in NHS facilities: Enable to satisfy a higher level of demand as well as improve the quality of services.
  • Easing the immigration barriers for doctors from abroad: As high-skilled staff requires long time to train.
  • Improve the qualities of appliances in existed NHS facilities: Other than building new ones.
  • Encourage and subsidy researches: For low-price medicines, stem cell and gene technology.
  • Organize campaign and informative programs: To educate people live, keep their family and surrounding environment healthy and hygiene.

As for the US, having a competitive market model helps the healthcare system become economic efficient, offer opportunities for business which stimulate innovation and technology development, and most importantly, avoid waste for both government and citizens. But, like the UK, the US system also has its own drawbacks. The provision of special treatments is not equally distributed for everyone, and the heavy reliance of Americans on the insurance system creates exploitation and domination of insurance companies. Though, economically, the US system is working well, it still requires government interventions to ensure social welfare and equality.

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Epidemiology of Alcoholism


Explain the epidemiology of Alcoholism. Critically discuss the public policy options which are available to address this problem.


According to Alcohol Concern Organisation (2015) more than 9 million people in England consume alcoholic beverages more than the recommended daily limits. In relation to this, the National Health Service (2015) actually recommends no more than 3 to 4 units of alcohol a day for men and 2 to 3 units a day for women. The large number of people consuming alcohol more than the recommended limits, highlights the reality that alcoholism is a major health concern in the UK which can lead to a multitude of serious health problems. Moss (2013) states that alcoholism and chronic use of alcohol are linked to various medical, psychiatric, social and family problems. To add to this, the Health and Social Care Information Centre (2014) reported that between 2012 and 2013, a total of 1,008,850 admissions related to alcohol consumption where an alcohol-related disease, injury or condition was the primary cause for hospital admission or a secondary diagnosis. This shows the detrimental impact of alcoholism on the health and overall wellbeing of millions of people in the UK. It is therefore vital to examine the aetiology of alcoholism in order to understand why so many people end up consuming excessive alcohol. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) (n.d.) supports this by stating that learning the natural history of a disorder will provide information essential for assessment and intervention and for the development of effective preventive measures. This essay will also look into the different public health policies that address the problem of alcoholism in the UK. A brief description of what alcoholism is will first be provided.

What is Alcoholism?

what is alcoholismIt is safe to declare that alcoholism is a lay term that simply means excessive intake of alcohol. It can be divided into two forms namely; alcohol misuse or abuse and alcohol dependence. Alcohol misuse simply means excessive intake of alcohol more than the recommended limits (National Health Service Choices 2013). A good example of this is binge drinking.

Alcohol dependence is worse because according to the National Institute for Health and Care Excellence (2011, n.p.) it “indicates craving, tolerance, a preoccupation with alcohol and continued drinking regardless of harmful consequences” (e.g. liver disease). Under the Diagnostic Statistical Manual of Mental Disorders (DSM)- 5, these two have been joined as one disorder called alcohol use disorder or AUD with mild, moderate and severe sub-classifications (NIAAA 2015).

Genetic Aetiologic Factor of Alcoholism

Alcoholism is a complex disorder with several factors leading to its development (NIAAA 2005). Genetics and other biological aspects can be considered as one factor involved in the development of alcohol abuse and dependence (NIAAA 2005). Other factors include cognitive, behavioural, temperament, psychological and sociocultural (NIAAA 2005).

According to Goodwin (1985) as far as the era of Aristotle and the Bible, alcoholism was believed to run in the families and thus could be inherited. To some extent, there is some basis that supports this ancient belief because in reality, alcoholic parents have about four to five times higher probability of having alcoholic children (Goodwin 1985). Today, this belief seems to lack substantially clear and direct research-based evidence. On the other hand, studies also do not deny the role of genetics in alcoholism. With this view, it is therefore safe to argue that genetics is considered still as an important aetiologic factor in alcoholism.

