Bellwether July 2020

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The Bellwether ď‚› An awards annual dedicated to housing the best and brightest student ideas at Bellevue University

Volume 12 2020


Editor: Amy Nejezchleb Editorial Team: Tony Jasnowski, Pat Artz, Karla Carter, Anthony Clarke, Adriana Seagle, Stephen Linenberger, Kaylene Powell, Brian Kear, Tyler Moore, Margaret Smith, Maria CardoĂąia, and Sierra Whitfield, with special thanks to David Candler, Bob Hankin, and Cris Hay-Merchant Cover artwork: Self-Portrait by Tyrone Subhan graphite on paper, 11 x 14, Spring 2020, Stouffville, Ontario, Canada The Bellwether recognizes and awards academic, innovative, and creative written and visual works. We encourage submissions from across the disciplines. Our mission is to feature outstanding academic projects with a diversity of voices, styles, and subjects meaningful to the BU community. The Bellwether is further evidence that critical thinking and creative expressions are valued and alive at Bellevue University. The Bellwether is published in July of each year, coinciding with commencement. Submissions are accepted year-round from BU students and from nominating faculty. Please submit works to bellwether@bellevue.edu, and direct any questions to Amy Nejezchleb by calling 402-557-7505 or emailing bellwether@bellevue.edu. The content of this publication does not necessarily reflect the views of the editorial team or anyone associated with Bellevue University.

Š2020 Rights revert to the author or artist after publication in The Bellwether. 2


TABLE OF CONTENTS

 4 Editor’s Notes 6 Best Overall 7 Ysa Love-Davis Rowland 11 Allison O’Driscoll, Nina Patel, and Jonah Brown 18 Tyrone Subhane 19 Department Cameo 20 Graduate Student Formal Composition 21 Lexi McCausland 38 Hilary Moore 51 Amy Schopperth 92 Graduate Student Creative Expression 93 Ysa Love-Davis Rowland 98 Undergraduate Student Formal Composition 99 Sarah Rothermund 106 Jataya Johnson 112 Bennet Lawler 115 Undergraduate Student Creative Expression 116 Christian Fairbanks 120 Julian Maxwell 123 Emily Drumm 130 Innovative Business or Community Idea 131 Elaine Carlin 145 Colton Walker 150 Technology Project 151 Jason Sands 158 Abbey Porambo 165 Jon Slack 175 Contributors

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EDITOR’S NOTES

 In Play It as It Lays, Joan Didion’s character, Maria, openly poses, “What makes Iago evil? some people ask. I never ask.” Shakespeare’s infamous bad guy represents those murky, hidden traits that often lead persons to commit nefarious, and in Iago’s case, deplorable—indeed, racist—actions against Othello. Iago refers to Othello by a degrading moniker, “the Moor,” a term whose etymology is rooted in the continent of Africa. Centering on today’s conceptual depictions of racism, change-agent artist Kara Walker pastes black cut-outs of the American South, the stereotyped testimonial mammies and sambos, on the white walls of the Guggenheim in 2009 and the Tate Modern from 2019-2020. Her thoughtprovoking work on racist stereotypes has anticipated much of the dialogue taking place this year in the United States. And yet, Americans’ rights have been violated not only in the South but in our backyard. A host of voices are breaking taboo subjects amidst racism that has placed, quite literally, its knee on the necks of black Americans to obstruct equality and justice for all. Such voices will not be silenced. Bellevue University alumna, Elexis Martinez, captured the geographical zoning that occurs today and occurred historically from 1885 through 1960 in her Omaha World Herald opinion piece. Folks would agree discrimination in the area continues when it comes to equal access to schools and public housing. What makes racial stereotypes evil? That at least five different banks would write off a valuable customer because she wanted to build her home in North Omaha…

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That it took until a black CEO looked at her very profitable, pecuniary portfolio that my friend succeeded in securing a loan to build her preferred house in her preferred home space… That a black mother practiced the art of reserving hotel rooms over the telephone in Alabama under Shawn White because her real name, Sean Jackson, would not find her family a room… That the hotel concierge, while looking at her, almost always had a look of shock when she stated her name upon arrival… Amidst George Floyd’s death from a Minneapolis police officer, as well as others during numerous protests against such brutality, fear drives some citizens to confront political unrest. What of the white couple who drew guns on protestors passing through their neighborhood of the Adirondacks of New York? What of the individuals who wish to remove confederate sculptures from parts of the South to call attention to the causes of racism? If one never asks, the truth cannot be found. Caroline Randall Williams offers an intriguing response in her New York Times op-ed piece, “My Body Is a Confederate Monument.” At the very least, she declares a worthwhile perspective that few will have arrived at before reading. In this volume, we have added commentary by Ysa Love-Rowland in her “Bottom Line Up Front” blog. Love-Rowland meets readers with an apology to her fellow Americans, a voice aligned with Williams’s own June 28, 2020 article. In visual form, Tyrone Subhan’s Self-portrait on the cover captures the aspiration and hope that many individuals feel during this social discontent, complementing Love-Rowland’s rhetoric. What of others who feel the knee of subjugation restraining their rights? Hilary Moore’s essay, “Gender Inclusion in the Workplace,” consults legal policies in business to make room for all persons, including those who may not fit binary gender conventions. Moreover, Jataya Johnson’s “A Guided Hand: An Argument for the Reform of the Juvenile Justice System in America” proposes a revised approach to rehabilitating youth. These are only a few of what this volume offers the BU community. In a year when many of us were locked down at home, working, caring for family members, and learning in affordance with what measures were put in place during COVID-19, good work was still being created, written, and exchanged. While 2020 may not be one that we wish to revisit when traveling back to the past, it has been a monumental year for the greater good and Bellevue University. ά-an

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BEST OVERALL

First Prize Ysa Love-Rowland Bottom Line Up Front Professor John McGaha

Second Prize Allison O’Driscoll, Nina Patel, and Jonah Brown The Effect of Light Sources on the Eye of Drosophila Melanogaster Dr. Tyler Moore

Third Prize Tyrone Subhan Self-portrait (cover) Professor Megan McLeay

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YSA LOVE-ROWLAND

Bottom Line Up Front: An Information Technology Blog An Apology, a Pause, a Word, and a Cause

An Apology First and foremost, I must duly express that the writings within this blog are MY thoughts and feelings alone. They are not a reflection of anyone or anything other than myself. Secondly, this past month has been emotionally draining for me to say the least, so I am apologizing to all my readers and supporters for not posting sooner. As Thomas Jefferson so aptly put it, “We hold these truths to be selfevident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty, and the pursuit of Happiness.� This statement was written into the Declaration of Independence, yet we still have brothers and sisters who are 7


being deprived of their right to life and liberty. I would be remiss as a writer if I chose to remain silent on this matter. I am so sorry that we, as Americans, are not ALL seen as equals. I am so sorry that there are systems set in place to continue to deprive people of their unalienable Rights. I am so sorry that while some mothers across America are having the discussion of what sports to play and how to keep their room clean with their sons, other mothers are having a discussion on how to not look threatening in their own skin, and how to be delicate and submissive when speaking to law enforcement. I am sorry, I am sorry, I am sorry. We MUST do better. A Pause As a nation, we need to take a pause and LISTEN. I mean REALLY listen to the people who are crying out to have their rights as citizens restored. We must pause and reflect on ways to remedy this situation; how do we ensure that we live by the words of the Founding Fathers and treat all men equally? This conversation must not start with a period, but rather a semicolon or a pause. We cannot have open dialogue if we are only willing to make absolute statements and not pause to listen. There needs to be a conversation, not a lecture. A Word The word of the day is brought to you by the letter “E.” E as in the word Ethics. Ethics covers the following dilemmas:    

our rights and responsibilities moral decisions–what is good and what is bad how to live a good life the language of right and wrong

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In the IT world, we have a code of ethics, and in both the SANS Institute and the ASIS code of ethics a few things are made ABUNDANTLY clear. 1. We are to practice our profession in accordance to the law and in ways that are morally and ethically correct. 2. We will not participate in any form of discrimination, whether due to race, color, national origin, ancestry, sex, sexual orientation, gender/sexual identity or expression, marital status, creed, religion, age, disability, veteran’s status, or political ideology. 3. Transparency - we practice our profession in a way that is honest and open. We do not conduct business in ways that could be perceived as untrustworthy or secretive (keep in mind there is a difference between secretive and private/privacy). Those three things stand out because I think that these are three principles that can be, and should be, applied everywhere. Especially now with our current state of civil unrest. A Cause Anonymous has seen a huge surge in support as protests against racial inequality sweep across the world. The online (h)activist “legion” has seen millions of new accounts follow its profiles and huge numbers of people sharing its posts. In early June, most of the largest Anonymous accounts have pledged their support to protestors against police brutality and racism that began after the death of George Floyd in Minneapolis. Make no mistake, the group has engaged in some ethically questionable tactics, so they aren’t really the hero the nation needs. However, it speaks volumes when a group who originally publicly disagreed with the Black Lives Matter organization and for six months targeted their website and brought it down using DDoS attacks is now standing by their side and saying “ENOUGH.” The collective group has joined the cause in the fight against racism and police brutality, and that, in of itself, is a wondrous thing. BLUF (Bottom Line Up Front) I am sure you are wondering about the black box above. It means I am standing in solidarity with my brothers and sisters who have for too long

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had their unalienable rights ripped from their arms and stomped upon until there was no life left in it. We must take the ethical route; we must be professionals and good ambassadors to our profession; we must ensure that these wrongs are righted. Remember, every waterfall started as a trickle and grew to a roar; the same goes for impacting change. You CAN make a difference. All you have to do is start by listening.

Editor’s Note: To view the Bottom Line Up Front blog in its entirety, please visit https://www.blufitblog.com/.

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Allison O’Driscoll, Nina Patel, and Jonah Brown

The Effect of Light Sources on the Eye of Drosophila Melanogaster

Abstract We tested if putting groups of Drosophilae under different light conditions would affect (specifically) the shape of their eyes over time. We put the Drosophila in light, dark, and controlled environments and observed them over four generations to look for any changes. After observing them, we found that the Bar allele was not relatively fit when normalized to the wild type allele. The correlation and relative fitness continued to slightly improve each generation, but we cannot be sure that this was caused by the conditions we placed on the Drosophila in our experiment or if it was due to recessive and dominant traits of the Bar and WT allele.

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There are many variations of mutations impacting the shape and color of eyes in Drosophila. Drosophila can have eye colors ranging from red to brown to apricot to white. The eyes can also be shaped differently being round, reduced rounds, kidney bean shaped, or even non-existent. Several people have performed research looking into the causes of evolution on the eyes of Drosophila, such as temperature-driven mutations (Grigliatti et al., 1973) and even the effects of stimuli on development (Verschut et al., 2017). We were curious about something that was not seen in these studies, which was whether or not light sources had an impact on the evolution of the eyes in Drosophila. It is expected that evolution will occur and favor different eye shapes (as shown in Figure 1) in different light source conditions. Materials and Methods Figure 1 Potential Eye Shapes of Drosophila from Evolution

A

B

C

Note. (A) Wild type eyes (WT); (B) Heterozygote or kidney bean shaped eyes; (C) Bar homozygote eyes. From “Application of the Hardy-Weinberg Model to a Mixed Population of Bar and Wild-Type Drosophila,” A. Bixler and F. Schnee, 2005, in M. A. O’Donnell (Ed.), Tested Studies for Laboratory Teaching, 26 (pp. 175-191). Copyright 2005 by the Proceedings of the 26th Workshop/Conference of the Association for Biology Laboratory Education.

Counting and Sorting. Drosophila melanogaster with alleles for wild type eyes and Bar eyes were obtained. Using a dissecting microscope for accuracy, Drosophila were sorted based on eye shape and sex as determined by the presence or absence of a male sex comb. Six tubes were used and labeled with three conditions: control, light, and darkness with two replicates under each condition. The control tubes were placed in a room that alternated between light and darkness. The light tubes were placed next to a bright window that had direct sunlight shining in during the day. The 12


dark tubes were placed in a drawer where no light was able to get in. Ten flies were placed into each of the conditions to begin (we did not have enough for everyone to have more). In light tube 1, the following were present: two wild type males, one wild type female, and two bar females. Light tube 2 contained one wild type male, one wild type female, and three bar females. Dark tube 1 contained three wild type males and two bar females. Dark tube 2 contained one wild type male, one wild type female, and three bar females. Control tubes 1 and 2 both contained two wild type males, one wild type female, and two bar females. The tubes were placed in the given positions for four total weeks to allow the populations to reproduce for a few generations for analysis. Calculations. After four weeks, the Drosophila were killed by freezing and were sorted into phenotypic groups using a dissection microscope. Once all counts were completed via Hardy Weinberg equations, those values were used to calculate the average expected frequencies of the next generation. Hardy Weinberg equilibrium: p2+2pq+q2=1 (P2= dominant allele frequency, Pq= heterozygous allele frequency, q2= recessive allele frequency) Wildtype (WT)= p2, Bar= q2, WTxBar= pq Insert p2, pq, and total values into the following formula: 2(p2)+pq/ 2(total)= p

Note: (p-1=q) Dp

q

pp

pq

pq

qq

p

q

This will yield the expected allele frequency of generation 2. pp=WT/WT, pq= WT/Bar, qq=Bar/Bar. We then compared the expected values to the observed values. As shown in Figure 2, to find relative fitness, we took the highest observed phenotype and divided it by its expected value. We divided this number by itself to find the first relative fitness number (W), which is always 1, and normalized the other phenotype values to it. 13


