Ryanair: PESTEL and Porters Five Analysis

Ryanair: PESTEL and Porters Five Analysis 1.0 Introduction Ryanair is an Ireland based airline company and it involved in commercial aviation business since 1986, operating scheduled passenger airlines, serving short haul and point to point routes primarily between Ireland, Britain and Europe. It is the pioneers of low fare airline in Europe and even until now Ryanair is the only airline that offers cheapest air fare to passengers travel around Europe. Micheal OLeary is the CEO of Ryanair, holds 4.6% stake of the company, His dynamic low fare strategies along with the evolution of Ryanair have had led to burst of many budget airlines and some of them had been bought by Ryaniar around Europe, simply because of their inability to compete with Ryanair. European aviation industry is wider, but squeezed with many incumbents that are operating both short haul and long haul routes. As European short haul airline market segment is price sensitive, Ryanair handles no frills strategy and charges lowest price from its customers. In order to obtain bett er margin in the low fare demanding market Ryanair held in a position of cost leader and fundamental low fare strategy supports for rapid growth of its business. The strategic capabilities underpinned by its unique resources and core competences are the preliminary constituents for Ryanair to be a cost leader and offer low fares. This will be explained in detail under below topics about the feasibility of various strategic circumstances. 2.0 External Analysis: The analysis of Macro-environment explores core cause of factor; assess the nature of effects and immediacy. PESTEL analysis has been undertaken to evaluate the external environment of Ryanair. 2.1 PESTEL Analysis: (P)olitical/(L)egal factors: Preferential Treatment of home base airlines in some countries, at the same time they prevent thriving foreign companies and inflict them in more operational cost. Increased terrorists activities have prompted airline industry to tighten security measures and alleged terrorist plots will adversely affect flight turn-around time. Detrimental mental effects are also possible due to any terrorists plots targeted on Ryanair. The rapidly changing government rules and regulations are an inevitable legal factor for Ryanair. This will be discussed in detail under suppliers bargaining power. (E)conomic factors: The instability in fuel price cause major problem for airline industry. If they do not hedge, the fuel price hike is inevitable and they need to find cost savings in other spheres of business when the fuel price is soared. Ryanair was especially more vulnerable to fuel price rises in the past. For example: In the last quarter of 2008, when the fuel price was in its hike, Ryanair reported losses of $130 million dollar and it blamed a 71% increase in the price paid for fuel during the quarter due to the abnormal surge of fuel price of more than $ 1,100 a ton (K, Capel. Airline. The Telegraph, Feb 2 2009.). (E)nvironmental factors: As the world is heading towards more and more greener, all governments taking appropriate measures to control greenhouse gases from carbon emission which would lead to catastrophic human and economic consequences. Ryanair has network virtually in all European countries, so it is more vulnerable to all EU environmental rules and regulations. The mounting pressure on EU laws to tax aviation fuel and anticipated charges on environmental pollution by airlines would have direct impact to Ryanair. (T)echnological factors: Technological factors such as internet, innovative developments in telecommunications such as video conferencing, instant messaging, web conferencing etc. will mean less need for travel, especially on scenarios such as business meetings. 3.0 Industry environment: 3.1 Segmentation and positioning: Ryanair is positioned in the lowest fare segment and has least customer experience among other budget airlines in the European market. The market segment for its rivalries is broader with larger geographical area including operations to main airports, whereas Ryanairs networks are limited only to low cost secondary airports with smaller geographical area. Ryanair predominantly focuses on only people who are desperate for low fare and it has no separate segment for people who want luxury service or business class. Despite, Ryanairs continuous traffic growth, shows that the people wanting low fare in European market are tremendous and European market is for the low fare short-haul carriers. Perhaps, high air fare carriers neither cope up nor sustain against low fare carriers. The competitive position is deeply elaborated in section 3.2. 3.2 Porters five forces: Industry environment analysis figures out the foreseeing competitive pressure in European aviation and the profitability of the industry likely to be in future. It explores the magnitude impact of Threat of substitutes, Threat of Entrants, Rivalries in European market, bargaining power of supplier and bargaining power of customers. Rivalries: The high rivalry impacts for Ryanair are from Easy Jet, Air Lingus, Lufthansa, Iberia, SAS, Airfrance, KLM and Air Lingus. Few airlines (Easy Jet, Air lingus and Lufthansa) the first three of them are roughly more or less equal in size to Ryanair and some of their performances are even better in terms of customer service. This is considered as a significant threat to Ryanair. Despite, among all short-haul carriers Ryanair is the cost leader with having highest market share in the European market. Although Ryanair has firmly improving its competitive advantage, the core strategy of the company is to maintain the operational cost as minimum and offer low fare to customers, which is virtually same among its rivalries, but the outstanding scenario is Ryanair constantly creates new paths to bring down the operational cost . Threat of New Entrants: The short haul no frill airline market is a highly profitable business in Europe so far, while long haul market in Europe is experiencing huge losses like Air Lingus long haul airlines. So, the business scope in the short-haul market may attract new entrants. Although, European airline industry is de-regulated and open for both national and international companies, Airline business is not something like setting up a dot.com with minimum capital in anticipated profit. Hefty capital investment is required to acquire route, fleet, set up flight maintenance centre, building infrastructure etc in order to establish an operation. Industry knowledge and time associated with entry are significant for companies that want to start short haul airline business in Europe from other industries such as tourism and Rail way etc, but for airline companies from some other market like Asia, South America, North America and Australia can trace out the European market in some extent and such huge investm ents also may be affordable for them. Threat of substitutes: The threat of substitute is possible threat for Ryanairs traffic growth as passengers tendency to switch to other means of transport such as buses, trains and cruise. This kind of threat has medium effect over Ryanair, despite, the ubiquity of other means of transport to travel across European countries. Particularly rapid growth of railway network is considered to be a most influential substitute for short haul air travel across Europe. Congestion in airports and difficulties (such as boarding, airport journey) involved in air travel could cause passengers more likely to choose railway. Some government like U.K is substantially funding for the expansion of high-speed rail networks to and from Europe, especially to curb short haul carriers through heavier taxation due to the pressure arising from the environmental groups to cut down carbon emission by domestic aviation. The government intervention to establish better rail links in other countries such as France, Germany and the Nethe rlands is more vulnerable to Ryanairs routes in those countries (Dan Milmo 2009. The Guardian. 