The current consensus simply indicates that there is more to a simple gene or two that triggers the predisposition of an individual to become an alcoholic. Scutti (2014) reports that although scientists have known for some time that genetics take an active role in alcoholism, they also propose that an individual’s inclination to be dependent on alcohol is more complicated than the simple presence or absence of any one gene. The National Institute on Alcohol Abuse and Alcoholism (2008) states that there is no one single gene that fully controls a person’s predisposition to alcoholism rather multiple genes play different roles in a person’s susceptibility in becoming an alcoholic. The NIAAA (2005) further claims that the evidence for a genetic factor in alcoholism lies mainly with studies that involve extended pedigree, those that involve identical and fraternal twins and those that include adopted individuals raised apart from their alcoholic parents.

For pedigree studies, it is believed that the risk of suffering from alcoholism is increased four to seven fold among first-degree relatives of an alcoholic (Cotton 1979; Merikangas 1990 cited in NIAAA, 2005.). First degree relatives naturally refer to parent-child relationships; hence, a child is therefore four to seven times at higher risk of becoming an alcoholic, if one or both of their parents are alcoholics. Moss (2013) supports this by stating that children whose parents are alcoholic are at higher risk of becoming alcoholics themselves when compared to children whose parents are non-alcoholics.

A study conducted by McGue, Pickens and Svikis (1992 cited in NIAAA 2005) revealed that identical twins generally have a higher concordance rate of alcoholism compared to fraternal twins or non-twin siblings. This basically means that a person who has an alcoholic identical twin, will have a higher risk of becoming an alcoholic himself when compared to if his alcoholic twin is merely a fraternal twin or a non-twin sibling. This study further proves the role of genetics in alcoholism because identical twins are genetically the same; hence, if one is alcoholic, the other must therefore also carry the alcoholic gene.

The genetic factor in alcoholism is further bolstered by studies conducted by Cloninger, Bohman and Sigvardsson 1981 cited in NIAAA 2005 and Cadoret, Cain and Grove (1980 cited in NIAAA 2005) involving adopted children wherein the aim was to separate the genetic factor from the environmental factor of alcoholism. In these studies, children of alcoholic parents were adopted and raised away from their alcoholic parents but despite this, some of these children still develop alcoholism as adults at a higher rate than those adopted children who did not have an alcoholic biological parent (Cloninger et al., 1981 cited in NIAAA 2005 and Cadoret et al., 1980 cited in NIAAA 2005).

One interesting fact about aetiologic genetic factor is that although there are genes that indeed increase the risk of alcoholism, there are also genes that protect an individual from becoming an alcoholic (NIAAA 2008). For example, some people of Asian ancestry carry a gene that modifies their rate of alcohol metabolism which causes them to manifest symptoms such as flushing, nausea and tachycardia and these generally lead them to avoid alcohol; thus, it can be said that this gene actually helps protect those who possess it from becoming alcoholic (NIAAA 2008).

Environment as an Aetiologic Factor of Alcoholism

Another clearly identifiable factor is environment, which involves the way an individual is raised and his or her exposure to different kinds of activities and opportunities. The National Institute on Alcohol Abuse and Alcoholism (2005) relates that the genetic factor and the environmental factor have a close relationship in triggering alcoholism in an individual. This can be explained by the simple fact that even if an individual is genetically predisposed to becoming an alcoholic, if he is not exposed to a particular kind of environment which triggers activities that lead to alcohol intake, the likelihood of his becoming an alcoholic will be remote.epidemiology of alcoholism

There are certain aspects within the environment that makes it an important aetiologic factor. According to Alcohol Policy MD (2005) these aspects include acceptance by society, availability and public policies and enforcement.

Acceptance in this case refers to the idea that drinking alcoholic drinks even those that should be deemed excessive is somewhat encouraged through mass media, peer attitudes and behaviours, role models, and the overall view of society. Television series, films and music videos glorify drinking sprees and even drunken behaviour (Alcohol Policy MD 2005). TV and film actors and sports figures, peers and local role models also encourage a positive attitude towards alcohol consumption which overshadows the reality of what alcohol drinking can lead to (Alcohol Policy MD 2005). In relation to this, a review of different studies conducted by Grube (2004) revealed that mass media in the form of television shows for instance has an immense influence on the youth (age 11 to 18) when it comes to alcohol consumption. In films, portrayals regarding the negative impact of alcohol drinking are rare and often highlight the idea that alcohol drinking has no negative impact on a person’s overall wellbeing (Grube 2004). In support of these findings, a systematic review of longitudinal studies conducted by Anderson et al. (2009) revealed that the constant alcohol advertising in mass media can lead adolescents to start drinking or to increase their consumption for those who are already into it.