Results The frequency of the Bar allele in our Drosophila increased in our “light� tubes even though we began with no Drosophila (with the Bar allele). We can assume that some type of evolution occurred. We found that frequency of the Bar allele was not relatively fit when normalized to the highest occurring allele frequency (Figure 2). Thus, we were not able to conclude if the Drosophila experienced any direct impact on the shape of their eyes due to light sources. There was not enough relative fitness between the Bar allele and the light source to say the light directly impacts the Drosophila eye shape. With each subsequent generation, the correlation and relative fitness continued to slightly increase. For example, in generation 1 dark 1, our Bar/Bar relative fitness was 0.019 when normalized to the highest allele frequency. However, after each subsequent generation, the relative fitness of the Bar allele became closer to the WT allele. For our Generation 1 Light Tube 1, we found the relative fitness (W), which came out to 0, meaning that it was not relatively fit because our expected frequency was 45% and our actual count came out to 0%. For our Generation 1 Light Tube 2, our relative fitness (W) came out as .02, meaning that it was not relatively fit because our expected frequency was 56% yet our actual count came out to 25%. For our Generation 1 Dark 1, we found the relative fitness (W), which came out to .019, meaning that it was more relatively fit because our expected frequency was 16% yet our actual count came out to 5%. For our Generation 1 Dark Tube 2, our relative fitness (W) came out as 1, meaning that it was relatively fit because our expected frequency was 56% and our actual count came out to 66%. For our Generation 3 Light Tube 1, we found the relative fitness (W), which came out to .11, meaning that it was not relatively fit, but closer, because our expected frequency was 2% and our actual count came out to 13%. For our Generation 3 Light Tube 2, our relative fitness (W) came out as .122, meaning that it was not relatively fit, but closer, because our expected frequency was 13% and our actual count came out to 23%. For our Generation 3 Dark 1, we found the relative fitness (W), which came out to .275, meaning that it was very closer to being relatively fit because our expected frequency was 4% and our actual count came out to 3%. For our Generation 3 Dark Tube 2, our relative fitness (W) came

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out as .12, meaning that it was very close to being relatively fit because our expected frequency was 41% and our actual count came out to 47%. Figure 2 Relative Fitness of Homozygous Bar Genotype, Generation 1 and 3, as Described in Materials and Methods

Discussion Over the course of four weeks, the Drosophila in each of the conditions evolved, but the assumption was not confirmed; that, light sources would affect the eye shape confirmed through the Hardy Weinberg equations and the use of the relative fitness test. We found that the Bar allele was not relatively fit when normalized to the wild type allele, and we were not able to conclude if the Drosophila experienced any direct impact on the shape of their eye due to light sources. We concluded that evolution did occur in all three conditions of Drosophila; however, we could not determine if the light availability impacted selection against the Bar allele. There are many different species of Drosophila found around the world in different habitats, including places that were represented by the three conditions that we chose to experiment with. It was found that most of the species who do not have eyes were found in dark habitats and the ones with eyes were in the other lighter habitats (Hou et al., 2016). These findings would support the original hypothesis that in different light conditions different eye phenotypes would be favored.

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It is possible that by the Drosophila being constantly exposed to the light they experienced some type of genetic adaptation that introduced the bar allele into the generations after the first. There also could have been a misidentification issue on our behalf due to the fact that we were not using an anesthetic and instead freezing the Drosophila. This could have caused the normally circular eyes to become shriveled, leading to misidentification. There is a chance the WT/Bar Drosophila was misidentified as a WT/WT due to the freezing. In order to fully expand upon the findings and truly see if the hypothesis is correct, that the conditions do have an effect on the eye shape, the experiment would have to track the different generations of Drosophila and their offspring over many generations. We would also need to switch over to using an anesthetic to eliminate the chance for error due to freezing.

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References Grigliatti, T. A., Hall, L., Rosenbluth, R., & Suzuki, D. T. (1973). Temperature-sensitive mutations in Drosophila melanogaster. Molecular and General Genetics MGG, 120, 107-114. Hou, Y., Li, S., & Luan, Y. (2016). Pax6 in Collembola: Adaptive evolution of eye regression. Scientific Reports (Nature Publisher Group), 6. Verschut, T. A., Carlsson, M. A., Anderson, P., & HambÓ“ck, P. A. (2017). Sensory mutations in Drosophila melanogaster influence associational effects between resources during oviposition. Scientific Reports (Nature Publisher Group), 7, 1-10.

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Tyrone Subhan

Self-Portrait

graphite on paper 11 x 14 Spring 2020 Stouffville, Ontario Canada

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DEPARTMENT CAMEO

Cybersecurity Cybersecurity involves protecting the confidentiality, integrity, and availability of data and other information assets from unauthorized access and attacks. Lead by program director and Maenner Endowed Chair Douglas Rausch, Bellevue University’s Cybersecurity programs enroll over 1100 undergraduate and graduate students, taught by a team of four fulltime faculty members and two score adjunct faculty members. Cybersecurity students develop and hone their communication skills by writing papers, presentations, infographics, and blogs on subjects, such as identifying security threats and vulnerabilities, managing risks, investigating breaches, creating security awareness, and countering social engineering and phishing. Bellevue’s Cybersecurity degree programs are designated as a National Center of Academic Excellence (CAE) in Information Assurance/Cybersecurity by the Department of Homeland Security (DHS) and the National Security Agency (NSA). The Bachelor of Science (BS) degree in Cybersecurity ranks as the #2 Online Cyber Security Degree Program for 2019 by SecurityDegreeHub.com and placed among the top 10 of Best Online Bachelor’s in Cyber Crime Programs for 2019 by BestColleges.com.

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GRADUATE STUDENT FORMAL COMPOSITION

First Prize Lexi McCausland Engaging the Deskless Workforce Dr. Kate Joeckel

Second Prize Hilary Moore Gender Inclusion in the Workplace Dr. Kate Joeckel

Third Prize Amy Schopperth

Level III Trauma Center: Gap Analysis to Level II Dr. Mike Freel

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LEXI MCCAUSLAND

Engaging the Deskless Workforce

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HILARY MOORE

Gender Inclusion in the Workplace

Executive Summary Intended for leadership and human resources professionals, this paper provides an overview of the debilitating ways in which transgender employees can suffer in the workplace if action is not taken via policy standards and exemplified workplace culture. This subject is pertinent and deserves necessary attention irrespective of industry or business size. The juxtaposition of a government unwilling to define transgender individuals as a protected community with organizations struggling to compose guidelines that allow all employees to feel respected and safe demonstrates that such an exploration is essential at this time. The path to improved inclusion for gender-nonconforming employees demands increased opportunities for feedback and support that is unambiguously communicated by management. The separate but related problem of transgender individuals’ difficulty finding employment is also discussed as one of the main obstacles faced by the community. This issue calls for a more nuanced approach to hiring and recruitment practices in order to actively reach out toward a population that may not have access or privilege afforded to them. The solution proposed herein takes the form of three steps referred to as the three IN’s of gender inclusion: invite, introduce, and incorporate. Transgender individuals comprise an area of untapped potential that has far-reaching organizational implications for the future. Therefore, business leaders must familiarize themselves with the best practices to implement in order to attract and support this underrepresented workforce. Keywords: Transgender, gender-nonconforming, workplace diversity, LGBTQ+, transgender employee rights 38


Imagine being constantly disrespected while at work. Not just by the occasional grumpy customer—by managers, coworkers, and subordinates. Perhaps it is completely unintentional — coworkers may not even realize that their behavior is affecting someone in this way, but the individual’s extreme discomfort prevents any possibility of addressing the situation in a supportive environment. The threat of repercussions, such as critical remarks from coworkers, lack of access to career advancement opportunities, or even termination, deter any attempts at resolution. Understandably, the stress begins to affect the person’s job performance as well as their personal life. The threat of verbal or even physical harassment is so prevalent, they even avoid using the restroom while at work. The person does not feel safe or able to comfortably make a living. For members of the transgender and gender-nonconforming communities, this scenario may sound all too familiar. These individuals do not have to imagine — it is often their reality. The purpose of this paper is to address this problematic environment by outlining areas of opportunity for organizations which may not even realize the mounting evidence that points toward the necessity of gender inclusivity. This issue begins with the hiring process, as research indicates that the primary concern of transgender individuals is the often insurmountable hurdle of simply acquiring gainful employment (Ashley, 2018; Chan, 2019; Cobb & McKenzie-Harris, 2019). Therefore, this paper seeks to address those working in leadership, recruitment, and human resource positions. At the same time, the workplace harassment experienced by those in the transgender community is documented and prevalent (Ashley, 2018; Chan, 2019; Cobb & McKenzie-Harris, 2019). As a result, any business seeking to ensure that their policies extend to transgender employees with regards to safety and respect in the workplace can benefit from the ideas discussed herein. This paper will begin by providing an overview of the experience of being an employed transgender individual, including frequently used terminology and historical social justice trends affecting the community. The current legal landscape will be briefly discussed before identifying the problematic concerns that exist despite the Supreme Court’s current inability to protect transgender employees. The argument will be made that working toward a solution is of paramount concern for businesses now, regardless of the lack of any existing legal requirements. Ashley (2018) shares an especially poignant and appropriate quote by renowned author and journalist Ta-Nehisi Coates: “The hammer of criminal justice is the preferred tool of a society that has run out of ideas.” The ideas shared throughout this paper are these implied overlooked tools, the tools with which organizations can learn and build improved hiring practices as well as more supportive diversity and human resource initiatives in order to better 39


support employees regardless of their gender expression. As a note of consideration for the reader, the paper’s author identifies as cisgender and does not wish to negate the experience of or otherwise speak for the community on which this paper is concentrated. Background As organizations grow and diversify, the concept of respect and how to equitably enforce it within a workplace context demands increased attention by those in leadership positions. Employee codes of conduct and hiring policies are invariably rooted in the laws imposed by the government, but these laws may not always extend to certain groups. Currently, no federally mandated legal protections prevent workplace discrimination on the basis of one’s gender identity in the U.S. (Allen, 2018; Clarke, 2019; Cobb & McKenzie-Harris, 2019). As a result, transgender and gendernonconforming individuals deserve unique consideration from a managerial, and particularly a human resources, perspective. Terminology Overview From bathroom and locker room facilities to official bureaucratic forms, many American workplaces are heavily influenced by the gender binary: the idea that all individuals identify as either male or female, a distinction typically assigned at birth based on physical characteristics. Although, 1 in 100 individuals have bodies that deviate from this standard interpretation (Clarke, 2019), and research indicates that transgender and gender-nonconforming individuals have existed for centuries crossculturally (Cobb & McKenzie-Harris, 2019; Dietert & Dentice, 2009; Halliwell, 2019). This imposed binary has created obstacles for those that do not identify as cisgender, someone whose gender identity aligns with the sex to which they were assigned at birth. An individual who does not identify as cisgender may identify as transgender, a term that describes those who do not identify as the gender they were assigned at birth based on biological sex. Similarly, the terms gender-nonconforming and nonbinary may refer to those who do not identify with the traditional expectations of their assigned gender. Although this paper may utilize the terms transgender and gendernonconforming interchangeably, it is important to acknowledge that not all transgender individuals may identify as gender-nonconforming and vice versa. For example, a transgender woman (assigned male at birth based on biological sex characteristics) may adhere to stereotypical “female” behaviors and expectations and therefore not identify as gendernonconforming. The above definitions, as well as additional helpful 40


terminology, are adapted and can be retrieved from the Human Rights Campaign webpage Glossary of Terms (n.d.). The Law and Transgender Employees It is essential to first appreciate the legal backdrop against which this issue is set. Congress’ reticence to explicitly prohibit against gender identity discrimination has resulted in a variety of contradictory rulings throughout recent case law. Ambiguous interpretations of Title VII of the 1964 Civil Rights Act are cited as one area of blame, as researchers note that banning “sex discrimination” may not always be interpreted to cover one’s gender identity or gender expression in the eyes of the federal government (Cobb & McKenzie-Harris, 2019; Higgins, 2019; McGregor, 2019; Turk, 2019). Another aspect to consider is the federally required EEO-1 form, which businesses must provide for every employee. Although certain state IDs and even the Social Security Administration allow for an X in lieu of selecting male or female on government documents, the EEO-1 form does not provide a third option, forcing nonbinary employees to choose a gender with which they may not genuinely identify (Allen, 2018; McGregor, 2019). Although several potentially groundbreaking cases are currently under review by the Supreme Court with decisions expected midway through 2020 (Higgins, 2019; McGregor, 2019), researchers have already adopted conflicting perspectives on the ways in which legal precedents may already be affecting transgender employees and what positive changes can be reasonably anticipated. Ultimately, despite a lack of government guidelines, the current literature emphasizes that businesses should include anti-discrimination policies in order to mitigate risk and clearly communicate support to all employees regardless of their gender expression or identification. A significant distinction to consider is the necessity of “consistent enforcement” alongside any written policies in order to perpetuate an environment of respect (Cobb & McKenzie-Harris, 2019, A. Building an Inclusive Anti-Discrimination Policy, para. 3). This resounding opinion is succinctly summed up by Peña (2018), who notes that regardless of the outcomes of upcoming Supreme Court rulings on the matter, businesses should continue to work toward inclusion policies for transgender employees not only to avoid lawsuits but to ensure enhancement of “employee morale and customer loyalty” (p. 38). Before turning to the intricacies of problematic workplace cultures and how to combat their negative consequences, there are opposing angles to acknowledge,. stemming from a sociocultural perspective in terms of the ability of lawmakers to enact significant change. These perspectives emphasize the