5th Aug). Bargaining power of supplier: Aircraft Supplier: In aviation Boeing and Airbus plays duopoly in manufacturing passenger aircrafts. Boeing is the main aircraft supplier for Ryanair, since its establishment. In terms of supplier bargaining power, Ryanair holds significant scale of power over Boeing, as it can easily switch to Airbus anytime in-case of high price charged by Boeing. The recent Micheal O Learys announcement of negotiation with Air Lingus evidenced the high bargaining power over its Aircraft supplier (Sarah Arnott., 2008. Ryanair looks to order 400 aircraft in plans for massive expansion. The Independent, 8th Aug.). Airports: The enforcement of new rules and regulations by airport authorities are inevitable, eventually they have more control on their bases with both short haul and long carriers airlines operating in any government airports. Ryanair has been either strongly protesting or recklessly withdrawing and switching its routes to alternative airports, at bases wherever it is experiencing significant problems. For example: Recently Manchester Airports Group refused to bring down its prices, which resulted Ryanair to pull nine out of its ten Manchester routes(Sarah Arnott., 2009. Price dispute sees Ryanair cut nearly all Manchester flights. The Independent, 18th Aug.). So, Ryanair can switch its destinations easily in case of its bargain does not take lead. Ryanair holds substantial power in the other spheres of suppliers such as staff recruitment agency, food providers and ancillary product suppliers etc due to substantial availability of those kind of suppliers in the market. Bargaining power of customer: European market is almost saturated with many airline companies including premium services to economy classes. Bargaining power of customers is high as low budget airline a commodity today and presence of more substitutes in European market. Ryanair had shrunken the bargaining leverage to its bottom with no other airlines could possibly offer such low fares, as the result that Ryanair is having extra-ordinary performance in traffic growth consistently year by year, but this growth is uncertain if Ryanair pushes its fare up. More people travelling on Ryanair, because they like the fare and can easily afford it. 3.3 Value Networks and Business Partners: It is necessary to analyse value creating areas in Ryanairs Industry value chain, which consolidates it competitive advantage by delivering those precious values to customers. According to porter, 1985, Value chain of any organization comprises of two activities, primary and secondary activities. Primary activities are directly concerned with delivery of service and that includes inbound logistics, operation, outbound logistics, marketing, sales and services. The support activities include administrative infrastructure management, human resource management, technology and procurement. Inbound logistics: Stock control of Food, beverages and Ancillary sale items: Although, Ryanair is a no frills airline, it is making huge profit through the sales of food, beverages and Ancillary items. Ryanair manages strong relationship with various foods and beverages suppliers, in-order to receive quality standard goods and on time delivery, which adds value throughout its value chain. Route selection and airport base: Ryanair only selects low cost route with the anticipation of traffic growth. Ryanair has strong relationship with various airport authorities around Europe, thus they provide subsidies in exchange for high traffic and low fares. Jet fuel: This is the most significant input that Ryanair has to scrutinize, as jet fuel contributes around half of the operating cost. Well hedged contracts will minimise cost, so recent hedging arrangements adds value to get control of fuel cost in some extent. Aircrafts and Maintenance: Deployment of single type aircraft Boeing 737-800. Operation: Ryanairs operational activities includes passenger check-In, loading ancillary and catering items in the flights, baggage check-In, Hospitality, In-flight services and daily flight operations. Contemporary online check-in system reduces cost associated with staff and avoids passenger queues in airports, thus it provides convenient journey for passengers. This adds value by enabling quick turnover of flights and prompt minimum waiting time of flights at airports. Additionally, Ryanair has contractors at certain airports for ticketing, passengers and aircraft handling (Includes loading various goods into aircraft) as well as for engine repairs and heavy maintenance at competitive rates. (Ryanair, 2004. Annual Report 2008-2009. [Online]. Available at: http://www.ryanair.com/doc/investor/2009/Annual_report_2009_web.pdf. [Accessed 10 Jan, 2010) This third party contracts are more cost-efficient than Ryanair perform these activities itself. Productivity-based incentives, this includes sales bonuses for on-board sale of products by flight attendance to increase ancillary revenue through reward mechanism and pilots are remunerated based on number of hours or sectors flown, which c uts unnecessary staff cost. Ryanair facilitate the usage of onboard mobile and electronic device for its passengers in order to add value for customers. Marketing, Sales, Services and Outbound Logistics: Ryanair advertise its seasonal fares and other company related commercial advertisements on its fleet with zero advertisement costs. Furthermore special ticket offers are being advertised on its website to promote sales. In order to curb substantial operational cost and tackle high number of booking, Ryanair has introduced new Online Reservation System in addition to the host system. The system new has been provided and maintained by an outside contractor, Navaitire. (Ryanair, 2004. Annual Report 2008-2009. [Online]. Available at: http://www.ryanair.com/doc/investor/2009/Annual_report_2009_web.pdf. [Accessed 5, Jan, 2010) It adds value for passengers by increasing system speed and avoid Ryanair is being on exposure to the risk of resolving system failure issues. There is no sales agent commission adds value on passengers fare and it adds value in terms of the distribution cost aggregate nearly to zero and convenient journey for passengers. Online baggage claiming system for baggage l ost passengers, which adds value to passengers as it is an easy way to claim their bags. 4.0 Resources and Capabilities: 4.1 Resources: Resources allocation and capabilities development are the source to gain competitive advantage for a company, while the market and environment establish constraints and pressures. Resources of Ryanair are basically what it holds as productive assets and can be differentiated into three different forms, tangible, intangible and human resources. Capabilities are what it can achieve by exploiting opportunities in the external environment and efficient deployment of its unique resources that exist within the company to achieve competitive advantage. Tangible Resource: Ryanair had 181 aircrafts in