Availability of alcoholic drinks is another important environmental aetiologic factor of alcoholism simply because of the reality that no matter how predisposed an individual is to become an alcoholic, the risk for alcoholism will still be low if alcoholic drinks are not available. On the other hand, if alcoholic beverages are readily available as often are today, then the risk for alcoholism is increased not only for those who are genetically predisposed to alcoholism but even for those who do not carry the “alcoholic genes”. The more licensed liquor stores in an area, the more likely people are to drink (Alcohol Policy MD 2005). The cheaper its price, the more affordable it is for people to buy and consume it in excess (Alcohol Policy MD 2005).

Another crucial environmental aetiologic factor is the presence or absence of policies that regulate alcohol consumption and its strict or lax enforcement. It includes restricting alcohol consumption in specified areas, enacting stricter statutes concerning drunk driving and providing for penalties for those who sell to, buy for or serve to underage individuals (Alcohol Policy MD 2005). It is worthy to point out that in the UK, the drinking age is 18 and a person can be stopped, fined or even arrested by police if he or she is below this age and is seen drinking alcohol in public (Government UK 2015a). It is also against the law for someone to sell alcohol to an individual below 18; however, an individual age 16 or 17 when accompanied by an adult can actually drink but not buy alcohol in a pub or drink beer, wine or cider with a meal (Government UK 2015a).

Policies to Combat Alcoholism

One public health policy that can help address the problem on alcoholism is the mandatory code of practice for alcohol retailers which banned irresponsible alcohol promotions and competitions, and obliged retailers to provide free drinking water, compelled them to offer smaller measures and required them to have proof of age protocol. It can be argued that this policy addresses the problem of alcoholism by restricting the acceptance, availability and advertising of alcohol (Royal College of Nursing 2012). Another is the Police Reform and Social Responsibility Act 2011 which is a statute that enables local authorities to take a tougher stance on establishments which break licensing rules about alcohol sale (Royal Collage of Nursing 2012).

There is also the policy paper on harmful drinking which provides different strategies in addressing the problem of alcoholism. One such strategy is the advancement of the Change4Life campaign which promotes healthy lifestyle and therefore emphasises the recommended daily limit of alcohol intake for men and women (Government UK 2015b). Another strategy within this policy is the alcohol risk assessment as part of the NHS health check for adults ages 40 to 75 (Government UK 2015b). This policy aims to prevent rather than cure alcoholism which seems to be logical for after all, an ounce of prevention is better than a pound of cure.


Alcoholism which includes both alcohol misuse and alcohol dependence is a serious health problem which affects millions in the UK. Its aetiology is actually a combination of different factors. One vital factor is genetics wherein it can be argued that some people are predisposed to becoming an alcoholic. For example, an individual is at higher risk of becoming an alcoholic if he or she has a parent who is also alcoholic. When coupled with environmental factors, the risk of suffering from alcoholism becomes even greater. Environment refers to the acceptability and availability of alcohol and the presence or absence of policies that regulate alcohol sale and consumption. Vital health policies such as Harmful Drinking Policy Paper advocated by the government, are important preventive measures in reducing the incidence and prevalence of alcoholism in the UK.


Alcohol Concern Organisation (2015). Statistics on alcohol. [online]. Available from: [Accessed on 28 September 2015].

Alcohol Policy MD (2005). The effects of environmental factors on alcohol use and abuse. [online]. Available from:[Accessed on 28 September 2015].

Anderson, P., de Brujin, A., Angus, K., Gordon, R. and Hastings, G. (2009). Impact of alcohol advertising and media exposure on adolescent alcohol use: A systematic review of longitudinal studies. Alcohol and Alcoholism. 44(3):229-243.

Goodwin, D. (1985). Alcoholism and genetics: The sins of the fathers. JAMA Psychiatry. 42(2):171-174.