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role of workplace policy and leadership in a time when government regulations may fail to address the needs of employees. When the Law Is Not Enough Some researchers argue that a focus on passing bills that support transgender individuals in the workplace are misguided efforts that belie the true goal of inclusion and support, a sentiment that is reminiscent of the quote shared earlier by Coates (Ashley, 2018). Although based in Canada, Ashley argues that governments may overestimate the impact of implementing laws that explicitly prohibit discrimination against transgender individuals. Rather than focus on punishing those who act against them, the author stipulates that resources may be better put toward tangible ways to support the well-being of transgender individuals (Ashley, 2018). This notion references the essence of a quote by A. C. Dumlao, program manager for the Transgender Legal Defense and Education fund, when it comes to gender inclusion in the workplace: “It is better to be proactive rather than reactive” (Allen, 2018, para. 8). In other words, anticipatory, proactive behavior may be more beneficial than reactionary measures, such as outlines of punishment or threats to the offending individual. Another related factor to consider that would not necessarily be addressed by passing new laws is the intersectionality of socially imbedded prejudices, such as racism, sexism, and classism. Halliwell (2019) shares staggering statistics that clarify the wildly disproportionate rates at which transgender women of color not only lack access to healthcare but are victims of violence and murder across the U.S. (p. 235). Burns (2019) emphasizes that the fight for marginalized identities within the transgender community demands increased considerations, a fact supported by a frequently cited lack of research into the transgender experience that involves people of color or additional marginalized groups (Chan, 2019; Nadal et al., 2016; Ozturk & Tatli, 2016). While it is clear that a one-sizefits-all legal solution may not exist at the federal level, it is important to evaluate the incremental yet effective changes that organizations are able to control and implement during daily operations. This paper seeks to emphasize how and why businesses should prepare to support transgender individuals in the workplace as well as demonstrate why such “reactionary” measures are not ideal. Problem One of the most overarching, evidence-based conclusions to be found amongst the literature is the documented symptoms of psychological 42


distress experienced by transgender employees who are subjected to various levels of discrimination within the workplace. Studies have shown that discrimination toward transgender individuals can predict depression, anxiety, and stress (Lloyd, Chalklin, & Bond, 2019), which in turn will negatively impact transgender employees’ future career paths and motivations to contribute meaningfully in their work environment (Ozturk & Tatli, 2016; Tebbe et al., 2019). Chan (2019) describes how issues involving an absence of adequate healthcare policies that cover transitioning can be detrimental in the same way as pervasive workplace microaggressions toward transgender employees. If an individual’s organizational culture does not allow them to feel comfortable with their most fundamental human needs as employees—safety, bathroom access, and basic respect from colleagues, to name a few—it is understandable that lasting mental health effects can emerge. Elaborating on the concept of microaggressions, Nadal et al. (2016) clarify how major effects can result from subtle behavioral changes, aggressive or not. Of the four psychological dilemmas the authors describe as resulting from increased exposure to microaggressions, the “catch-22” of responding to microaggressions is especially salient within the context of workplace culture. This concept encapsulates differing perceptions, fear of repercussions, and the resources needed (time, mental energy) to confront an aggressor (Nadal et al., 2016). Failing to support transgender individuals at work can take the form of discrimination at every stage, from denying an interview or an opportunity for promotion to subliminally discouraging transgender employees from speaking up with new ideas as they are subjected to various forms of workplace harassment. Therefore, the problem faced by transgender workers is twofold: finding a job first, followed by finding success, safety, and respect once at work. Solution: the Three “IN’s” of Gender Inclusion No matter the size or reach of a business, it is clear that organizations must turn their attention to evaluating concrete and consistent ways to enact positive change that is policy-based and actionable in order to promote gender inclusion in the workplace. The steps proposed here can be referred to as the three IN’s of gender inclusion: invite, introduce, and incorporate. Although formulated to be embraced sequentially, these steps may be equally beneficial when explored concurrently. Each step builds upon the last in order to assist organizations that are in need of learning the foundational basics of including transgender individuals in the workplace. At the same time, companies with policies already in place that strive to protect transgender employees may also

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benefit from the ideas surrounding active recruitment policies as well as ongoing cultural reform within the organization itself. Step 1: Invite As mentioned previously, the main obstacle that transgender individuals face in the workforce is initially acquiring a job (Ashley, 2018; Chan, 2019; Cobb & McKenzie-Harris, 2019). Therefore, this first step takes on both a literal and a figurative meaning. Primarily, recruitment efforts and hiring practices must evolve in order to invite transgender individuals to the workforce table to being with. For a community that struggles with unemployment at rates three times that of the national average (as cited in Chan, 2019), a meeting point must be reached. Considering the adversity faced by transgender workers, organizations might evaluate the possibility of conducting job fairs or even posting flyers at LGBTQ+ community centers or virtually via websites. This simple change communicates an openness and a desire to support individuals who may have faced the opposite in the past. More figuratively, this step necessitates the need for establishing resources within organizations that cater to transgender individuals, especially those who may not be comfortable disclosing their gender identity with their managers or peers. Research demonstrates that transgender employees exhibit an increased need for access to mental health services as well as career counselors with experience related to the transgender community (Halliwell, 2019; Tebbe et al., 2019). This opportunity for invitation is especially resonant, considering the earlier discussion surrounding the workplace harassment experienced by the transgender community. Organizations that do not provide an outlet through which to identify this problematic behavior risk what Beauregard et al. (2018) refer to as the “vicious cycle” that results from neglecting transgender employees: “When voices are unheard, they are likely to become silenced and marginalized. When voices become silenced and marginalized, they go unheard” (p. 870). In order to be successful, organizations must work toward actively hiring and providing supportive outlets for transgender employees. Step 2: Introduce The second step to improving gender inclusivity in the workplace is to introduce the topic of gender-nonconformity to the business. This step entails providing and making readily available resources that appropriately explain the needs and expectations of transgender employees. Reviewing these resources should be required of all members of a business or 44


leadership team, but regular trainings or seminars could assist in reaching a wider audience. Human resources departments already familiar with implementing diversity initiatives may have an advantage. Many organizations devoted to this step already exist and provide a bevy of accessible information via their website, such as the Human Rights Campaign (hrc.org), the National Center for Transgender Equality (transequality.org), and Out & Equal (outandequal.org). Learning about important terminology helps introduce organizations to the small changes that can be made to make all employees more comfortable with gender inclusion. Gibson and Fernandez provide a comprehensive overview in their frequently referenced and quintessential 2018 book, relating why organizations should familiarize themselves with practices that support transgender employees. The authors’ emphasis on the link between an inclusive atmosphere and improved organizational performance cannot be understated, and their practical steps for inclusion are supported with various case studies to illustrate effectiveness (Chapter 6). Educational trainings have also proven beneficial for coworkers and leadership (Dietert & Dentice, 2009). Manuals such as Gibson and Fernandez’s (2018) deserve attention in order to shape a given organization’s unique action plan and introduce a shift toward gender inclusivity. Step 3: Incorporate The final step toward a more gender inclusive working environment concerns the evolution of a workplace’s culture, which may take time. An organization that is determined to change its policies will undeniably cause a shift in the workplace culture. The example set by leadership teams is most critical during this step, as they must uphold the changing policies in order to sufficiently incorporate them into the existing workplace culture. This incorporation should not be viewed as an assimilation of the gender-nonconforming employee by any means; rather, an opportunity for businesses to expand their policies to include a more diverse workforce as well as support those who may not be ready to be completely out at work. Pasek et al. (2017) note that disclosure of one’s gender expression should not be explicitly required or discussed as some individuals may not yet be comfortable sharing this information publicly. Responsible efforts at providing the opportunity to discuss gender expression are outlined as more important than requiring an entire company to disclose pronouns in one’s email signature, for example. Required disclosures (enforced pronouns on name tags or email signatures, or even bathroom facilities that do not allow for an “all genders” option) may risk forcing an individual to publicly identify in a way that does not 45


align with their true nature. Coming out as transgender is a highly personal experience, and consequently, businesses should not impose any more than is necessary. Some researchers argue that American law is more than equipped to support nonbinary individuals in the workplace by both basing the shift in recognizable civil rights concepts and working around existing parameters. Clarke (2019) discusses the benefits of a recognition model over a gender-neutrality model, as recognition of transgender individuals may be “more politically palatable” than shifting an entire culture to dissolve gender as a primary identifying characteristic (p. 949). Extending designations from M or F on identification documents to allow for an X option would be simple to implement, Clarke (2019) argues, and would also help delineate how to classify discrimination protections. Allen (2018) shares how some companies circumvent the EEO-1 form by simply adjusting the verbiage that it is “for EEO purposes” only, allowing the organization to separate itself and emphasize that all gender identifications are still respected within the confines of the business (para. 39). Ultimately, the incorporation step will be unique to every business that ventures down the path of gender inclusion. These examples provide a basis from which to consider the advantages that lie in wait for those organizations that choose to persevere. These perspectives also provide a well-developed starting point for businesses of any nature and size to begin the recursive process of creating an environment supportive of employees of all gender expressions. Conclusion Rather than one prescribed, straightforward answer, providing outlets that communicate openness and a desire to allow all employees to feel accepted is the most basic way to reach a community that is still underrepresented and underresearched with regards to workplace cultures. This communication needs to start at the recruitment stage and be exemplified in daily organizational routines and consistently and reliably enforced by management. Most importantly, if an employee comes forward and shares that their gender expression differs from how they are being treated in any way, organizations must listen and be willing to admit when there is room for improvement. Beauregard et al. (2018) note that this access to power in terms of voicing opinions and concerns is one of the most significant ways in which transgender employees may differ from their cisgender peers. Although personal opinions abound, the rights of transgender and nonbinary employees are multifaceted issues that will only become more articulated and pressing with time. It is paramount that businesses evaluate why, but more critically, how, to create an atmosphere of inclusion. 46


Beginning with an understanding of legal precedents and their future implications, organizations can appreciate how trends indicate the necessity of putting policies in place that prohibit discrimination on the basis of one’s gender. By utilizing legal trends as a roadmap to anticipate change, the importance of perpetuating supportive workplace cultures can then be appreciated. Finally, the extant research provides numerous guidelines for instigating improvements in the workplace in order to fluidly accommodate nonbinary gender expression as well as transitioning employees via the three IN’s: invite, introduce, and incorporate. As noted by Dietert and Dentice (2009): The issue is not a matter of allocating “special” rights to transgender people but rather one of allocating rights that are enjoyed by the society as a whole: the right to work in an environment free from harassment, fear, and discrimination. (p. 138) It is unsurprising that workplaces are often at the forefront of research concerning civil rights issues, for it is at work that individuals collide into a collective workforce comprised of every opinion and experience imaginable. In order to perpetuate a culture of respect, leaders and human resource professionals must consider the perspectives of transgender employees so that all organizations may embrace a future that is becoming increasingly nonbinary.

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References Allen, S. (2018, September 11). Workplaces need to prepare for the nonbinary future. https://www.thedailybeast.com/workplaces-needto-prepare-for-the-non-binary-future Ashley, F. (2018). Don’t be so hateful: The insufficiency of antidiscrimination and hate crime laws in improving trans wellbeing. University of Toronto Law Journal, 68(1), 1–36. https://doi.org/10.3138/utlj.2017-0057 Beauregard, T. A., Arevshatian, L., Booth, J. E., & Whittle, S. (2018). Listen carefully: Transgender voices in the workplace. International Journal of Human Resource Management, 29(5), 857–884. https://doi.org/10.1080/09585192.2016.1234503 Burns, K. (2019, July 17). The LGBTQ civil rights fight is far from over. https://www.vox.com/first-person/2019/7/17/20697174/lgbtqcivil-rights-fight-not-over Chan, C. D. (2019). Broadening the scope of affirmative practices for LGBTQ+ communities in career services: Applications from a systems theory framework. Career Planning & Adult Development Journal, 35(1), 6–21. Clarke, J. A. (2019). They, them, and theirs. Harvard Law Review, 132(3), 895–991. Cobb, J., & McKenzie-Harris, M. (2019). “And justice for all”. . . maybe: Transgender employee rights in America. ABA Journal of Labor & Employment Law, 34(1), 1–21. Dietert, M., & Dentice, D. (2009). Gender identity issues and workplace discrimination: The transgender experience. Journal of Workplace Rights, 14(1), 121–140. Gibson, S., & Fernandez, J. (2018). Gender Diversity and Non-Binary Inclusion in the Workplace: The Essential Guide for Employers. Jessica Kingsley Publishers. Glossary of Terms (n.d.). Retrieved from https://www.hrc.org/resources/glossary-of-terms

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Halliwell, P. (2019). The psychological & emotional effects of discrimination within the LGBTQ, transgender, & non-binary communities. Thomas Jefferson Law Review, 41(2), 222–237. Higgins, T. (2019, October 7). LGBT workers head to Supreme Court for blockbuster discrimination cases: “I’ll be that person to stand up.” https://www.cnbc.com/2019/10/07/supreme-court-lgbt-workerrights-kavanaugh.html Lloyd, J., Chalklin, V., & Bond, F. W. (2019). Psychological processes underlying the impact of gender-related discrimination on psychological distress in transgender and gender nonconforming people. Journal of Counseling Psychology, 66(5), 550–563. https://doi.org/10.1037/cou0000371 McGregor, J. (2019, July 7). How employers are preparing for a gender non-binary world. https://www.washingtonpost.com/business/2019/07/02/howemployers-are-preparing-gender-non-binary-world/ Nadal, K. L., Whitman, C. N., Davis, L. S., Erazo, T., & Davidoff, K. C. (2016). Microaggressions toward lesbian, gay, bisexual, transgender, queer, and genderqueer people: A review of the literature. Journal Of Sex Research, 53(4–5), 488–508. https://doi.org/10.1080/00224499.2016.1142495 Ozturk, M. B., & Tatli, A. (2016). Gender identity inclusion in the workplace: Broadening diversity management research and practice through the case of transgender employees in the UK. International Journal of Human Resource Management, 27(8), 781–802. https://doi.org/10.1080/09585192.2015.1042902 Pasek, M. H., Filip, C. G., & Cook, J. E. (2017). Identity concealment and social change: Balancing advocacy goals against individual needs. Journal of Social Issues, 73(2), 397–412. https://doi.org/10.1111/josi.12223 Peña, K. M. . (2018). LGBT Discrimination in the Workplace: What Will the Future Hold? Florida Bar Journal, 92(1), 35–39. Tebbe, E. A., Allan, B. A., & Bell, H. L. (2019). Work and well-being in TGNC adults: The moderating effect of workplace

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protections. Journal of Counseling Psychology, 66(1), 1–13. https://doiorg.ezproxy.bellevue.edu/10.1037/cou0000308 Turk, K. (2019, October 8). The Supreme Court must extend The Civil Rights Act’s protections to LGBTQ employees. https://www.washingtonpost.com/outlook/2019/10/08/supreme -court-must-extend-civil-rights-acts-protections-lgbtq-employees/

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AMY SCHOPPERTH

Level III Trauma Center: Gap Analysis to Level II

Abstract Traumatic injuries have been the leading cause of death in the U.S. in patients aged 1-45 and a major cause of disability (American College of Surgeons, 2014). The history of organized trauma care has evolved over the course of the last few centuries. Trauma center levels provide different levels of trauma care to the injured patient; however, access to this trauma care has inconsistencies across the United States. This capstone project will examine the trauma data of a local Dayton, Ohio, Level III trauma center to determine if there is a need for increased trauma care in the area. If a need is found, this capstone project will explore the gaps between Level II and Level III trauma center criteria requirements and evaluate the recommendations for furthering trauma care at the same Level III trauma center.