operation as of March, 21, 2009, among which 109 aircrafts were funded by The Export and Import Bank, 43 aircrafts were in operating lease, 20 of the aircraft in the fleet were treated as financially leased by Japanese operating leases with call options, 6 of the aircraft in the fleet were encumbered with commercial debt financing and three remaining aircrafts are entirely owned by Ryanair without any finance related encumbrances. Ryanair also owns and operates six Boeing 737-800 flight simulators for the purpose of pilot training. All the above are long-lived assets virtually all of them were aircraft totalled to 3.6 billion Euros. [Ryanair, 2004. Annual Report 2008-2009. [Online]. Available at: http://www.ryanair.com/doc/investor/2009/Annual_report_2009_web.pdf. [Accessed 4 Jan 2009]. Even though many aircraft are encumbrances, ownership accompanied with the bank loan gives greater independency and financially the cost involved in leasing arrangements i s higher than being owner of aircraft. In addition to aircraft, administration offices in Dublin and East Midlands Airport, simulator and training centres are entirely owned by Ryanair. It also has leasehold property in eight airports for the purpose of flight maintenance and an office building in Dublin Airport Business Park. The recent investment of 702 million Euros for the purchase of property, plant and equipment in 2008 is remarkable. [Ryanair, 2004. Annual Report 2008-2009. [Online]. Available at: http://www.ryanair.com/doc/investor/2009/Annual_report_2009_web.pdf. [Accessed 4 Jan 2009]. Ryanair serves over 1000 routes across Europe and Morocco from 40 airport bases, which is considered to be high in numbers compare to its rivalries. (http://www.ryanair.com/doc/investor/2010/q3_2010_doc.pdf, accessed on: 15th Jan 2010). Airport bases served by Ryanair are ultimately considered as strategic assets due to its low cost. Financial Resources: The huge cash reserves held in the company of over 2.5 billion Euros will allow having abundant cash flow for its operation. Cash pile would financially leverage to take strategic decision in future expansion of business. Ryanair holds 93.15 million Euros worth of available-for-sale financial assets, which are not considered as an investment in an associate company due to insufficient power of Ryanair to influence over the investee. And also, Ryanair is the biggest investor on its rivalry Aer Lingus with the acquired stake of 29.8% of Aer Linguss share capital through private acquisition with the total aggregate cost of 407.2 million Euros. Ryanairs long term debt totalled to 2398.40 million as of 2009 annual report, which is an increase of 131.9 million from 2008 annual report. The latest debt increase is primarily due to financing of new aircraft, which will be delivered within two years as per the schedule. [Ryanair, 2004. Annual Report 2008-2009. [Online]. Available at: http://www.ryanair.com/doc/investor/2009/Annual_report_2009_web.pdf. [Accessed 4 Jan 2009]. Intangible resources: Ryanairs climbing traffic growth and established brand name are most consolidated and valuable intangible assets for the company that embedded in its relentlessly flowing low fare strategies to make huge profit. In terms of operational prospective, minimum aircraft age of 3.77 years average age of all its Boeing 737-800s is a unique intangible asset and no aircraft is more than 9 years old. The company also holds considerable intangible asset of landing rights that flows future benefit into the company. Human Resources: There are 6616 staffs working at Ryanair as of March 2009, this includes 1041 additional experienced pilots contracted from employment agencies to satisfy short term pilot requirements. The employees figure is constantly increasing year by year due to rapid expansion of the company. Ryanairs top management comprises of eight boards of directors, all of them are having more than 7 years of experience with the company and their remuneration including different share options scheme are available and based on experience, as well as their job position. David Bonderman, Chairman of the Board and Director, who has served more than 13 years with the company. CEO and Director of Ryanair, Micheal OLeary is the most valuable human resources in the company and he has been successfully leading the company for nearly two decades, as CEO since 1994. (Ryanair, 2004. Annual Report 2008-2009. [Online]. Available at: http://www.ryanair.com/doc/investor/2009/Annual_report_2009_web.pdf. [Accessed 20 Jan, 2010]). 4.2 Capabilities: In this section, we will discuss about the special knowledge and a skill possessed by Ryanair in order to gain competitive advantage and the key success factors that positioned the company as cost leader. The companys innovative pioneer strategies to keep the operating cost low and its ability to carrying passengers at lowest fare demand are the special capabilities it posses. Apart from these, the table below contains Ryanairs last three years operational data up to March 2009, which will demonstrate the operational capabilities during that period. The average yield per revenue passenger mile and average yield per available seat miles are decreased in 2009 due to the intense competition and further reduction of average booked passenger fare by approximately 4 Euros compare to the previous years. Yield management is crucial for airlines as the gross profit of the company mainly depends on it, so achieving better yield would perhaps maximise Ryanairs profit. The fares of Ryanair need to be continuously monitored in a way that would create demand, at the same time that would maximise companys profit. Ryanair has only little control over the fuel fluctuations like many other airlines, so increase in fuel cost is an unavoidable increase in operating expenses. The remarkable factor is the recent fuel hedging arrangements increased Ryanairs power to some extent to influence those cost aroused due to high fuel price. The next factor is cost per available seat miles, which is operating cost by available seat miles. This is one of the mo st success factors that gain competitive advantage for Ryanair, as it always being low compared to all other short haul airlines in Europe. In the table above, the increase in the operating cost in 2009 is mainly due to the rise in fuel cost. The low fare strategy is embedded in the companys capability and it is most valuable for the company by creating demand for its service. The constantly increasing load factors year by year, while the average booked passenger fare is decreasing indicates that the unique capability of Ryanair to make the traffic grow and how well it filling its seats through creating demand by stretching its fare to lowest possible. So the increased load factor is mainly due to decrease in the fares. One of the main mottos of companys CEO, Micheal OLearys is to maximise profit through selling ancillary products. Ryanair is the highest ancillary revenue making airline in Europe, which add extra profit for the company. Motivating cabin crews through commissions to sell ancillary product, consistently increasing and introducing various ancillary products and having many commission based related business are the main source for ancillary revenue. The number of airport served and average flight utilisation hours are some other measurable capabilities of Ryanair. The best service to the passengers in terms of punctuality of its flights and less baggage missing scenarios are in Top Priorities and it makes competitive advantage for Ryanair in its operation. In fact it has the policy of publishing its customer service statistics every month to show the leads from its competitors. The table below shows that the Ryanairs capability in terms of punctuality, Bags handling and journey completions among its few rivalries. 