Government UK (2015a). Alcohol and young people. [online]. Available from: [Accessed on 28 September 2015].

Government UK (2015b). policy paper 2010 to 2015 government policy: Harmful drinking. [online]. Available from: [Accessed on 28 September 2015].

Grube, J. (2004). Alcohol in the media: Drinking portrayals, alcohol advertising, and alcohol consumption among youth. [online]. Available from: [Accessed on 28 September 2015].

Health and Social Care Information Centre (2014). Statistics on alcohol England, 2014. [online]. Available from: [Accessed on 28 September 2015].

Moss, H.B. (2013). The impact of alcohol on society: A brief overview. Social Work in Public Health. 28(3-4):175-177.

National Health Service (2015). Alcohol units. [online]. Available from: [Accessed on 28 September 2015].

National Health Services Choices (2013). Alcohol misuse. [online]. Available from: [Accessed on 28 September 2015].

National Institute on Alcohol Abuse and Alcoholism (2015). Alcohol use disorder: A comparison between DSM-IV and DSM-5. [online]. Available from: [Accessed on 28 September 2015].

National Institute on Alcohol Abuse and Alcoholism (2008). Genetics of alcohol use disorder. [online]. Available from: [Accessed on 28 September 2015].

National Institute on Alcohol Abuse and Alcoholism (2005). Module 2: Etiology and natural history of alcoholism. [online]. Available from: [Accessed on 28 September 2015].

National Institute for Health and Care Excellence (2011). Alcohol-use disorders: Diagnosis, assessment and management of harmful drinking and alcohol dependence. [online]. Available from: [Accessed on 28 September 2015].

Royal College of Nursing (2012). Alcohol: policies to reduce alcohol-related harm in England. [online]. Available from: [Accessed on 28 September 2015.

Scutti, S. (2014). Is alcoholism genetic? Scientists discover link to a network of genes in the brain. [online]. Available from: [Accessed on 28 September 2015].

Answers to NSG4028 Quizzes (Solutions)