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Level III Trauma Center: Gap Analysis to Level II Trauma is a result of an energy transfer causing injury to the human body (Society of Trauma Nurses, 2019). Traumatic injuries occur from motor vehicle crashes, falls, assaults, and many other mechanisms. According to the American College of Surgeons: Committee on Trauma (2020), trauma has been the leading cause of death in those aged 1-45 and accounts for more years in disability than any other disease process. Trauma is considered a public health problem of significant proportion given the extent of death and disability. Access to trauma care depends on the population’s access to a trauma center within a trauma system. It is possible that a patient could die if the patient cannot access a trauma center for treatment of a lifethreatening injury. According to the American College of Surgeons: Committee on Trauma (2020), some areas of the United States are not covered by trauma centers or have sparse covering of trauma centers while other areas are oversaturated in definitive trauma care. Both scenarios can be detrimental to the care of the trauma patient as decreased access to care can lead to increased mortality and disability in the patient and increased access to care can reduce the number of patients cared for by the providers, therefore diminishing the providers’ skills (American College of Surgeons: Committee on Trauma, 2020). Organizational Review ACME Medical Center is part of the Pretend Health Network (PHN) in the greater Dayton area of Ohio. ACME is located in Blue County, Ohio (Pretend Health Network, 2019). PHN is a faith-based, nonprofit organization consisting of nine hospitals, several freestanding emergency centers, the Pretend Physician Network (PPN), and many outpatient primary and specialty clinics. PHN strives to provide the right care in the right place (Pretend Health Network, 2019). The PPN mission and vision are to improve the quality of life of the communities served through education and innovation (Pretend Health Network, 2019). The mission and vision are achieved through the core values: trustworthy, innovation, caring, competent, and collaboration (Pretend Health Network, 2019). ACME has a variety of services, including emergency department, labor and delivery, surgical services, catheterization laboratory, imaging, laboratory, and on-sight clinics. ACME is a certified primary stroke center, a Hernia Center of Excellence, and a Level III trauma center. The Level III

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trauma center and the trauma department will be the primary focus of this text. Leadership/Organizational Structure The leadership structure within PPN is both network and hospital level. The hospital level Chief Executive Officer (CEO) is part of the network leadership, as well as the hospital leader (Pretend Health Network, 2019). Hospital leadership includes executives, directors, managers, coordinators, and team leaders across all units (B. Smith, personal communication, March 11, 2020). The trauma department leadership consists of the Trauma Program Manager (TPM) and Trauma Medical Director (TMD) (ACME Medical Center, 2019). The TPM reports to the Director of Emergency Services and then to the Chief Nursing Officer and Vice President of Patient Care (ACME Medical Center, 2019). The TMD is a PPN-employed general surgeon who has a dotted reporting line to the CEO for the hospital (ACME Medical Center, 2019). Trauma department staff report to the TPM (ACME Medical Center, 2019). All manager, director, and executive leaders are required to have a master’s degree in a healthcare-related field of study, and leadership experience in healthcare is preferred (Pretend Health Network, 2019). Mandatory monthly leadership meetings and quarterly employee town hall meetings occur to update leaders and staff on the events of the hospital (B. Smith, personal communication, March 11, 2020). These meetings are mandatory to promote excellent communication; promote direction and planning across the continuum of care; and provide a setting for the advancement of quality, communication of organizational goals, financial stewardship, and strategic planning (B. Smith, personal communication, March 11, 2020). The trauma department consists of the TPM, trauma performance improvement (PI) coordinator, a trauma registrar/analyst, a trauma registrar, two full-time advanced practice providers (APPs) and two parttime APPs (ACME Medical Center, 2019). The trauma department is no different in the promotion of quality or performance improvement and patient safety (PIPS) concerns, the communication of department goals, and strategic planning. The TMD and TPM chair trauma-related hospital and network committees to ensure consistency with practice guidelines, continue PIPS measures throughout the trauma continuum of care, and inform team members of changes and developments (ACME Medical Center, 2019). The trauma department staff participate in a monthly staff

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meeting and monthly one-to-one meetings with the TPM (ACME Medical Center, 2019). ACME is required to give back to the community as part of the non-profit organizational status (Pretend Health Network, 2019). Network leaders and staff partner with community organizations to volunteer time and resources to support the community (B. Smith, personal communication, March 11, 2020). An example of community involvement is in the trauma program. The trauma program supports the community by focusing on injury prevention as part of the Level III trauma program verification (ACME Medical Center, 2019). The trauma department provides complimentary first-aid training to children, schools, and in partnership with the police department; free STOP the Bleed hemorrhage control classes monthly to the community and at community businesses and schools; Car Fit inspection to the elderly in partnership with county organizations and the American Automobile Association (AAA); and many other community prevention events and health fairs (ACME Medical Center, 2019). Data and Informational Management Like many healthcare organizations, PPN is responsible for managing large amounts of data and protecting patient and business information. Mandatory data, such as hospital performance reports, quality data, adverse events, and specific medical conditions, amongst others, must be reported to state, regional, and national entities to maintain accreditations and certifications (ACME Medical Center, 2019). Data is used for many purposes, such as reviewing network performance; examining competitive position; planning strategic management; and monitoring and improving quality, patient satisfaction, and operational and financial performance. The trauma program is required to maintain a dependable, thorough and comprehensible trauma registry as part of Level III trauma verification (American College of Surgeons, 2014). The trauma department has a wide variety of data it is responsible for per the verification guidelines from the ACS. Mandatory data is reported to the Southwestern Ohio Regional Trauma System, the state of Ohio, the National Trauma Data Bank (NTDB) and the Trauma Quality Improvement Program (TQIP) (ACME Medical Center, 2019). The trauma department uses and collects data for performance improvement, public health, injury prevention, outcomes measurement, resource utilization and cost analysis, research, and organization of trauma systems (American College of Surgeons, 2014). Per

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the trauma verification standards, it is required to benchmark data against similar trauma centers through TQIP (ACME Medical Center, 2019). Performance Improvement and Quality Assurance Quality, performance improvement, and patient safety are pillars to the mission and values of PPN (Pretend Health Network, 2019). Key stakeholders participate in monthly, bi-monthly, and/or quarterly meetings to discuss quality initiatives and measurable quality goals (ACME Medical Center, 2019). Quality updates are given in all leadership and town hall meetings (B. Smith, personal communication, March 11, 2020). PHN provides a Just Culture, a program that reviews all viewpoints of issues and process problems within a no-blame atmosphere (Pretend Health Network, 2019). All leaders are required to attend training on Just Culture to best understand the environment (Pretend Health Network, 2019). The trauma department is required to have a high-functioning PIPS program to provide the highest quality and efficient care to the injured patient (American College of Surgeons, 2014). The goals of the trauma PIPS process are to identify issues, develop actions, and provide loop closure to improve the process and care (American College of Surgeons, 2014). Cases are primarily reviewed by the trauma PI coordinator (ACME Trauma Department, 2019). The trauma PI coordinator then determines if the case meets the trauma program criteria for secondary review by the Trauma Quality Director and the Trauma Medical Director (ACME Trauma Department, 2019). Tertiary reviews of cases are evaluated in a multidisciplinary committee structure led by the TMD (American College of Surgeons, 2014). Strategic Management Strategic planning is conducted at all levels of PPN. Network and hospital leaders perform strategic planning sessions regularly to assure goals are aligned with the needs of the community and the needs of the community are met. Strategic plans are broken into immediate, short-term (less than one year), or long-term (up to three years) (B. Smith, personal communication, March 11, 2020). ACME hospital leadership has started a new strategic planning process in the last year to provide better organization and follow-through with strategic efforts (B. Smith, personal communication, March 11, 2020). Plans are regularly reviewed by the executive committee and key stakeholders involved in key initiatives (B. Smith, personal communication, March 11, 2020).

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The trauma department started yearly planning in 2019. The TPM, trauma PI coordinator, and trauma registrars met for two days to discuss initiatives to help develop the department and modernize into the future (ACME Medical Center, 2019). Ideas were compiled and timelines set based on current resources and goals and prioritizing goals affecting patient care gaps. The plans were broken into immediate, short-term, and long-term. Individuals outside the trauma department, including executive and medical staff partners, were or will be included to assure plans put in place will move forward (ACME Medical Center, 2019). Customer Satisfaction With Centers for Medicare and Medicaid (CMS) payments being tied directly to patient experience and increased awareness from patients as consumers of care, it is important to assure that customer satisfaction is at the forefront in the healthcare setting. Most healthcare organizations utilize patient experience tools to assist in assuring patient satisfaction goals are met. PHN contracts with Press Ganey to obtain patient experience data and results (B. Smith, personal communication, March 11, 2020). These data and results are utilized to improve patient experience. Press Ganey data can be extracted to provide whole hospital or department patient experience scores. A Google search for ACME Medical Center reveals the percentage of star rating has grown consistently from 3.3 to 4.7 over the last two years (B. Smith, personal communication, March 11, 2020). The Hospital Consumer Assessment of Healthcare Providers (HCAHPS) scores measure domains of patient experience related reimbursement (Herman et al., 2019). The domains of communication with nurses and providers drive the total HCAHPS scores (Herman et al., 2019). The trauma department has done some work in reviewing patient satisfaction scores related to provider communication (ACME Medical Center, 2019). Changes in provider staff and the addition of 12-hours-perday APP coverage improved patient experience scores by approximately 10% in less than six months (ACME Medical Center, 2019). Customers outside of the patient population include ancillary departments, providers, nursing staff, EMS providers, and partner agencies within the city, county, and state. Over the last year, the ACME trauma department has worked with leadership, staff, and community partners to improve relationships in an effort to improve overall trauma care (ACME Medical Center, 2019). Continued communication, education, engagement, and exposure with clinical and community partners will enhance and grow the relationships and improve patient care in the long term.

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Business Results Healthcare is an ever-changing world, and continued focus on results can assist in assuring the organization is moving forward. Business results focus on key services and performance indicators within the organization. Results are reviewed throughout the year so the network can determine if focus needs to change (B. Smith, personal communication, March 11, 2020). The business development and rural development managers are responsible for understanding the hospitals catchment area to assure business result goals are met (B. Smith, personal communication, March 11, 2020). Quality and patient safety through people are a big driver to operational excellence throughout PPN (Pretend Health Network, 2019). In January 2020, it was announced that PHN received the honor of being a Top 100 Fortune company (B. Smith, personal communication, March 11, 2020). Business results for the trauma department have mostly been related to maintaining trauma verification and designation. In mid-2019, with continued hospital and trauma program growth, it was decided to assess the possibility of increased services related to care of the injured patient (ACME Medical Center, 2019). With a growing trauma program and growing trauma and hospital volume, partnered with the closing of a community Level II in 2017 and a county Level III in 2020, a need for trauma care in the future is evident (ACME Medical Center, 2019). Problem Statement The challenge of remaining competitive in healthcare today is difficult as the landscape continues to evolve. Providing services at a hospital that are needed by the community is important to the longevity and future of the healthcare business. PHN is not only responsible for expanding its footprint in the communities it serves and beyond but also to withstand the competition in the region (ACME Medical Center, 2019). Currently in the Dayton area, there are numerous hospitals between two hospital networks, Premier and PPN. Some are verified and designated trauma centers. Premier has four hospitals in the Dayton area, and they are all designated trauma centers (ACME Medical Center, 2019). The longest standing and highest-level Level I trauma center in the area is a Premier facility, Dade Valley Hospital, in downtown Dayton (ACME Medical Center, 2019). In 2017, Premier had one Level I trauma center and one Level II trauma center, and PPN had one Level II trauma center. The Premier Level II trauma hospital closed for business in late 2017. At that time, Premier had two Level III trauma centers, Lower Valley Hospital and 57


Front Medical Center, and PPN had three Level III trauma centers, Smallville Medical Center, Blue Memorial Hospital, and ACME Medical Center, in the Dayton area. Two PPN Level III trauma centers, Blue Memorial Hospital and ACME Medical Center, existed in Blue County (ACME Medical Center, 2019). Currently, PPN has one Level II trauma center, Pretend Medical Center, and three Level III trauma centers, Smallville Medical Center, Fort Washington Hospital, and ACME Medical Center (one center exists in Blue county) (ACME Medical Center, 2019). Premier has one Level I trauma center, Dade Valley Hospital, and three Level III trauma centers, Lower Valley Hospital, Entry Medical Center, and Dade Valley South Hospital. The current trauma centers are depicted in the maps located in Appendix A and Appendix B to include the University of Cincinnati Level III trauma center, located near a PPN Level III (Fort Washington Hospital), a Premier Level III (Entry Medical Center) center near Cincinnati, and the Level I Pediatric Trauma Center, Dayton Children’s Hospital in downtown Dayton. Currently, according to data pulled from the ACME Medical Center’s business development department, Blue and Clark counties are predicted to have a two percent community growth rate over the next five years (M. Cain, personal communication, April 29, 2020). According to Figures A1 and A2 in Appendix A, there are no trauma centers to the east, southeast, or northeast areas aside from ACME. The next trauma center to the east of the Dayton area is in Columbus, Ohio, approximately 70-75 minutes away (Ohio Trauma System, 2020). This poses the concern for timely access to trauma care in the geographic area between Dayton and Columbus. With the closing of the Premier Level II trauma center in 2017 and the population growth in the area, specifically the growth in the Blue County area where ACME is located, it begs the question if the community and the area need and could support another Level II trauma center. If the area could support another high-level trauma center, an analysis should be done to determine where the trauma center should be placed. With the closing of one Level III trauma center in Blue County and no trauma centers in neighboring Clark County, an analysis should be done to determine if trauma care in this area is sufficient for the growing population. Purpose Statement The purpose of this capstone project paper is to examine if there is a community need for ACME Medical Center to become a Level II trauma