4.3 Strength and intellectual assets: All routes are point to point rather than transitional. Although it is easy to establish point to point routes for a short haul carrier, it enhances convenient journey to the passengers. Ryanair has entered into fuel hedging arrangements followed by the huge losses on 2008. The unprecedented hedging arrangements will provide substantial protection against fluctuations in fuel prices, generally through forwarding contracts covering certain periods in the future. Ancillary services including non-flight scheduled such as Car hire, Hotels, Travel Insurance, in-flight sales, rail and bus ground transport services in its business model adds extra revenue for the company. Ryanair has direct sales channels; the only way to book ticket nowadays is via the website or via Ryanair direct call centre. It helps to take out sale agents commission and special offers would directly reach the customers without any discrepancies. Ryanair has been deploying Boeing 737-800s, same fleet community in all its routes. The company can save training cost as all staffs are only be trained for one type of aircraft and also saves on maintenance supplies and labour as only one type of parts and skills needed. High seat density of 189 seats per aircraft accommodates more passengers (compare to its older version Boeing 737-200A, which had only 130 seats per aircraft) and it tends to extra revenue for the company. The use of Secondary Airport with frequent transport medium to populated cities for the purpose to keep its airport charges low and for high turnaround times. The well known scattered strategy of no frills such as, free food, drink, and lounges etc 4.5 Weakness: Even though its fares are far cheaper than any other airlines in Europe, it is being severely criticised by many people for its extravagant hidden charges. The basic reason for this criticism is advertising fares without the disclosure of most basic inevitable charges such as, taxes, online check-In or airport check-In charge(which is outrageously costlier than the online check-In), card surcharge other than master card (only possible way to pay as the booking can feasibly done through either website or call centre), administration fee etc Ryanairs deliberate controversial advertisements and statements by its CEO such as charging one pound to use the toilets in flight, are practically generate additional free publicity for the airline, but significantly it depletes brand reputation and it often perceived as bad impression among peoples mind. The poor customer service by its staffs employed and disgrace treatment of passengers by its CEO, Micheal O Leary and the company are misleading companys reputation for not even providing the basic services and rudeness involved in customer query replies are the weakness that embedded in its system. According to the comments analysed from 280 websites, Ryanair came bottom of the ranking with minus 40 points. Poor customer service and extra cost the airline charge for check-in bags are the major complaints. [Lisa Minot, 2008. Sun Air News: Ryanair suffer Over Service. The Sun, 2nd Aug.] The company is heavily addicted for traffic growth and rivalry led in European short haul market. Because of that growth, Ryanair is not able to identify the reputation and loyalty in its brand among passengers. 5.0 Strategic situation: Perhaps, I have mentioned about 2.5 billion cash reserves in its financial resources. It has announced plans of start paying dividend from its cash pile to their shareholder from 2013. (Sarah Arnott, 2010. Ryanair to pay dividend from 2013. The independent, 8th Jan). Instead of paying dividend out of its cash reserves or by using companys profit, it should decide to deploy its cash reserves in its on-holding strategy towards long haul routes. The company will get significant future growth by launching long-haul transatlantic routes. According to CEO, Micheal O Learys statement, if Ryanair introduces long haul routes from Europe to six US destinations, two segments of seat will be offered, one lowest unprecedented economic class and ever high fare business class with extravagant services. This rational strategy will generate huge profit by luring middle economic-class passengers; perhaps transatlantic passengers will want something cheaper in their tickets. The cheapest fare no frill for economic class passengers with onboard sale of everything from breakfast to dinner, beverage to entertainment would create substantial ancillary revenue. In spite the airline destinations must be in populated area or rich cities such as Chicago Midway Airport, Atlanta Hartsfield International Airport and Dallas Fort Worth International Airport etc to fill up business class seats, Otherwise there is no logic in adding business class seats in long haul routes. Alternatively, it can choose rural destinations in US, but the business class passengers firmly transited to populated cities without any delay and inconveniency by having alliance with US luxury short haul carriers. Although, I have mentioned Ryanairs 29.8% stake over Aer Lingus, its first bid in 2006 to acquire entire share capital of Aer Lingus was firstly blocked by European commission on competition grounds and the second bid in 2007 was also failed after the Irish Government (25% stack holder on Aer Lingus) said Ryanair undervalued the company, while the offer totalled  £701 million. So, Ryanair is not yet planned to make any further bid in recent future, rather it aims to boost its cash reserves. [Pilita, C, Vincent, B, 2010. Third Ryanair bid for Aer Lingus unlikely. Financial Times, 7th Jan.] Perhaps, the acquired stakes consolidate its financial position over Aer Lingus for convenient takeover in the future, in case of any failure or the acceptance of further bid by Aer Lingus. In consideration to Ryanairs future growth in the existing market and anticipated transatlantic expansion, it has to press hard for a horizontal integration over Aer Lingus by raising the offer price from its last bid of  £701 million. The acquisition of Aer Lingus is more likely to see tremendous expansion in European market by acquiring market share and implementing low cost operating strategy over it rivalry. In a situation when a competitor disappears in the market, the competition gets ease for some instance. The acquisition also allow Ryanair to get easy access into the transatlantic routes, as Aer Lingus already operating flights to some major airports in the United States such as, Houston (HOU), Houston (IAH), Indianapolis (IND), Columbus (CMH) and San Francisco (SNF) etc 6.0 Strategic Choice: Identification: The first choice what I suggest is Ryanair can expand its market through Related Diversification by the launch of new international routes from Europe to Selected Asian countries, such as India, Malaysia and Singapore. Ryanair will be able to grow its traffic by selecting core destinations such as Mumbai, Bangalore, Goa, Chennai and New Delhi in India, Kualalampur in Malayasia and Singapore. In the other end, Ryanair would be able to cover travellers and tourists from all European countries by setting up transit hubs in selected airports in Europe such as