Download the solutions below

Question 1: Barriers to teaching can be best described as factors that
Student Answer: negatively impact on the learner’s efforts to establish a mutual partnership with the nurse educator.
interfere with the learner’s ability to attend to and process information.
impede the nurse’s ability to deliver educational services to the learner.
limit the nurse’s focus to conducting only formal, intended teaching and learning encounters.
Question 2. Question : Which are two ways to decrease a behavior or response?
Student Answer: Avoidance conditioning and escape conditioning
Punishment and nonreinforcement
Positive reinforcement and punishment
Punishment and escape conditioning
Question 3. Question : The foremost challenge for nurses is to demonstrate:
Student Answer: a definite link between education and positive behavioral outcomes in the learner
competence in their teaching sills
accurately documenting teaching to meet accreditation standards
the ability to create a positive learning environment
Question 4. Question : Which best defines the term teachable moment? The moment when
Student Answer: the nurse feels educationally prepared to teach.
the patient views new and different situations as challenges rather than defeats.
illness suddenly forces an individual to take a less active role in his or her care.
an informed patient complies with medical treatment plans.
Question 5. Question : Barriers to teaching differ from obstacles to learning in that obstacles to learning:
Student Answer: are barriers that impede the nurses ability to provide education
are barriers that prevent the learner from paying attention
are psychosocial issues presented by the learner
include lack of time for the nurse to teach
Question 6. Question : Learning that is directed by the individual learner where information is received, interpreted and reorganized is known as:
Student Answer: information processing
cognitive learning
discrimination learning
stimulus generalization
Question 7. Question : The major contribution of QSEN is to develop
Student Answer: competencies related to patient education and safety
an educational program for undergraduate nursing students
staff development guidelines for patient safety
programs to change the attitudes of nurses related to patient education
Question 8. Question : Which learning theory is described by the idea to change behavior, change a person’s subjective feelings about the self.
Student Answer: Psychodynamic
Question 9. Question : The broad purposes, benefits, and goals of the teaching-learning process are
Student Answer: to predetermine client outcomes to accomplish the goals of care.
to improve the efficiency and effectiveness of practice.
to ensure client/family compliance with therapeutic regimens.
to increase the competence and confidence of the learner.
Question 10. Question : With which learning theory individuals to be motivated, individuals need to be in a state of deprivation; there needs to be something that they want. Thus, giving children everything they want when they want it may undermine their motivation to perform
Student Answer: humanistic
Question 11. Question : Which learning theory is described by the idea to change behavior, change the stimulus conditions in the environment and a person’s responses to the environment?
Student Answer: Psychodynamic
Question 12. Question : Which of the following actions would not enhance the permanence of learning?
Student Answer: utilizing the new skill
reinforcing the information
the nurse is called away during the teaching
relate previous experiences to the learner
Question 13. Question : Which learning theory represents a combination of behaviorist and cognitive principles of learning?
Student Answer: Gestalt
Social learning
Question 14. Question : Which learning theory is described by the idea to change behavior, change a person’s perceptions and thoughts?
Student Answer: Psychodynamic
Question 15. Question : When comparing nursing process and education process, the education process focuses on:
Student Answer: the physical and psychosocial needs of patients
changing knowledge, skills, attitudes and values (p. 11)
quality outcomes
meeting patient needs
Question 16. Question : The primary role of the educator is to:
Student Answer: teach
create partnerships with learners
promote learning in environments conducive to learning (p.13)
meet accreditation and legal mandates related to patient teaching
Question 17. Question : Which statement concerning nurses as educators is false?
Student Answer: It is predicted that the growth of managed care will impact negatively on the nurse’s responsibility for health education of clients.
During the past few decades, client and staff teaching have begun to be recognized as independent nursing functions.
Nurses must be prepared to teach colleagues, staff and students effectively.
The role of the nurse as educator has changed from a disease-oriented approach to a health-promotion approach
Question 18. Question : When learning a new motor skill, the learner completes the skill and is praised by the nurse. This type of feedback is described as:
Student Answer: intrinsic
Question 19. Question : What is the single most important goal of the nurse as educator?
Student Answer: To prepare the client for self-care management
To determine the trends in the delivery of high-quality care
To understand the forces affecting nurses’ responsibilities in practice
To maintain the client’s sense of value and self-worth
Question 20. Question : Which of the following is not a perspective within cognitive theory?
Student Answer: Systematic desensitization
Social constructivism
Question : Which principle is not applicable to adult learning?
Student Answer: Learning is self-controlled and self-directed.
Learning is person-centered and problem-centered.
The nature of learning activities remains stable over time.
Learning is reinforced by application and prompt feedback.
Question 2. Question : The nurse demonstrates to a client how to change a dressing. During the return demonstration the nurse should include which intervention?
Student Answer: Question the client about the procedure.
Offer the client cues when necessary.
Explain each step as the client does it.
Reduce the client’s anxiety with casual conversation.
Question 3. Question : What is the purpose of writing clear and concise behavioral objectives?
Student Answer: To specify what the teacher is expected to teach
To specify what the learner is expected to be able to do
To keep the learner motivated
To allow the learner to achieve many possible outcomes
Question 4. Question : Which is the most significant guideline to consider when selecting audiovisual aids?
Student Answer: Computer-assisted technology will be the more effective way to convey messages to the learner in the future.