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center and to see if PPN and the Dayton area could support another Level II trauma center. If it is determined a Level II trauma center could be supported by the community and the area, the second purpose of this capstone project paper is to review the gaps for ACME Medical Center to advance from a Level III to a Level II trauma center and to make recommendations based on significant findings throughout the analysis. Literature Review According to the National Academies of Science, Engineering, and Medicine (2016), when looking at trauma care in the United States, it was identified from 2001-2011 that approximately two million people died from causes related to traumatic injury in the United States. Over the same 10year time period, approximately 250,000 lives were lost related to traumatic injury in the United States that could have been prevented (National Academies of Science, Engineering, and Medicine, 2016). Trauma injuries account for approximately $670 billion in healthcare spending per year and cause more disability in the American population than illness alone (American College of Surgeons: Committee on Trauma, 2020). History of Trauma Care in the United States Organized care for patients who have suffered traumatic injuries has been in place from as early as the Civil War. President Lincoln encouraged the conception of the first trauma manual related to processes implemented during war related to field triage of injured patients and transportation to make-shift battlefield hospitals (American College of Surgeons: Committee on Trauma, 2020). Wartime care of the injured soldier has guided the organization of care for traumatic patients across centuries and continues today (American College of Surgeons: Committee on Trauma, 2020). Wartime lessons and innovations in trauma care have been mimicked in the civilian healthcare setting to provide an effort during peacetime to continue to learn and advance trauma care as a nation (National Academies of Science, Engineering, and Medicine, 2016). Trauma care practices in the Civil War era evolved throughout World War I and II, the Korean War, the Vietnam War, and wars in the Middle East (American College of Surgeons: Committee on Trauma, 2020). In an effort to provide education and continued guidance to surgeons, the American College of Surgeons formed the Committee on Fractures in 1922 (later renamed to the Committee on Trauma in 1950) to provide improvement and surgical leadership to the care of injured patients 59


(American College of Surgeons, 2014). In post-World War II 1946, the United States government implemented the Hill-Burton Act, offering grants to hospitals to provide emergency care in an emergency department as medical care specialization began with the realization there was a need for specialized care (American College of Surgeons: Committee on Trauma, 2020). The National Academy of Sciences (1966) published a report in 1966, examining current practices and discussing the need for action on accidental death and disability in the United States. The first Optimal Hospital Resources for Care of the Injured Patient was provided in 1976 in an effort for hospitals to have set guidelines to follow for care of the injured (American College of Surgeons: Committee on Trauma, 2020). The first trauma verifications began in 1980 for trauma centers to become officially recognized as a tertiary care center for trauma care (American College of Surgeons: Committee on Trauma, 2020). This evolved to the Optimal Resources for Care of the Injured Patient in the early 1990’s as the focus shifted from a hospital resource to a guide book for care of the injured at any level of care (American College of Surgeons, 2014). Trauma Centers The first organized trauma programs date back to the 1960’s in the United States and Japan (Gregory et al., 2018). Trauma centers began to be held accountable through a verification process by the ACS or a like governing body to assure care was consistent across states as best practices in the care of the injured patient began to take hold nationally (American College of Surgeons, 2014). As previously stated, the ACS began conducting verification reviews in 1980 for trauma centers to officially be recognized as a trauma center (American College of Surgeons: Committee on Trauma, 2020). In order to be identified as a trauma center, the hospital must meet the published criteria and be verified by a governing body stating that they meet the criteria (American Trauma Society, 2020). The verifying body refers to the ACS or a state, regional, or local entity recognized by the designating body (American Trauma Society, 2020). The designating body grants the hospital designation to be a trauma center if it meets the criteria per the verifying entity. The designating body varies by geographic area and is a government agency, typically the state, county, region, or city (American Trauma Society, 2020). There are five trauma center levels throughout the United States (American Trauma Society, 2020). It is important to understand that not all states recognize all trauma center levels. For example, the state of Ohio only recognizes Level I, II, and III (ACME Medical Center, 2019). All trauma centers are required to have a multidisciplinary PIPS program, 60


participate in injury prevention and community outreach at some level, and provide some level of trauma education. Level I. Level I trauma centers are lead, tertiary care facilities typically located in a large urban setting (American Trauma Society, 2020). Level I trauma centers are required to have immediate, 24-hour, in-house responses by a number of clinical resources, such as trauma surgeons, orthopedic surgeons, neurosurgeons, anesthesiology, emergency medicine physicians, surgical critical care physicians, and interventional and diagnostic radiologists (American College of Surgeons, 2014). Level I trauma centers are required to have availability to perform cardiac surgery, dialysis, microvascular surgery, oral and maxillofacial surgery, internal medicine, and plastic surgery (American College of Surgeons, 2014). There are a variety of medical services also required to include cardiology, gastroenterology, infectious disease, nephrology, pulmonary medicine, and pediatrics (when appropriate) (American College of Surgeons, 2014). Level I centers are required to be a regional resource for trauma-related education medical staff, emergency medical services (EMS) personnel, and nursing staff , as well as an educational resource for lower-level trauma and nontrauma centers (American Trauma Society, 2020). Level I centers are required to be a leader in community injury prevention efforts and should guide the geographical area in prevention (American College of Surgeons, 2014). Level I centers are required to see 1200 trauma patients per year in their trauma registry, with 240 of these patients with an injury severity score of 15 or greater (American College of Surgeons, 2014). Level I trauma centers are the only level centers required to have research (American Trauma Society, 2020). Level II. Level II trauma centers are either a complimentary center to a lead Level I center or a lead center in an area with no Level I trauma center (American College of Surgeons, 2014). Level II trauma centers are required to be clinically equivalent to a Level I center; however, it can be acceptable to transfer patients with a need for cardiac surgery, microvascular surgery, or hemodialysis (American Trauma Society, 2020). Level II trauma centers are also required to be lead centers in education and prevention, but they are not required to have research or a minimum volume requirement (American College of Surgeons, 2014). Level III. Level III trauma centers are put in place to stabilize injured patients and assure the patient receives definitive treatment at the right facility (ACME Medical Center, 2019). This treatment could be at the Level III center or at a Level I or Level II center depending on the resources available at the Level III trauma center (American College of Surgeons, 2014). Level III centers are required to have immediate response by emergency medical physicians and prompt response by trauma surgeons, 61


orthopedic surgeons, anesthesiology, critical care, and diagnostic radiology (American Trauma Society, 2020). Level III centers are required to be an education resource for nursing and EMS and to provide prevention and outreach to the community (American College of Surgeons, 2014). Level III trauma centers are required to have well-developed transfer agreements with Level I and Level II trauma centers to provide definitive trauma care (American College of Surgeons, 2014). Level IV. Level IV trauma centers are put in place to treat minor injuries, stabilize trauma patients, and expedite transfer to a higher level of trauma care (American College of Surgeons, 2014). Level IV centers are required to have prompt response by emergency medicine physicians and trauma nurses (American College of Surgeons, 2014). They are required to have specific equipment to provide immediate lifesaving trauma care (American College of Surgeons, 2014). Like Level III centers, Level IV centers are required to have well-developed transfer agreements with definitive care facilities (American College of Surgeons, 2014). Level V. Level V trauma centers provide basic stabilization and expedite transfer of the injured patient to a higher level of trauma care (American Trauma Society, 2020). Level V trauma centers are put in place to provide immediate lifesaving measures by a physician and trauma nurse and have well-developed transfer agreements in place to get patients to higher level trauma care facilities (American Trauma Society, 2020). According to the American Trauma Society (2020), Level V trauma centers exist mostly in remote areas in the lower western states from South Dakota and North Dakota to Washington. Trauma Systems Individual trauma centers are important to trauma care; however, the focus of the nation began to shift from trauma centers to trauma systems of care to provide the best care to the injured patient in each unique setting (American College of Surgeons, 2014). Trauma systems include trauma centers, non-trauma centers, EMS agencies, and government and community organizations and partners (American College of Surgeons, 2014). Trauma systems provide an organized response to care for patients with traumatic injuries (Soto et al., 2018). In many cases, trauma systems are a model of care for other emergency situations, such as stroke, sepsis, or cardiac care (Eastman et al., 2013). While trauma care has continued to improve over the last 40 years, there is still a significant amount of work to be done (National Research Academy, 1985). Trauma systems have improved and the focus from trauma centers to trauma systems has grown in the eyes of many trauma 62


care experts (Gregory et al., 2018). With variability across states and no standard within the federal government, trauma societies and groups across the nation lead and lobby these efforts (Hashmi et al., 2019). Gregory et al. (2018) identified the key elements in place for a strong trauma system including timely transport and transfer of critically ill trauma patients to a trauma center, system inclusiveness and regionalization, education and communication, a formal verification process for the trauma centers, and a cohesive prehospital component within the trauma system. A welldeveloped trauma system should have a high-level process improvement program, education across the continuum, and the ability to have benchmarked outcomes (Gregory et al., 2018). There are many challenges facing the trauma system today, including problems of coverage, assessment and accountability, rehabilitation services, and physical viability (Eastman et al., 2013). Assuring all physician call schedules are covered for the appropriate days can be a challenge at some trauma centers depending on resources available within the trauma system. If the system is oversaturated with trauma centers, it could be a challenge to assure continued, required coverage occurs. Some geographic areas have limited available rehabilitation beds open for patients with long-term needs or post-traumatic injuries (Eastman et al., 2013). Assuring the trauma system can support the needs of the patient after initial trauma care is important, as these beds will be shared by all regional resources. In the state of Ohio, assessment and accountability is not a significant issue, as there are requirements for participation in regional trauma systems and verification by the ACS (ACME Medical Center, 2019). These assist in providing accountability of the trauma centers within the system; however, transparency of information and competition amongst system entities can bring additional challenges to the table (ACME Medical Center, 2019). One additional reason for the support of trauma systems is response to disaster events that continue to occur around the nation. With man-made and natural disasters happening regularly across the nation, it has continued to show the need for coordinated systematic response to management of care of injured patients (American College of Surgeons, 2014). In the Dayton area, there were multiple real-world disaster situations in 2019 with multiple tornados on Memorial Day and a shooting with multiple casualties in August. The trauma system was put into action for both events, and patients were cared for at the two high level trauma centers and the local Level III centers (ACME Medical Center, 2019). Disasters have shown the importance of sustaining a coordinated regional approach to trauma and emergency care in a system that functions with

63


trauma patients daily to provide high-level care for all injured patients (Eastman et al., 2013). Access to Trauma Care Access to trauma care across the nation was a significant problem in the early years of organized trauma care (American College of Surgeons: Committee on Trauma, 2020). There were few centers and many Americans without access to care. The numbers of deaths related to inadequate care continued and was highlighted in the National Academy of Science’s 1966 paper on accidental death and disability. The National Academy of Science (1966) stated a large magnitude of concern, needing action to improve prehospital, emergency center, and organized trauma care with a focus on prevention, research, and a registry to track injured patients across the nation. In the 1980’s and 1990’s, more information was published, discussing the need for improved trauma care and increased access across the continuum (American College of Surgeons: Committee on Trauma, 2020). In the most recent publication by the National Academy of Science, Engineering, and Medicine (2016), needs were identified in trauma care across the nation with approximately one-third of Americans still without access to trauma care. Many distinct gaps are identified in the trauma system, both nationally and locally, regarding access to timely and adequate trauma care. Access to trauma care continues to be an issue in some of the United States rural areas and areas related to insurance status and income (Branas et al., 2005; Carr et al., 2017). It is uncertain at what point the appropriate amount of trauma access is right within the trauma system. By placing excessive amounts of trauma centers in a small geographical area, it waters down the system and the clinical professionals have less experience (Branas et al., 2005). With higher numbers of severely injured patients being taken care of at one or two centers in the trauma system, it enhances the experience of the providers and improves the overall quality of the trauma care (Branas et al., 2005). While regionalization and the needs for the sociogeographic area are important to the access of trauma care, this is not always the case. Political competition amongst hospitals and healthcare organizations and profitability for centers play a significant role in trauma center placement (Gregory et al., 2018). Many states and local government do not have a mechanism in place to dictate where trauma centers are located, creating gaps in trauma center access as previously stated (Hashmi et al., 2019). Some areas are oversaturated with trauma centers for patients in the region and others are lacking due to financial constraints to provide care with little 64


reimbursement and many unfunded and underfunded patients (Soto et al., 2018). The cost of trauma care at a Level I or II trauma center has been shown to be increased to that of a non-trauma center or a lower-level trauma center due to high-cost resources, but the incremental cost of lives saved was shown to be considerably less at a trauma center than at at a nontrauma center or a lower-level trauma center (Eastman et al., 2013). The cost of trauma care is expensive for continuous human resources on-call and in-house, continued education to maintain competency or care, research efforts, community outreach and prevention, and equipment that may not be needed at a lower-level facility (Eastman et al., 2013). Two studies showed data related to trauma-center access and prehospital care access in each state. The hospital system in this capstone project is in Ohio; only Ohio data in each of these studies was reviewed. When reviewing accessibility to a trauma center across the nation, Ohio was found to have 80.3% of the population within 45 minutes of Level I and II trauma centers and 96.8% within 60 minutes (Branas et al. 2005). When Level III centers were added, 82.3% of the population were located within 45 minutes and 98.8% had access to a Level I, II, or III trauma center within 60 minutes (Branas et al., 2005). With the data of accessibility to a trauma center in the state of Ohio, it begs the question if an increased number of higher-level centers in Ohio are needed. Another study reviewed the averages of prehospital to in-hospital trauma deaths. Ohio ranked below the national average of 1.18 (at 1.05) for the ratio of prehospital to in-hospital deaths and below the national average of 44.4 (at 41.3) age-adjusted mortality rate per 100,000 population (Hashmi et al., 2019). Ohio was considered a hospital with non-high prehospital burden, meaning there was improved access to trauma center care within 45 and 60 minutes (Hashmi et al., 2019). States with non-high prehospital burden were found to have a decreased prehospital death rate in patients with injury (Hashmi et al., 2019). The relationship with pre-hospital care at a state and local level has also shown a correlation to trauma care and pre-hospital death related to the access to trauma center care. According to Hashmi et al. (2019), states with higher-level state participation for prehospital trauma care were shown to have a lower rate of prehospital trauma-related deaths opposed to those states that had a poor relationship. It was also identified that the relationship between prehospital care providers and trauma centers show overall improved care across the trauma system with improved education and communication (Gregory et al., 2018). Prehospital protocols, including transportation of trauma patients to trauma centers for significant injury, field triage criteria to dictate where a patient should be transported, and agreements for the ability for ambulance to transport across state lines, 65


when necessary, should be in place to assist in the best trauma patient care (Soto et al., 2018). Access to trauma care for the elderly patient is another consideration with trauma center placement within the trauma system. Elderly patients in the setting of trauma present a unique challenge in that they typically do not have a high-injury severity, but they are at higher risk for complication, and the physiological changes that present with aging affect the likelihood that they will return to baseline health after injury (Mackenzie et al., 2006). It was identified that the elderly population are at an above-average risk of under-triage for significant injuries when compared with their adult counterpart, and the risk increased considerably from ages 65 to 80 (Uribe-Leitz et al., 2019). Eastman et al. (2013) identified that older patients had a high potential for under-triage in the field and would benefit for improved education in the prehospital setting and in the trauma center, resulting in increased mortality and morbidity. The elderly population would benefit from guideline developments specific to the geriatric trauma patient (Eastman et al., 2013). Overall, the elderly trauma patient would benefit from an improved triage system to include adult-field triage criteria, increased education specific to the elderly population and trauma care, the development of elderly trauma patient guidelines to care, and trauma-center access. Literature Review Summary Trauma continues to be a leading cause of death in a large portion of our population over the last decades. The history of trauma care can be followed across the years with significant advances identified in wartime eras across the last several centuries in the United States. There are five distinct levels of trauma centers recognized in the United States with a variety of verification and designation processes at the state, county, and local levels across the nation. With this vast variability in trauma care, trauma systems are not yet thriving, and there continues to be a large portion of Americans without access to trauma care. There should be a judicious approach to selecting trauma centers based on geographical need, in consideration of air and ground prehospital transportation, and with formal agreements for sharing trauma resources across state lines (Branas, et al., 2005). Taking into consideration cost, sociogeographic needs, prehospital relationships, and care of special populations, trauma access and trauma systems should continue to be the goal of the United States to meet the goal of zero preventable deaths from injury (American College of Surgeons: Committee on Trauma, 2020).