Frankfurt, Madrid, Milan, Glasgow and Dublin (So, flights from the new market will land in those transit hubs and then passengers can reach their end destination by Ryanairs local network flights through transit from these airport) travelling to our selected destinations in Asia, as it already has firm and established operation in Europe. The above selected strategic choice would be demonstrated under Ansoff Strategic Direction Matrix Market/product choices. According to Ansoff Matrix (developed by Igor Ansoff, 1957) the above selected business is launching of new service in new market, so it will be categorized under Diversification. Although, Ryanair has an on-holding plan of introducing transatlantic routes, but not yet lunged, the new strategic choice is to flourish market share in developing nations. The assumed service in those markets is clearly business to consumer type of activity, as Ryanair directly engaged in carrying passengers or providing service directly to the customers. Ryanairs main targeting customer segment in the above three countries are tourists and passengers who are looking for low fares, as well as high fare over luxury service. The differentiations in fares with price premium for passengers perceive it as on luxury segment and without price premium for passengers perceive cost benefit under low fare segment. All the three countries are developing nations with low income, middle class and rich people. Among them, people who afford to travel to Europe are

Pressure Ulcers

Feature Strategies to improve the prevention of pressure ulcers Judy Elliott describes a project that sought to improve tissue viability during the patient journey from admission to discharge Summary This article outlines the actions taken by one acute trust to implement evidence-based, best practice recommendations for pressure ulcer prevention. Initially, an exploratory study identified specific areas for practice development, particularly improving early risk assessment, intervention and focus on heel ulcers.Further actions included recruiting tissue viability support workers to promote a pressure ulcer campaign. Prevalence audit results demonstrated improved prevention and reduced prevalence of hospital-acquired pressure ulcers by 6 per cent and heel ulcers by 4. 9 per cent. Further work is required to ensure prevention strategies are consistent and documented. Keywords Best practice, evidence base, pressure ulcer prevention ( Institute for Innovation and Improvement 2009), there fore it is important to seek further initiatives to eliminate avoidable pressure ulcers from NHS care.Tissue damage A pressure ulcer is defined as (European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP) 2009): ‘†¦ localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. ‘ Healthy individuals are continuously moving and readjusting their body posture to prevent excess pressure and shear forces. Reduced mobility or sensation interrupts this natural response, rendering an individual vulnerable to tissue damage.Eurther susceptibility is influenced by an individual's intrinsic risk factors reflected by their tissue tolerance (Bonomini 2003). Individual risk factors include immobility, malnourishment, cognitive impairment, acute and chronic ulness (National Institute for Health and CUnicad Excellence (NICE) 2005). Pressure ulcer preventio n involves the modification of an individual's risk factors by the whole multidiscipUnciry team (Gould et al 2000). Risk assessment Identification of vulnerable individuals can be challenging.Designated risk assessment tools have been found to lack reliability and validity with a tendency to overestimate risk (Pancorbo-Hidalgo et al 2006). The NICE (2005) guideline emphasises the importance of early assessment, within sbc hours, using clinical judgement. Vanderwee et al (2007a) found skin inspection more reliable compared with an assessment tool, with 50 per cent fewer patients identified as requiring intervention cuid no significant difference in patient outcomes. The skin should be assessed for early signs of tissue damage, which November 2010 | Volume 22 | Number 9PRESSURE ULCERS have potentially devastating consequences for patients, hospitals and the overaU hecdth economy. An estimated 5 to 10 per cent of patients admitted to hospital develop pressure ulcers, resulting in incre ased suffering, morbidity and mortaUty (Clark 2002, Redelings et al 2005) and depleting NHS budgets by 4 per cent, or more than ? 2 billion ? mnually (Bennett et al 2004). Prevention is a complex, multifactorial process and although it is accepted that some pressure ulcers are unavoidable, most are considered preventable.Acknowledging the difficulty in establishing national comparative prevalence data because of variances in methodology and settings (Calianno 2007), a prevalence of 21. 9 per cent of patients affected was reported in a pilot study of UK acute hospitals in 2001 (Clark et al 2004). Pressure ulcer prevention is a nursing quality indicator and high impact action for nursing and midwifery (NHS NURSING OLDER PEOPLE Feature Figure 1 I Illustrations showing a correctly fitting chair to ensure sufficient I pressure redistribution and poor sitting posture 1.The patient should be seated with hips and knees at right angles, feet flat on the floor and arms/shoulders supported. Th e patient's weight is evenly displaced through the feet, thighs and sacrum. 2. The chair is too low; the patient's upper legs are not supported, and weight is increased onto the buttocks leading to greater risk of pressure damage. include observable discolouration and palpable tissue changes such as localised bogginess, heat or cold (NICE 2005). International guidelines (EPUAP/NPUAP 2009) advise a structured approach to risk assessment using a combination of all three techniques.Ecirly intervention Once risk is identified immediate action is imperative to minimise risk of pressure ulcer development. As evidence is weak for specific interventions a number of areas should be addressed, involving ecirly initiation of preventive action, improving tissue tolerance and protecting from the adverse effects of pressure, friction and shear (Calianno 2007). Nutrition and tissue loading are two areas of nursing influence. Strategies to ensure optimal nutrition should be used and the provision o f oral nutritioneil supplements has been associated with reduced tissue breakdown (Bourdel-Marchasson et al 2000).Tissue loading may be addressed by manual and mechcinical repositioning, mobuisation and exercise. Strategies to minimise shear forces include addressing posture, moving and handling techniques and use of electric profiling beds (Keogh and Dealey 2001). Positioning and repositioning Research has not established an optimeil frequency of patient repositioning (Defloor et al 2005). Repositioning should be undertaken on an individual basis in Une with ongoing skin evaluation, avoiding bony prominences (NICE 2005).The skin shoiUd be closely monitored to ensure effectiveness of the regimen and further actions taken if ciny signs of tissue damage occur. November 2010 Volume 22 Number 9 A flatter position distributes body weight more evenly. Semi-Fowler (semi-recumbent) and prone positions yield the lowest interface pressures with sitting cind 90-degree side-lying the highest (S ewchuk et al 2006). Repositioning using the 30-degree tuted side-lying position (alternately right side, back, left side) or prone position is advised (EPUAP/NPUAP 2009).The repositioning regimen should be agreed with the