Materials of all types should be previewed for accuracy and appropriateness of content and delivery.
Purchasing the best equipment available will ensure currency information for the longest period of time.
The suitability of a medium depends on its diversity in communicating information.
Question 5. Question : Who is the noted expert in defining the key milestones of psychosocial development?
Student Answer: Erikson
Question 6. Question : What should be included in the performance characteristic of a well-written behavioral objective?
Student Answer: The testing situation or constraints under which the learner’s behavior will be observed
With what accuracy, or to what extent, the learner will be able to carry out the behavior
Who will do the learning, such as the patient, family member, or significant other
What behavior the learner is expected to be able to do to demonstrate evidence of achievement
Question 7. Question : Which statement is false regarding the cognitive, affective, and psychomotor domains of learning?
Student Answer: Each domain is ordered in a taxonomic form of hierarchy from a series of simple to complex behaviors.
The cognitive, affective, and psychomotor domains are separate and unrelated, reflecting the development of skills, thinking, and feeling capabilities, respectively.
The cognitive and psychomotor domains represent the degree of understanding and skill attainment while the affective domain represents the degree of internalization and commitment to a feeling.
The learner must be successful at demonstrating behaviors at the lower levels of any domain before being able to achieve behaviors at the higher levels in that domain.
Question 8. Question : Which of the following statements is false with respect to the characteristics of goals and objectives?
Student Answer: A goal is multidimensional and long-term.
An objective describes the specific performance a learner must exhibit to be considered competent.
An objective is unidimensional and short-term.
A goal is the intended result of instruction that is derived from the stated objectives.
Question 9. Question : A nurse educator is conducting a learning needs assessment prior to teaching a group. Which is the best method to collect information quickly while safeguarding individual privacy?
Student Answer: Structured interviews
Focus groups
Question 10. Question : Which of the following is mandated by The Joint Commission?
Student Answer: Teaching plans must address stage-specific competencies of the learner.
Families must decide whether to participate in patient education prior to patient discharge.
The client is required to initiate education about his or her diagnosis.
The nurse must provide patient education in written form.
Question 11. Question : How does anxiety affect emotional readiness to learn?
Student Answer: As the level of anxiety increases, emotional readiness peaks and then begins to decrease.
The optimal time for learning is when a person experiences a low level of anxiety.
A person is most ready to learn when his or her anxiety is on either end of the continuum, either mild or severe.
Moderate anxiety interferes with a person’s readiness to learn.
Question 12. Question : Educators provide the best teaching when:
Student Answer: educators avoid using only teaching methods that match their own learning style.
learning activities reinforce the teachers learning style
only one learning style is used by the educator
the educator stimulates learners to utilize new learning styles
Question 13. Question : Which is a common argument by educators against the use of behavioral objectives for teaching and learning?
Student Answer: Written objectives tailor teaching only to the learner’s particular circumstances and needs.
Careful construction of objectives directs educators to keep their teaching targeted and learner-centered.
Predetermined objectives force teachers and learners to attend only to specific objectives, thereby stifling creativity and freedom in teaching and learning.
Mutual decision making in establishing objectives requires effort on the part of both the teacher and the learner.
Question 14. Question : All of the following statements are true about learning styles except:
Student Answer: Leaning style theory assists the nurse educator to ensure that each individual learner is given an equal opportunity to learn.
Nurse educators tend to prefer abstract and unstructured approaches to teaching.
No single mode describes someone’s learning style, because each person is unique and comes with other factors that are equally important in learning.
Preference for a particular style of learning tends to change very little over time.
Question 15. Question : The most important criterion in evaluating an instructional method is to determine whether the method:
Student Answer: facilitates the achievement of objectives.
uses resources efficiently.
promotes active learning.
is enjoyed by learners.
Question 16. Question : Which guideline should the educator follow when selecting instructional materials?
Student Answer: The goal for learning should be set before materials are selected.
The choice of materials should give direction in the establishment of objectives for learning.
The selection of appropriate materials should assist the educator in determining the domains of learning on which to focus instruction.
The audiovisual tools available should guide the educator’s decision making regarding the content for instruction.
Question 17. Question : Learning needs can best be defined as
Student Answer: gaps in knowledge that exists between a desired level of performance and the actual level of performance.
the manner by which an individual perceives and processes information.
an outcome by which learners demonstrate more confidence in what they are expected to do.
an interest and an ability in learning the type and degree of information or skills necessary to maintain optimal health.
Question 18. Question : The nurse educator is preparing a class for a group of middle-aged adults. Based on the developmental stage of this group, which topic should the nurse select for this class to meet the immediate needs of these learners?
Student Answer: Accident prevention
Stress reduction
Chronic illness management
Treatment of acute illnesses
Question 19. Question : Which is not part of the instructor’s role when using gaming as an instructional method?
Student Answer: Explain the objectives and rules for the players.
Intervene during the game to explain concepts.
Award prizes to winners at the finish.
Debrief players after the game.
Question 20. Question : Which method is best to accomplish objectives in the psychomotor domain?
Student Answer: Computer-assisted instruction
Group discussion