66


Data Collection Network and trauma registry data were pulled from the ACME trauma registry and the PHN Trauma Analytics reports. The data were examined to review network trauma volumes, emergency medical services (EMS) volumes, and trauma patient injury data to determine the need of a Level II trauma center in the Dayton area and to determine if it should be placed at ACME Medical Center. The data is listed in the tables and figures below and discussed regarding the need for an additional Level II trauma center in the Dayton area. ACME Medical Center Trauma Volume ACME Medical Center trauma volume is depicted in Figure 1. This figure shows trauma registry volume by quarter from 2013 through 2020 Q1. Figure 1

Q1

2018

130 119 157

170

2020

56 50 67

102 119 56 63 64

Q2

2019

204

2017

206

217

2016 176

2015

108 108

2014

49 65 80

69 83 106 115 131

33

TOTAL NUMBER OF PATIENTS

2013

189 216

ACME Medical Center Trauma Quarterly Trauma Volume 2013-2020

Q3

CALENDAR YEAR

Q4

Note. From ACME Medical Center trauma registry data obtained April 15, 2020.

ACME Medical Center trauma volume has shown a steady increase quarter after quarter since the opening of the trauma center in 2013 (ACME Medical Center, 2020). The data identified in small volumes of patients were seen in the early years of the trauma program in each quarter. Annual data showed a steady increase in 2013 through 2016. A sharp increase in volume started to become apparent in 2018 Q2 and has continued through 2020 Q1. It is unknown why significant, sudden growth has occurred. It is possibly related to improved EMS relationships and/or increased trust of the hospital by the community over the eight years the medical institution 67


has been open (ACME Medical Center, 2019). In February 2019, complete turnover of the trauma program staff occurred with a new trauma program manager and trauma registrar; therefore, this could account for improved data collection (ACME Trauma Department, 2019). Figure 2 ACME Medical Center Trauma Volume by Emergency Department Disposition

464 221

2015

2016

2017

2018

2

5

0 0

25 4

83

130

195

144

176

285

351 2014

0 1

83

164

165 128

273 2013

0 0

118 92 0 0

TOTAL NUMBER OF TRAUMA PATIENTS

Trauma admissions to Soin Transfers out to higher level trauma care

2019

CALENDAR YEAR

Note. From ACME Medical Center trauma registry data obtained April 15, 2020.

Figure 2 shows trauma program data regarding disposition of the trauma patient from the emergency department. Trauma dispositions from the emergency department are separated into admission to ACME, regardless of admitting service, transfers to a higher level of trauma care, discharge to home from the emergency department, and trauma-related emergency department death (ACME Medical Center, 2020). The process for inclusion of patients into the trauma registry is outlined in Appendix B from the National Trauma Data Standard (2020). Trauma admissions are entered into the trauma registry regardless of admitting service. Patients who arrive at the hospital with a mechanism of injury and a codable injury per the ICD-10 coding standard who are then transferred to higher level of trauma care are included. According to the data in the trauma registry, described in Figure 2, it appears there may have been a process change in capturing patients discharged from the ED in 2016. It is unknown why there are no reported ED discharges in 2017; 68


however, 2018 and 2019 data show an appropriate amount of ED discharges related to trauma team activations as noted in Table 1. Patients discharged home from the ED would only be recorded in the trauma registry if they arrived as a trauma team activation (ACME Medical Center, 2020). In 2020, the hospital started to have an increase in direct admissions related to process change. Previously, all hospital transfers in, although few, were directly transferred from the sending facility to the emergency department of ACME Medical Center (ACME Medical Center, 2020). The low number of trauma related deaths in the ED is a positive effect over the years. It is likely in earlier years that the acuity of the trauma patients coming to the hospital were exceptionally low. As acuity rose over the years, the total number of trauma-related deaths increased with volume for a short time while improved processes were put in place to manage patients with increased acuity (ACME Medical Center, 2020). ACME Medical Center Trauma Patient Mode of Arrival Most trauma patients historically arrive via emergency medical services (EMS) across the nation (American College of Surgeons, 2014). As discussed in the literature review, it is important to build a strong relationship with prehospital partners via communication and education to improve trauma patient outcomes and access to care (Gregory et al., 2018; Hashmi et al., 2019). Over the last six years, the data obtained from the ACME trauma registry on April 15, 2020, as shown in Table 1, identified that between 31% -49% of patients arrived by walk-in and 51%-69% of patients arrived by EMS. An insignificant number of patients arrived via police across the span of six years as shown in the data. In 2018 and 2019, a significant drop occurred in the percentage of patients arriving by walk-in, and a significant rise in the percentage of patients arriving by EMS occurred. It is likely with improved processes, communication, and an increased acuity of trauma patients, as identified in the trauma-activation and transfer-to-higher-levelof-care data, the number of EMS arrivals will continue to rise over walk-in arrivals (ACME Medical Center, 2020). Table 1 ACME Medical Center Trauma Mode of Arrival Data and Total ACME Emergency Department EMS Volume 69


Calend ar Year

EMS Arrival

% EMS Arrival

WalkIn

Police

60

% WalkIn 45%

1

Total EMS Volume to ACME NA

2013

133

55%

2014

165

51%

81

49%

1

NA

2015

201

54%

92

46%

1

NA

2016

309

56%

137

44%

0

7,248

2017

321

56%

140

44%

0

8,328

2018

484

69%

150

31%

0

8,616

2019

606

66%

209

34%

1

9,804

Total

2,219

61%

869

39%

4

33,996

Note. From ACME Medical Center trauma registry data obtained April 15, 2020; Pretend Health Network Trauma Analytics data obtained on April 10, 2020.

ACME Medical Center Trauma Mechanism of Injury Trauma patient mechanisms of injury have changed significantly over the first six years of the program. Nationally, mechanism of injury is related to patient outcomes and mortality (Society of Trauma Nurses, 2019). Blunt mechanisms, including falls and motor-vehicle crashes (MVCs), are most common across the nation and in the Dayton area (Society of Trauma Nurses, 2019; ACME Medical Center, 2019). Penetrating injuries are less common locally and nationally and are associated with a higher mortality rate (Society of Trauma Nurses, 2019). Table 2 ACME Medical Center Trauma Mechanism of Injury by Year Calen dar year

Fall

2013

138

Motor Vehicl e Crash 30

Assa ult

Penetra ting Injury

0

2

70

Motorc ycle/A TV Crash 4

Blunt Injur y

Other

16

20


2014

172

27

0

15

3

14

16

2015

204

35

13

2

1

22

17

2016

338

46

11

11

9

12

19

2017

357

39

8

7

3

20

27

2018

452

91

15

16

20

12

28

2019

581

125

8

32

26

22

22

Total

2,242

393

55

85

66

118

149

Note. From ACME Medical Center trauma registry data obtained April 15, 2020.

ACME has shown a rise in all mechanisms of injury over the last six years as volume has increased according to the injury data in Table 2. Falls and MVCs lead the mechanisms of injury common at ACME and follow the national trends as leading mechanisms in the nation, state, and region (Society of Trauma Nurses, 2019; ACME Medical Center, 2019). The increased number of penetrating injuries and MVCs over the last six years can also show the increase in trauma patient acuity at ACME (ACME Medical Center, 2020). The “blunt injury” category includes any blunt trauma injury that does not specifically fit into the other categories (ACME Medical Center, 2020). The “other” category includes injuries, such as burns or blast injuries that do not fit into another category (ACME Medical Center, 2020). ACME Medical Center Trauma Activations Trauma team activations are important to the trauma program, providing all pertinent resources are promptly available to the patient Table 3 ACME Medical Center Trauma Team Activation (TTA) Data Calen dar year

Categor yI TTA

Billed Amt./ Categor y I TTA

Categor y II TTA

71

Billed Amt./ Categor y II TTA

Trauma consult

Billed Amt./Tr auma Consult


2013

1

$10,000

6

$30,000

2

$2000

2014

0

$0

0

$0

1

$1000

2015

1

$10,000

4

$20,000

0

$0

2016 2017

1 7

$10,000 $70,000

0 36

8 157

$8000 $157,000

2018

20

163

281

$281,000

2019

27

440

$440,000

Total

57

$200,00 0 $270,00 0 $570,00 0

$0 $180,00 0 $815,00 0 $1,275,0 00 $2,320,0 00

889

$889,000

255 464

Note. From ACME Medical Center trauma registry data obtained April 15, 2020.

With the growth in volume and increased number of patients admitted to and transferred from ACME, the increase in higher-level mechanisms of injury and the increased number of EMS arrivals as shown in Figures 1 and 2 and Tables 1 and 2, it is appropriate that the volume of trauma team activations has increased. The trauma registry data shown in Table 3 shows an increase in volume, acuity, and revenue related to traumateam activations (TTA) from 2013 to 2019. Category I TTAs represent the highest level of trauma-team activation, identifying the use of the most resources and an increased likelihood for the most significant injuries. Category I TTAs are billed at $10,000 per activation related to a significant use of resources deployed and promptly available to the patient within 10 minutes (in-house personal) and 30 minutes (trauma surgeon and out-of-house personal) (ACME Medical Center, 2020). This amount is billed to the patient in addition to emergency department charges. This amount does not signify the total amount reimbursed, as it varies by payer; however, insurance companies tend to pay either all of or a portion of the trauma activation charge, meaning reimbursement for all trauma charges is favorable (ACME Medical Center, 2020). Category II TTAs are the lowest level activation at ACME. As portrayed in the data, the number of Category II TTAs has increased exponentially over the course of six years. Category II TTAs are billed at $5000 per activation. The same holds regarding the amount reimbursed by the payers (ACME Medical Center, 2020). It is unknown why there are four

72


years with no Category II trauma team activations documented in the trauma registry (ACME Medical Center, 2020). Trauma consults are cases when the injured patient arrived when no TTA was available but the patient was admitted by the trauma service or the trauma service was consulted in the care of the patient (ACME Medical Center, 2020). Based on the data shown, it is unknown why the trauma consults were not originally tracked in the trauma registry (ACME Medical Center, 2020). Trauma consults are billed at $1000 per patient; although, reimbursements may be different (ACME Medical Center, 2020). ACME Medical Center Trauma Financial Data Trauma payor data were pulled from the PHN Trauma Analytics reports obtained on April 10, 2020 and are outlined in Table 4. As discussed in the literature review section, a considerable financial burden can be put in place for a higher-level trauma center due to increased needs for call services, equipment and education, amongst other costs (Eastman et al., 2013). A favorable payor mix with a low percentage of self-pay patients is ideal. Table 4 ACME Medical Center Trauma Financial Data Payor Mix Calen dar year 2015

Anthe m

Med Mutual

Medica id

Medica re

Other Comm ercial

SelfPay

United Health care

32

9

65

236

38

3

15

2016 2017

41

4

72

340

54

12

18

41

6

75

351

61

4

33

2018

58

9

93

392

56

12

16

2019

46

4

79

396

80

14

31

Total Total Perce nt

218

32

384

1,715

289

45

113

8%

1%

14%

61%

10%

2%

4%

Note. From Pretend Health Network Trauma Analytics report data obtained April 10, 2020

73


Table 4 outlines the payor mix for ACME from 2015 through 2019. The data for 2013 and 2014 are unavailable at the time of this project. Medicare patients are the highest percentage of trauma patients seen at ACME at 61% according to the PPN Trauma Analytics data (2020). Commercial insurances, Anthem, United Healthcare, and other commercial insurances account for 22% of the trauma payor data at ACME. Medicaid patients demonstrate 14% of the trauma population. The percentage of patients with self-pay is 2%, showing a favorable payor mix overall. The total amount of self-pay has remained mostly the same year over year since 2015. The number of patients with Medicare and other commercial insurance has shown a steady increase year after year since 2015. In further review of the PHN Trauma Analytics report data in Table 5, the total number of cases accounted for in the financial data are equal to 2,150 cases from 2015-2019. The net patient revenue total and by case, the direct cost per case, the direct margin per case and the total direct contribution margin percentages are reflected in Table 5. The cases differ slightly from the total number of trauma registry cases for an unknown reason. It is likely the case difference is related to billing errors or poor documentation in the electronic medical record (Pretend Health Network Analytics, 2020). Overall, the cases show a positive average direct margin per case of $1,249 and a direct contribution margin percentage of 18.7%. Table 5 ACME Medical Center Trauma Financial Data – Direct Patient Revenue and Contribution Margin Calen dar year 2015 2016 2017 2018 2019

Cases 291 379 425 466 589

Net Patient Revenu e $1,930,6 71 $2,322,4 04 $2,642,6 67 $3,051,6 12 $4,386,0 93

Net Patient Revenu e/Case

Direct Costs/ Case

Direct Margin /Case

Direct Margin %

$6,635

$5,670

$964

14.5%

$6,128

$5,146

$982

16.0%

$6,218

$5,707

$511

8.2%

$6,549

$5,663

$885

13.5%

$7,447

$5,065

$2,381

32.0%

74


Total or 2,150 Averag e

$14,333, $6,667 448

$5,418

$1,249

18.7%

Note. From Pretend Health Network Trauma Analytics report data obtained April 10, 2020.