patient and will require adaptation to ensure concordance with comfort, symptoms and medical condition. Prolonged chair sitting is impUcated with greater risk of pressure ulcer development (Gebhardt and BUss 1994). Chair sitting should be Umited to less than two hours at ciny one time for the acutely ul at-risk individual (Clark 2009). A correctly fitting chair is important to ensure sufflcient pressure redistribution (Figure 1).Poor sitting posture may cause posterior pelvic tilt (sacral sitting) or pelvic obUquity (side tUting onto one buttock), with the ideal chair allowing feet to sit flat on the floor, with hips and knees at 90 degrees and arm/shoulders supported (Beldon 2007). Support surfaces High specification foam mattresses have demonstrated improved perf ormance in pressure ulcer prevention (Defloor et al 2005), leading assessme Low risk †¢ Use static foam mattress. †¢ Reassess if patient's condition changes. Medium risk †¢ Use static foam mattress. †¢ Implement repositioning regimen. Check skin at least daily. †¢ If any signs of pressure damage request dynamic (air) mattress. †¢ Reassess if patient's condition changes. High risk (contraindicated if patient weighs more than 39 stone (refer to guidelines), has a spinal injury (refer to trauma and orthopaedics) or unstable fracture). †¢ Use dynamic (air) mattress. †¢ Implement repositioning regimen. †¢ Check skin at least daily. †¢ If any further signs of pressure damage increase repositioning programme. †¢ Reassess and step down onto static mattress as patient's condition improves.Remember to apply heel protector boots for patients at risk or with heel pressure ulcers. NURSING OLDER PEOPLE Feature to replacement of standard mattr esses by most hospital trusts. There has also been considerable investment in mechanical (dynamic) support surfaces, where air is pumped through the mattress via alternating pressure or low air loss. However, the benefits of these devices remain unclear in terms of clinlccd and cost effectiveness (Reddy et al 2006). Pressure ulcer incidence rates of 5 to 11 per cent have been reported in studies, with longer use associated with greater risk (Theaker et al 2005).These devices should be considered m conjunction with other support surfaces as delayed or inconsistent use may negate the benefits. Multiple strategies A number of studies have attained favourable outcomes using multiple interventions. Examples include introducing a multidisciplinary working party, improving management of pressure-relieving equipment, educational programmes and developing new guidelines (Gould et al 2000, Catania et al 2007, Dobbs et al 2007). Variations in approach suggest the commitment of practitioners is vital to success. For example, a support surface . howed improved outcomes only when used In conjunction with an educational programme for registered nurses (RNs) (Sewchuk et al 2006). Factors identified as impeding pressure ulcer prevention include lack of time, staffing levels and staff knowledge (Moore and Price 2004, Pancorbo-Hidalgo et al 2006, Robinson and Mercer 2007). Skill mix may also influence outcomes. Horn et al (2005) investigated staffing levels in a nursing home and found fewer pressure ulcers were associated with more direct RN care for each resident. heels' protocolj Apply heel protector boots to patients at high risk of heel ulcers when on bed rest.Assessment criteria include limited mobility and: †¢ †¢ †¢ †¢ I Is patient immobile, heavily sedated or unconscious? Can patient lift his or her leg up in bed? Is there any evidence of heel tissue breakdown, blistering or ulceration? Does the patient have diabetes, vascular or renal disease? experie nces highlighted the challenges in delivering timely, optimal preventive care. Opportunities to improve preventive care during the patient journey from admission to discharge were identified. These processes were influenced by the level of communication and collaborative care.Practice development recommendations included: †¢ Improve early risk assessment and intervention. †¢ Direct resources to the start of the patient journey. †¢ Prevent heel ulcers. Further actions were taken during 2009/10 to develop practice in line with these recommendations. Method Tissue viabUity support workers were recruited for each hospital site to focus on pressure ulcer prevention, in particular managing pressure-relieving equipment. They reclaimed dynamic mattresses and recurected them to admitting areas to enable immediate access ‘at the front door'.They were entrusted with keeping a ‘float' of mattresses in a clean library store and helping with maintenance, decontamination eind training. In September 2009 a trust-wide pressure ulcer campaign was launched. This focused on three Interventions: support surface, positioning and repositioning and heel offloading: 1. Risk assessment within six hours and appropriate support surface (Box 1). A simple flow chart was disseminated highlighting a structured patient pathway, based on NICF (2005) best practice recommendations.Initial risk assessment was encouraged using clinical judgement to help early assessment in the emergency admitting areas. A more detailed assessment was requested during the following 24 hours using the Waterlow assessment tool (Waterlow 1988) to provide risk status confirmation and identify individual risk factors. Patients were assessed as low risk (fuUy mobile and minimal risk factors/Waterlow score 20). All trust static mattresses consist of high specification foam offering protection to all admitted patients. The trust has purchased November 2010 Volume 22 BackgroundAn exploratory study of pressure ulcer prevention was undertaken in the project hospital trust during 2007/08. The trust includes three acute sites covering a large geographical area consisting of more than 1,200 beds and serving a predominantly ageing population. A case study meth(3dology was used to consider the topic from a range of perspectives using quantitative zind qualitative data (Yin 2003). A reduction in overall and hospital-acquired pressure ulcer prevcdence since 2001 was found. Steady reduction in sacral ulcers was observed with the heel emerging as the most common site for hospital-acquired pressure ulcers by 2008.Increased prevalence observed in 2009 reflected revised data collection methods and improved reuabuity with thorough skin inspection. Data were also generated from focus group interviews with multidisciplinary clinicians. Their NURSING OLDER PEOPLE Feature more than 350 dyncimic mattresses and local recommendations prioritise patients at high risk, unless contraindicated. 2. Im plementation of revised positioning cind repositioning documentation. Revised documentation included a visual care plan/ regimen, repositioning chart and skin evaluation for all vulnerable patients. 3. F*revention of heel ulcers.The ‘hecilthy heels' project ran concurrent to the Ccimpaign cind was undertaken from October 2009 to March 2010. Funding was procured for regular provision of heel protector boots that ‘float the heel' and offload pressure to augment the repositioning and positioning programme. A protocol was disseminated aiming to protect patients with high risk factors such as diabetes or early signs of tissue damage located at the heel (Box 2). The annual prevalence audit methodology was revised to improve reliabUity of data collection cind undertciken in Februcuy 2009 and repeated in February 2010.Data was collected by tissue viabibty nurses at the bedside including skin inspection eind related preventive interventions. Previously, ward nurses supplied the d ate using vcirious collection methods. Data analysis was undertaken by the trust's clinical audit team. ulcers as some patients hav e more than one pressure ulcer. Audit results from Februciry 2010 showed a reduction in hospital-acquired pressure ulcer prevcilence by 6 per cent and a reduction in total pressure ulcer prevalence by 4. 7 per cent (Table 1). Prevalence of patients with pressure ulcers had reduced from the previous audit by 2. per cent to 13. 4 per cent (Table 1). More than half of the total inpatient population was assessed as vulnerable to pressure dcimage. This information enables comparison with similar populations and indicates a 2 per cent increase in the population at risk from the previous year. There was also a reduction in all grades/ categories of hospiteil-acquired pressure ulcers (Table 2). The grade (category) of ulcer is used to assess depth of tissue damage, with grades 1 to 2 affecting the top skin layers and grades 3 to 4 including the deeper underlyin g tissues (EPUAP/ NPUAP 2009).The origin of some pressure ulcers was not fully established, mainly because of lack of documentation and appearance of the ulcer (Table 2). There were observable improving standards in best practice and patient comfort and care on the wards. Repositioning care plcinning documentation had improved by 7 per cent but ongoing documented repositioning had reduced by 1 per cent (Table 3). Further improvements are required to meet best practice standards in both cases. Although the heel remained the most common site for pressure dcimage, there was a reduction in hospital-acquired heel ulcers by 4. per cent. Results Benefits beccime apparent during the campaign with observable improvements in patient access to equipment cind eeirly intervention. The results were analysed in terms of patient prevalence (percentage of patients with one or more pressure ulcer) and pressure ulcer prevcilence (percentage of pressure ulcers). The prevalence of pressure ulcers is usu ally greater than the prevalence of patients with pressure Prevalence of pressure ulcers Discussion The tissue viability support workers were instrumental in raising awareness of prevention 009 Number Number of patients Population at risk Prevalence of patients with pressure ulcers Prevalence of pressure ulcers Pressure ulcers acquired in hospital Pressure ulcers present on admission Origin not known (unsure/not completed) Percentage Number 2010 Percentage Change Percentage 976 497 151 242 132 930 51 15. 5 24. 7 13. 5 492 125 186 53 13. 4 20. 0 7. 5 6. 8 5. 7 T2. 0 i 2. 1 J. 4. 7 J. 6. 0 i 0. 8 I2. 2 70 63 53 75 35 7. 6 3. 5 1 November 2010 Volume 22 Number 9 NURSING OLDER PEOPLE Feature in the admitting areas and improving early access to dynamic mattresses.Previously, dynamic systems were often a late intervention, once pressure damage was appeirent, cind competing demands from the wards impeded availability. A structured approach supported fairer allocation, prioritisation by pat ient need and improved availability. The support workers also improved processes by fostering good teamwork with support staff, hospital management teams and nursing departments. Their presence in the ward areas improved preventive care, related protocols and provided a link with the tissue viability nurses.Our experiences suggest that further education and communication are essential to reach a staff. The ‘healthy heels' campaign demonstrated the effectiveness of heel protectors in a prevention strategy. These devices were used for prevention and treatment to ‘float the heel', with resolution of superflcial tissue damage often achieved through continued use. This included the treatinent of superficial necrosis (black heels), which in many cases were kept dry cind allowed to slough off retaining viable deeper tissues, as recommended by EPUAP/NPUAP (2009).The audit results mirror previous reports of less than 10 per cent of hospiteil patients having documented adequate pr eventive care (Vanderwee ef al 2007b). Some nurses expressed concems over time constrEiints and extra paperwork, which may have contributed to a reluctance to adopt revised positioning and repositioning documentation. Communication and education Achievement of best practice standar Best practice standard quired pressujmJceyar^ajeiKe by grad Grade of pressure ulcer Grade 1 Grade 2 Grade 3 Grade 4 Total 2009 Number 59 54 7 12 2010 Number 35 24 6 5 70 Percentage Change Percentage Percentage 6,0 5. 3,7 2,5 0,6 0,5 i 2. 3 4-3. 0 0. 7 1. 2 i 0,1 1 0,7 132 Origin not known (unsure/not completed) Grade 1 Grade 2 Grade 3 Grade 4 16 15 2 2 1. 6 1. 5 0,2 0. 2 23 23 7 0 2,4 2. 4 0. 7 T0. 8 i 0,9 IO. 5 _ Total 35 † 1 issues were other possible factors. The trust operates a link nurse system for tissue viability education that may limit dissemination to all nursing staff. In an audit of 44 UK hospitals Phillips and Buttery (2009) also found a lack of documentary evidence of risk assessment on admission and C2ire planning, together with the need to improve immediate allocation of appropriate resources.Early risk assessment and immediate intervention may also be hcimpered by the focus on emergency care in admitting areas. Robinson and Mercer (2007) identified contextual barriers to pressure ulcer prevention in emergency departments as use of a stretcher and a lack of basic care provision for older Patients having a documented pressure ulcer risk assessment within six hours of admission. Patients with documented risk assessment at time of audit. Patients nursed on appropriate mattress.Patients with a high or medium risk of developing a pressure ulcer with documented evidence of a positioning and repositioning regimen. Patients with a high or medium risk of developing a pressure ulcer with documented evidence of repositioning. Use of heel protectors and offloading techniques (of total number heel ulcers). Ulcers with resolving/treated infection. Prevalence of patients wit h hospital-acquired heel ulcers. 75 79 88 13 T9 11 33 2 7,9 10 4. 1 36 0. 2 3,0 I3 Improved by 1. 8 i 4. 9 NURSING OLDER PEOPLE November 2010 Volume 22 adults.The improvement of resources and processes in admitting cireas is crucial to prevention. Technological advances may cdso have created a culture focused on dynamic systems as the primary intervention. Eurther difficulties may cuise in maintaining individual repositioning schedules in busy hospital Wcirds where competing demands often require a more immediate response. Hobbs (2004) demonstrated improved outcomes when regular repositioning schedules were re-established. Eurther work is required to place the emphasis on patient mobilisation and prevention and away from equipment and treatment.Education and leadership are peiramount to generate this culture shift and rebalance these nursing priorities. Conclusion A comprehensive review of previous and current prevention activity was invaluable in identifying appropriate areas for i mproved intervention. The recruitment of tissue viability support staff assisted with early risk assessment and intervention, particularly in terms of pressure-relieving equipment. A pressure ulcer campaign was useful in raising awareness of three interventions: early risk assessment and intervention, positioning cind repositioning regimens eind ‘healthy heels' project.Audit results from Eebruary 2010 showed a reduction in hospital-acquired pressure ulcer prevalence by 6 per cent and a reduction in total pressure ulcer prevalence by 4. 