ACME Medical Center Trauma Data Summary The ACME trauma data reviewed and discussed in the above tables and figures show a significant year-after-year total trauma patient growth from 2013 through 2019. There was an increase in the total number of EMS transported trauma patients, the number of highest-level trauma team activations, and an increase in the number of patients with MVCs and penetrating trauma, eluding to an increase in trauma patient acuity. The percentage of patients arriving by EMS increased significantly, especially in 2018 and 2019, speaking to improved communication and process with prehospital partners. Regarding cost of care, the increase in the total number of trauma team activations at both levels and trauma consults show improved process and documentation. The payor mixes for the trauma patients at ACME from 2015 through 2019 show a low number of patients with self-pay and high number of patients with Medicare and commercial insurance. The favorable payor mix and the increased number of trauma team activations show an enhanced association in trauma activation revenue. The direct contribution margin average of $1,249 per case at 18.7% for the last five years shows a favorable market for growth. The map of the trauma centers in Appendix A, Figure A1, shows ACME Medical Center in an ideal location from the higher-level trauma centers in the area. According to Google Maps, ACME Medical Center is located 11 miles, or 16 minutes, from Dade Valley Hospital, the Level I Premier facility in downtown Dayton and 15 miles, or 25 minutes, from Pretend Medical Center, the Level II PPN facility in Pretend. While ACME is within 45 minutes of these local higher-level trauma centers, areas within the northeast, east, and southeast portions of the map are not within an ideal distance to these centers. With the closing of Blue Medical Center’s trauma program (not shown on the map, but a PPN hospital located in Xenia in the east section of the map), ACME remains the only trauma center in this area of the map, closing a gap in the aforementioned sections in the east, northeast, southeast, and to the east beyond. The next trauma center to the east is located approximately 75 minutes away in Columbus (Ohio Trauma System, 2020). 75


Review of Trauma Verification Standards The American College of Surgeon’s Optimal Care of the Injured Patient (2014), referred to as “the orange book� by the trauma community across the United States, is a book listing the criteria for all ACS-verified trauma centers. For this capstone project, the orange book is used to determine the difference between Level II and Level III trauma centers. The criteria similarities and differences will be outlined for ACME Medical Center in this section under the following categories: hospital organization and trauma program, improved partnership with prehospital partners, enhanced strength in intrahospital transfer, increased clinical services, enhanced performance improvement and trauma registry services, advancement of education, and expansion of community outreach and prevention efforts. Hospital Organization and the Trauma Program. There are several similarities amongst the hospital organization and trauma program at Level II and Level III trauma centers. Level II and Level III trauma programs are required to have an infrastructure to support the care of the injured patient. The hospital should have documentation of commitment from hospital administration and the hospital medical staff at both levels renewed every three years (American College of Surgeons, 2014). Administrative support of the trauma program should consist of human resources, including a trauma medical director, trauma program manager, trauma registry staff, trauma performance improvement personnel, a trauma service, a trauma resuscitation team, and a multidisciplinary team approach to peer review and performance improvement (American College of Surgeons, 2014). Administrative support should also include support of educational activities and advancements; assistance of prevention and outreach efforts to promote community partnerships; and adequate funding for equipment, education, human resources, and outreach efforts (American College of Surgeons, 2014). There are a few differences in hospital organization and trauma program between Level II and Level III trauma centers. Level II trauma centers are required to have a response time of 15 minutes to the highest level of trauma team activation while Level III trauma centers are required to respond within 30 minutes (American College of Surgeons, 2014). At a Level II trauma center, the trauma medical director is required to actively participate in a state or national trauma organization (American College of Surgeons, 2014). At a Level III trauma center, this is desired but not required (American College of Surgeons, 2014). Improved Partnership with Prehospital Partners. It is important for the right patient to be treated at the right place at the right 76


time (Gregory et al., 2018). Level II and Level III trauma centers rely on sophisticated prehospital protocols, field triage guidelines, and transportation criteria to a trauma center. In Ohio, protocols are put in place by the state to ensure continuity of process across all regions (Ohio Trauma System, 2020). Field-triage and trauma-transportation criteria state patients should go to the highest-level trauma center or the nearest trauma center within 30 minutes for traumatic injuries (Ohio Trauma System, 2020). This is the same for both Level II and Level III facilities. Participation in prehospital education and outreach, regular engagement for improved processes, and communication is required for both Level II and Level III trauma facilities (American College of Surgeons, 2014). The trauma department should actively participate in disaster planning and emergency management at the hospital and local levels at any level of trauma care (American College of Surgeons, 2014). There are no significant differences in prehospital management between Level II and Level III trauma centers. There are no differences in disaster and emergency preparedness between Level II and Level III trauma centers. Both Level II and Level III trauma centers should actively participate in prehospital care of the trauma patient. Enhanced Strength in Intrahospital Transfer. Hospital collaboration across the trauma system should continue to be a priority. Robust trauma-patient-transfer guidelines should include patient identification and injuries requiring transfer; physician-to-physician communication and agreement on transportation mode; transportation guidelines on type of transportation (air versus ground); and proper documentation to meet federal transport responsibilities (American College of Surgeons, 2014). The Emergency Medical Treatment and Labor Act (EMTALA) requires agreements to be in place for facilities to transfer patients to a higher level of trauma care when the patient’s needs outweigh those of the facility (American College of Surgeons, 2014). The primary differences in Level II and Level III trauma centers regarding intrahospital transfer are resources and capabilities for higher level of care. The American College of Surgeons (2014) recommends patients with particular injuries be transferred from a Level III to a Level I or Level II trauma center as they are associated to a higher mortality rate and necessitate an increased number of resources not always available at a Level III center. These injuries include arterial or great vessel injury to the carotid, aorta, abdominal vessels or vertebral artery; rupture of the cardiac membrane; bilateral pulmonary contusions; grade IV or V liver laceration with significant blood loss; unstable or complex pelvic fractures with or without significant blood loss; fracture/dislocation with loss of pulses; open skull injuries or altered mental status with trauma; injuries to the spinal 77


cord; or significant injury to the chest or abdomen with significant comorbidities (American College of Surgeons, 2014). Increase in Clinical Services. Level II and Level III trauma centers are required to have trauma surgeons, emergency medicine providers, anesthesia providers, and orthopedic surgical services (American College of Surgeons, 2014). Both levels are required to have critical care services, an intensive care unit (ICU), operating rooms (ORs), a postanesthesia care unit (PACU), social workers to assist with discharge planning, physical and occupational therapy services, speech therapy, the ability to manage nutritional support for the patient, pain management services, laboratory services, in-house radiology capabilities with a radiologist available to read images, the ability to manage psychological issues, and medical consultants (American College of Surgeons, 2014). Participating physician services are required to have a designated liaison and participate in the trauma performance improvement process (American College of Surgeons, 2014). There are substantial differences in the clinical services at a Level II and a Level III trauma center. The Level II trauma center is required to have the same clinical provision as a Level I trauma center (American College of Surgeons, 2014). Level II centers are required to have neurosurgical capabilities and all surgical specialties required to care for the injured patient, which include interventional radiologists for embolization, maxillofacial surgeons, plastic surgeons, ophthalmologists, hand surgeons, and vascular surgeons (American College of Surgeons, 2014). Level II trauma centers can transfer patients with a need for cardiac surgery needing bypass or microvascular surgery for reimplantation to a Level I facility as needed (American Trauma Society, 2020). Level II trauma centers should have a physical medicine and rehabilitation physician to guide all rehabilitation efforts (American College of Surgeons, 2014). In Level II centers, the trauma surgeon, critical care physician, and anesthesia provider must be in-house and promptly available within 15 minutes for all trauma activation patients (American College of Surgeons, 2014). The OR staff must always be in-house with a back-up call team available (American College of Surgeons, 2014). In hospitals where there are no residents, advanced practice providers play a key role (American College of Surgeons, 2014). Performance Improvement and Registry Services. A robust trauma PIPS program and a trauma registry are required at all trauma centers regardless of trauma center level (American College of Surgeons, 2014). Level II and Level III trauma centers are required to submit data to the National Trauma Data Bank (NTDB) and use risk-adjusted benchmarking for data (American College of Surgeons, 2014). Level II and 78


III trauma centers must have one trauma registrar for every 500-750 patients entered in the trauma registry (American College of Surgeons, 2014). The trauma registry should be used for PIPS efforts and utilized as part of the PIPS program for all trauma centers (American College of Surgeons, 2014). The TMD and TPM should have the power and authority to manage performance efforts throughout care and be supported by administration (American College of Surgeons, 2014). The trauma PIPS program should be tied to the hospital quality department (American College of Surgeons, 2014). Specific PIPS indicators are listed in the orange book for all trauma-center levels (American College of Surgeons, 2014). The Level II and Level III indicators are the same (American College of Surgeons, 2014). Each trauma center should use trauma data for hospital specific trauma PIPS initiatives. There are no significant differences between the Level II and Level III trauma PIPS programs or registry services. The Level II trauma center will have more data points for tracking related to a rise in number of injuries related to higher patient acuity, physician specialists, procedure codes to be entered on higher acuity patients, enhanced PIPS data related to required prevention information, information related to response times and team members responding, and any additional information the trauma program decides to track and trend over time (ACME Medical Center, 2020). Advancement in Education, Community Outreach, and Prevention. Level II and Level III trauma centers are required to engage in education for the public and professionals, including physicians, advanced practice providers, nurses, prehospital providers, and ancillary staff (American College of Surgeons, 2014). Both level centers should have the ability to provide Advanced Trauma Life Support (ATLS) (American College of Surgeons, 2014). Level II and Level III trauma centers should have an organized approach to outreach and injury prevention efforts using trauma registry data to drive the prevention program (American College of Surgeons, 2014). Each center should have someone with injury prevention in their job description (American College of Surgeons, 2014). All level trauma centers are required to have a screening tool for alcohol use on all injured patients (American College of Surgeons, 2014). Level II trauma centers should have the ability to provide educational resources and a means of information referral to lower level and non-trauma centers (American College of Surgeons, 2014). Level II trauma centers are required to provide documented intervention to all those who screened positive for alcohol abuse (American College of Surgeons, 2014). Level II prevention programs must include at least two programs 79


that address major causes of injuries in the community and must track partnerships with other community organizations (American College of Surgeons, 2014). Research efforts are not required at Level II trauma centers, but they are recommended. Recommendations Based on the data review in the data collection section, it is recommended that ACME Medical Center continue to evaluate transitioning to a Level II trauma center over three to five years. Regardless of designation level, ACME Medical Center should consider an increase of the services provided to meet the needs of the community as a stronger Level III or Level II. The review of the American College of Surgeon’s Optimal Care of the Injured Patient (2014) highlights the similarities and differences between Level II and Level III trauma centers. Based on these similarities and differences, recommendations will be outlined for ACME Medical Center under the following categories: hospital organization and trauma program, improved partnership with prehospital partners, enhanced strength in intrahospital transfer, increased clinical services, enhanced performance improvement and trauma registry services, advancement of education, and expansion of community outreach and prevention efforts. These recommendations are highlighted for the intention of developing trauma services to support the community as a higher functioning Level III trauma center or a Level II trauma center. Recommendations for Hospital Organization and the Trauma Program The hospital administrative support should continue for the trauma department with continued administrative and medical staff support of resources, equipment, education outreach, and funding. Continue to monitor the infrastructure and support for the number and type of individuals needed on the trauma service as it grows. The trauma medical director should join and actively participate in a state or national trauma organization. It is unnecessary to begin a faster response time to highestlevel activations until there are more clinical components in place to support the need for such a response. Recommendations for Improved Partnership with Prehospital Partners

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ACME Medical Center should continue to build and grow a strong relationship with prehospital partners. ACME should also continue to strengthen communication, education, and process improvement between hospital and prehospital partners. It is critical to remain and grow in preparedness and disaster management across PPN and within the trauma system. As the trauma program grows, a continued stronger presence with prehospital partners should exist. Recommendations for Enhanced Strength in Intrahospital Transfer Major injuries, as listed above, should be cared for at a Level I or II trauma center. As some of the required services are not available at ACME, many of these injuries would need to be transferred to a higher level of trauma care until services were available. The list of injuries will need to be evaluated over time as services at the hospital are introduced to provide care. Recommendations for an Increase in Clinical Services It is recommended to begin adding services to the Level III trauma center already in place to assist in building and solidifying process and standardizing care while onboarding new services. Neurosurgical services should be the first service to be added with a tiered approach to care for spinal fractures, stable, nonoperative head bleeds, operative cases, and spinal cord injuries. This would meet a community need as these patients are typically transferred for relatively minor injuries when they could stay at ACME if the services were available (ACME Medical Center, 2020). Additional surgical services may take time to find and build into the trauma program. A phased approach should be considered to onboard new surgical services, such as maxillofacial, plastic surgery, or ophthalmology. Existing services at ACME that are not currently involved in the care of the trauma patient should be added in with a phased approach to determine if the right service can be performed by the current providers. These services include interventional radiology, vascular surgery, hand surgery, and expanded orthopedic capabilities (ACME Medical Center, 2020). Additional staff will need to be added to the OR team to provide the ability to provide coverage in-house. Trauma surgeons, anesthesia providers, and critical care physicians who are normally not in-house will have to have contract modifications to provide in-house coverage. Additional trauma service APPs will need to be added to provide increased continuity of care and assistance to the trauma surgeons in lieu of resident physicians. 81