7 per cent. Heel offloading using heel protector boots was an effective strategy for prevention and treatment of heel pressure ulcers. Although the heel remained the most common site for hospital-acquired pressure ulcers, there was a reduction in prevcilence by 4. 9 per cent. Improvements are indicated in the provision of documentary evidence to support prevention, particularly in terms of risk assessment, positioning and repositioning programme s.This project has demonstrated that responding to organisational specific factors can produce encouraging results in pressure ulcer prevention and identify' areas for continued effort. Dedicated leadership, education, teamwork and commitment are fundamental to continue to improve standards and ensure best possible patient outcomes. Online archive For related information, visit our online archive of more than 6,000 articles and search using the keywords Find out more Copies of the positioning and repositioning regimen can be obtained by emailing the author at: Judy. [email  protected] nhs. ukThis article has been subject to double-blind review and checked using antiplaglarism software. For author guidelines visit the Nursing Older People home page at www. nursingolderpeople. co. uk Judy Elliott is lead tissue viability nurse. East Kent Hospitals NHS University Foundation Trust, Canterbury References Bcldon P (2007) Silting safely to prevent pressure damage. Wound Essentials. 2, 10 2-104. Bennett G, Dealey C, Posnetl J (2004) The cost oi pressure ulcers in the UK. A^e and Ageing. 33, 3, 230-235. Bonomini J (2003) Effective interventions for pressure ulcer prevention. Nursing Standard. 17. 32. 4300.Bourdel-Marehasson I, Barateau M, Rondeau V el al (2000) A multicenter trial of the effects of oriu nutritional supplementation in critically ill older inpatients. Nutrition. 16, 1, 1-5. Calianno C (2007) Quality improvement strategies to prevent pressure ulcers. Nurse Practitioner. 32, 7, 10, 13-I5. Catania K, Huang C, James P et al (2007) PlIPI'l: The Pressure Ulcer Prevention Protocol Interventions. American Joumai of Nursing. 107, 4, 44-52. Clark M (2002) Pressure ulcers and quality of life. Nursing Standard 16. 22, 74-80. Clark M (2009) Guidelines for seating in pressure ulcer prevention and management.Nursing Times. 105, 16, 40-41. Clark M. Defloor T, Bours G (2004) A pilot study of the prevalence of pressure ulcers in European hospitals. In Clark M (Ed) Pressu re Ulcers: Recent Advances in Tissue Viability. Quay Boolcs. London. Defloor T, De Bacquer D, Grypdonck M (2005) The effect of various combinations of turning and pres. sure reducing devices on the incidence of pressure ulcers. International Joumai of Nursing Studies. 42, 1, 37-46. Dobbs N, Spanbauer P, Datz D (2007) Continuous automated pressure ulcer monitoring. Journal for Nurses in Staff ue-elopment. 23. 3, 132-135.European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (2009) I're. ‘^sure Ulcer Prevention Quick Reference Guide. NPtJAP, Washington DC. Gebhardt K, Bliss M (1U94) Prevention of pressure sores in orthopaedic patients: is prolonged chair nursing detrimental? Journal of TLisue Viability. 4, 2, 51-54. Gould D, James T, I^rpey A et al (2000) Intervention studies to reduce the prevalence and incidence of pressure sores: a literature review. Joumai of Clinical Nursing. 9, 2,163-177. Hobbs B (2004) Reducing the incidence of pressure ulcers: implementation of a tum-team nursing program.Joumai of Gerontological Nursmg. 30, 11,46-51. Horn S, Buerbaus P, Bergstrom N et al (2005) RN staffing time and outcomes of long-stay nursing home residents: pressure ulcers and other adverse outcomes are less likely as RNs spend more time on direct patient care. American Joumai of Nursing. 105, 11, 58-70. Keogh A, Dealey C (2001) Profiling beds ver. sus standard hospital beds: effects on pressure ulcer incidence outcomes. Joumai of Wound Care. 10,2, 15-19. Moore Z, Price P (2004) Nurses' attitudes, behaviours and perceived barriers towards pressure ulcer prevention. Joumai of Clinical Nursing. 3,8,942-951. NHS Institute for Innovation and Improvement (2009) High Impact Actions for Nursing and Midwifery. NHS Institute for Irmovation and Improvement, Coventry: National Institute for Health and Clinical Excellence (2003) The Prevention and Treatment of Pressure Ulcers. Clinical Guideline 29. NICE, London. Pancorbo-Hidalgo P, Garcia-Femande z F, Lopez-Medina I et al (2006) Risk assessment scales for pressure ulcer prevention: a systematic review. Journal of Advanced Nursing. 34, 1,94-110. Pbillips L, Buttery J (2009) Exploring pressure ulcer prevalence and preventadve care. Nursing Times. 05, 16, 34-36. Reddy M, Gill S, Rocbon P (2006) Preventing pressure ulcers: a systematic review. Journal of the American Medical Association. 296, 8, 974-984. Redelings M, Lee N, Sorvillo F (2003) Pressure ulcers: more lethal than we thought? Advances in Skin and Wound Care. 18. 7. 367-372. Robinson S, Mercer S (2007) Older adult care in the emergency department: identifying strategies that foster best practice. Joumai of Gerontological Nursing. 33, T, 40-47. Sewcbuk D, Padula C, Osborne E (2006) Prevention and eari> detection of pressure ulcers in patients undergoing cardiac surgery.AORN Joumai. 84. 1, 75-96. 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November 2010 Volume 22 I Number 9 NURSING OLDER PEOPLE Copyright of Nursing Older People is the property of RCN Publishing Company and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

The City Of The Great Metropolis - 1082 Words

There was a house in the great Metropolis older than the city. Many said that it was older than the cathedral, and that before the Archangel Michael raised his voice as advocate in the conflict for God, the house stood there in its evil gloom, defying the cathedral from out its dull eyes. The house had lived through the time of smoke and soot. Every year which passed over the city crept, when dying, into this house, until at last the house was a cemetery filled with dead years. Set into the black wood of the door stood, copper-red and mysterious, the seal of Solomon, the pentagram. It was said that a magician, who came from the East (and in the track of whom the plague wandered) had built the house in seven nights. But the masons and†¦show more content†¦They died, and no doctor knew the illness. The house resisted its destruction with so great a force that word of its malignity went out over the borders of the city, spreading far over the land. At last, there was no honest man who would have ventured to make war against the house. Yes, even the thieves and the rogues, who were promised remission of their sentence provided they declared themselves ready to pull down the magician s house, preferred to go to the pillory, or even to the scaffold, rather than enter the spiteful walls, past the latchless doors, which were sealed with Solomon s seal. The little town around the cathedral became a large town and grew into Metropolis, and into the center of the world. One day there came to the town a man from far away, who saw the house and said, â€Å"I want to have that.† He was initiated into the story of the house. He did not smile. He stood by his resolution. He bought the house at a very low price, moved in at once and kept it unaltered. This man was named Rotwang. Few knew him. Only Joh Fredersen knew him very well. 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Becoming A Counselor, Therapist, Or Psychiatrist - 886 Words

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