Recommendations for Evolution of Performance Improvement and Registry Services PIPS and registry efforts will not change significantly aside from the total amount of patients. The total amount of and the acuity of patients will likely continue to increase over time, adding to the total amount of required work. Currently, there are 1.75 full-time equivalents (FTE) in registry employees and 1.0 FTE in the PI Coordinator at ACME (ACME Medical Center, 2020). The trauma registry staff may increase over time in total number of patients entered as required. As new processes are put in place and new services are added, close attention to new guidelines and processes will need to be analyzed by the PI Coordinator through the PIPS process over time. New physician liaisons will be added to the PI and Peer Review meeting for input and review of care significant to their area of expertise. Recommendations for Advancement in Education, Community Outreach, and Prevention A trauma education and injury prevention coordinator should be hired in year one to assist with coordination and ongoing education of new services added to the trauma program for nursing, physicians, advanced practice providers, and ancillary staff. This coordinator would also be responsible for continuing to strengthen partnerships with prehospital providers and community members. In year three or four, there may be consideration to separate the roles for direct focus on both education and prevention efforts. The trauma registry should continue to be used to track causes of injury in the community. Recommendations for Further Analysis and Limitations Data and financial information pulled for this capstone project did not include market analysis for cost-of-call pay for increased physician specialty services required for Level II of increase to Level III services, among other elements. It would be recommended to do further analysis of the financial cost of increased trauma services or increased trauma level at ACME Medical Center. The analysis should include specific equipment needed for increased surgical services, not limited to cost of equipment; market analysis for cost-of-call pay for each specialty service added; cost of additional OR staff to cover the OR 24 hours per day; cost of additional educational needs, both for new education for new services and more 82


education to support growth; additional needs to expand prevention and outreach efforts into the current catchment area and beyond; and any additional costs that may present themselves while adding supplementary services. It would also be beneficial to review the transfer data from ACME to higher level of trauma care to prioritize community needs in regard to clinical services. The project would also benefit from a deeper look into regional and state trauma and EMS data. It would be interesting to review data on where transports are coming from and which hospitals they are going to within the trauma system. Expanding this data to the Cincinnati and Columbus areas may be helpful to capture the void in trauma systems as depicted in Appendix A. Ethical Implications There were no specific ethical implications for this study. The author has a bias towards PHN as a manager in the trauma program at ACME Medical Center. Further analysis utilizing state and regional trauma and EMS data would provide a broad analysis of the area in a more unbiased setting. Conclusion Trauma care across the nation has shown many advances over several centuries from the first recorded trauma field triage and transport in the Civil War, to the Resources for Optimal Care of the Injured Patient in the 1990’s, to the most recent publication on public health needs of the injured patient and access to trauma care across the nation in 2016. Across this span of time, trauma continues to account for more deaths and disability than any other disease process. Trauma center verification has advanced since its inception in the 1960’s. Trauma centers are required to be verified by the American College of Surgeons, or a like governing body, and designated by the state, county, or local authority. Trauma center levels vary across the United States from Level I, highest level of care, to Level V, lowest level of care. Trauma center levels beyond Level III are not recognized in all states but serve a purpose in remote areas. Trauma care in Ohio, according to Branas et al. (2005) and Hashmi et al. (2019), appears to have adequate access to trauma centers, Level I through Level III, and transport times below the national average for the large amount of rural space in the state. Trauma access to care in the Dayton area is covered by one Level I, one Level II, and six Level III trauma centers. The area has recently lost Levels II and III trauma centers 83


in the area. According to the population growth in Blue County and uncovered trauma center space between Dayton and Columbus shown in Figure A2 of Appendix A, the need for additional trauma center coverage at a higher level was evaluated at ACME Medical Center. In assessment of the trauma program at ACME Medical Center from 2013 through 2019, there was evidence of significant increase in volume, acuity, trauma patient EMS arrivals, trauma admissions and trauma team activations, and a decrease in the total number of transfers to higher level of care. In review of the ACME trauma finances, a favorable payor mix from 2015 through 2019 was identified. The ACME trauma financial data also showed increased total net patient revenue, increased net patient revenue per case, decreased direct cost per case, significant direct margin per case, and direct contribution percentage for trauma patients. Based on the ACME trauma data, it was determined to look further into the differences between Level II and Level III trauma verification standards and criteria gaps. Trauma criteria were reviewed in six categories: hospital organization and trauma program, improved partnership with prehospital partners, enhanced strength in intrahospital transfer, increased clinical services, enhanced performance improvement and trauma registry services, advancement of education, and expansion of community outreach and prevention efforts. Recommendations were made for changes to the trauma program based on these six categories as highlighted in the trauma criteria. The most significant suggestions are related to expansion of clinical services to meet the needs of the community. It was indicated further information be explored to ensure recommendations for advancement of trauma level or expansion of clinical services under the current trauma level are needed.

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References ACME Medical Center. (2019). American College of Surgeons: ACME Medical Center Trauma Pre-Review Questionnaire. Retrieved on November 11, 2019 from ACME Trauma Department. ACME Medical Center. (2020). Trauma Registry Data. Retrieved on April 15, 2020 from trauma registry reports. ACME Trauma Department. (2019). Trauma Performance Improvement and Patient Safety Plan. Retrieved on April 5, 2020 from ACME Trauma Department. American College of Surgeons: Committee on Trauma. (2020). National trauma system. https://www.facs.org/qualityprograms/trauma/tqp/systems-programs/trauma-series American College of Surgeons. (2014). Resources for Optimal Care of the Injured Patient. (6th ed.). American College of Surgeons. American Trauma Society. (2020). Trauma center levels explained. https://www.amtrauma.org/page/TraumaLevels Branas, C., MacKenzie, E., Williams, J., Schwab, C., Teter, H., Flanigan, M., Blatt, A., & ReVelle, C. (2005). Access to trauma centers in the United States. Journal of the American Medical Association, 293(21), 2626-2633. Carr, B., Bowman, A., Wolff, C., Mullen, M., Holena, D., Branas, C., & Wiebe, D. (2017). Disparities in access to trauma care in the United States: A population-based analysis. International Journal of the Care of the Injured, 48(2), 332-338. Dodson, B., Braswell, B., David, A., Young, J., Riccio, L., Kim, Y., & Calland, C. (2017). Adult and elderly population access to trauma centers: An ecological analysis evaluating the relationship between injury-related mortality and geographic proximity in the United States in 2010. Journal of Public Health, 40 (4), 848-857. Eastman, A. B., MacKenzie, E., & Nathens, A. (2013). Sustaining a coordinated, regional approach to trauma and emergency care is critical to patient health needs. Health Affairs, 32(12), 2091-2098. 85


Google Maps. (2020). https://www.google.com/maps/ Gregory, J., Walker, C., Young, K., & Ralchenko, A. (2018). Essential processes of successful trauma systems: Template for analysis of trauma systems. Journal of Emergency and Critical Care, 2(2), 1-20. Hashmi, Z., Jarman, M., Uribe-Leitz, T., Goralnick, E., Newgard, C., Salim, A., Cornwell, E., & Haider, A. (2019). Access delayed is access denied: Relationship between access to trauma center care and prehospital death. Journal of the American College of Surgeons, 228(1), 9-20. Herman, R., Long E., & Trotta, R. (2019). Improving patients’ experiences communicating with nurses and providers in the emergency department. Journal of Emergency Nursing, 45(5), 523-530. Pretend Health Network Analytics. (2020). Network trauma analytics. http://intranet.ketthealth.com Pretend Health Network Employee Resources Guide. (2019). http://intranet.ketthealth.com/kh/DeptPages/PPNHR/docs/Fin al%20version_Jan%2025_2016HR1147%20Employee%20Resourc e%20Guide%20v7%20Updated%20(2)%20LinkNoBox%20(2).pdf Kumar, R. (2014). Research methodology: A step-by-step guide for beginners. Sage. Mackenzie, E., Rivara, F., Jurkovich, G., Nathens, A., Frey, K., Egleston, B., Salkever, D., & Scharfstein, D. (2006). A national evolution of the effect of trauma-center care on mortality. The New England Journal of Medicine, 354(4), 366-378. Nathens, A., Jurkovich, G., Maier, R., Grossman, D., MacKenzie, E., Moore, M., & Rivara, F. (2001). Relationship between trauma center volume and outcomes. JAMA, 285(9), 1164-1171. National Academy of Sciences. (1966). Accidental death and disability: the neglected disease of modern society. The National Research Council. National Academies of Sciences, Engineering, and Medicine. (2016). A national trauma care system: Integrating military and civilian trauma systems to achieve zero preventable deaths after injury. The National Academies Press. 86


National Institute of General Medical Sciences. (2020). Physical trauma. https://www.nigms.nih.gov/education/factsheets/Pages/physical-trauma.aspx. National Research Council. (1985). Injury in American: a continuing public health problem. The National Academies Press. National Trauma Data Standard. (2019). National trauma data bank data dictionary. https://www.facs.org/-/media/files/qualityprograms/trauma/ntdb/ntds/datadictionaries/ntdb_data_dictionary_2019_revision.ashx. Ohio Trauma System. (2020). Ohio trauma system and map. https://www.ems.ohio.gov/trauma-system.aspx Society of Trauma Nurses (STN). (2019). TCRN Study Guide. Society of Trauma Nurses. Soto, J., Zhang, Y., Haung, J., & Feng, D. (2018). An overview of the American trauma system. Chinese Journal of Traumatology, 21(1), 7779. Uribe-Leitz, T., Jarman, M., Sturgeon, D., Harlow, A., Lisitz, S., Cooper, Z., Salim, A., Newgard, C., & Haider, A. (2019). National study of triage and access to trauma centers for older adults. Annals of Emergency Medicine, 75(2), 125-135.

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Appendix A Figure A1 Dayton, Ohio Area Map of Trauma Centers

Note. Pretend Health Network Trauma Analytics Report obtained April 10, 2020.

ACME Medical Center

Pretend Health Network Level II

Pretend Health Network Level III

Premier Level I

Premier Level III Dayton Level I Univ. of Cincinnati Level III

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Figure A2 State of Ohio Trauma System Map

Note. Ohio trauma system map retrieved from Ohio State trauma system website (2020).

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Appendix B Figure B1 Trauma Registry Inclusion Criteria

Note. National Trauma Data Standard. (2019).

Trauma registry patients are defined as:  Any patient with a mechanism of injury AND a codable injury  Trauma Admission  Trauma Transfer Out from the ED  Trauma Death in the ED  All Trauma Team Activations (including those discharged to home from the ED)

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Table B1 Table of Trauma Center Mandatory Criteria by Level: Level II & Level III Differences

Note. American College of Surgeons (2014).

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GRADUATE STUDENT CREATIVE EXPRESSION

First Prize Ysa Love-Rowland Bottom Line Up Front Professor John McGaha

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YSA LOVE-ROWLAND

Bottom Line Up Front When Seeing Is No Longer Believing

(Toews, 2020)

Take a look at the above photos. What do these four people have in common? At first glance they all seem unrelated, but in reality, they all share one simple thing. None of them exists. That’s right, these pictures are of people who do not exist. They were created by a new technology dubbed “deepfake.”

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(Baker & Capestany, 2018)

https://youtu.be/gLoI9hAX9dw As you can see from the above video, deepfakes can be very dangerous, even if they haven't been used in an overtly threatening way. How you might ask? Well, our county is a democratic one and in 2016, for the first time, our elections were tampered with by technology via “fake news.� 2020 is an election year..... So far, 2020 has brought us COVID-19 deaths, global pandemic, lockdowns, murder hornets, locust attacks, cyclones, floods, raging wildfires, riots, and economic recession; that list isn't comprehensive and worst of all....the year is only halfway over. Legitimately, this is most of the world right now:

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(Plante, 2016)

If fake news was a big problem for the 2016 election....deepfake videos could be an even bigger problem in 2020. This technology can easily be used to create videos that show politicians saying and doing things they never did. In April of 2018, Jordan Peele created a video that pretended to show former President Obama bad mouthing President Trump in a speech. This is when this problematic technology first gained widespread attention. The technology is a problem not only because the videos are incredibly realistic (abet, fake) and easy to make, but also because like any type of shock-value media, such as the “fake news” pieces on social media, they are highly likely to be shared. Gone are the days when all you had to worry about was how much a politician was lying....now thanks to advanced technology, we have to question everything we see and hear regarding that politician. So what does this mean? In the era of disinformation and trickery, believe only half of what you hear and none of what you see. For the last 10 years, governments and political parties have had to face the threat of hactivists and cybercriminals hacking into their computer networks and engaging in cyberwar. What this has given rise to is a new evolution or “likewar”: the hacking of people on social networks, by driving ideas viral. Like the movie Inception stated so beautifully, “An idea is like a virus, resilient, highly contagious. The smallest seed of an idea can grow...” 95


With this being the new weaponized technology, what kind of fruit do you think will be born from a tree that grew from a deepfake seed? The possibilities are endless.

(Johnson, 2011)

BLUF (Bottom Line Up Front) Be vigilant and don’t be so eager to drink the kool-aid. We should be fact-checking things we see and hear and across multiple sources if we want to stay ahead of the misinformation. Sites such as Politifact.com and factcheck.org are great for keeping yourself in the know as far as politics go. For information that is non-political, a couple of my favorites are snopes.com and truthorfiction.com. Also remember that Google is free, so there is no reason to not check and then double check your facts.

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References Baker, H., & Capestany, C. (2018, September 28). It’s getting harder to spot a deep fake video [Video]. YouTube. https://youtu.be/gLoI9hAX9dw Johnson, D. K. (2011, November 8). Inception and philosophy: Did the spinning top fall? Psychology Today. https://www.psychologytoday.com/us/blog/platopop/201111/inception-and-philosophy-did-the-spinning-top-fall Plante, C. (2016, May 5). This Is Fine creator explains the timelessness of his meme. The Verge. https://www.theverge.com/2016/5/5/11592622/this-is-finememe-comic Toews, R. (2020, May 25). Deepfakes are going to wreak havoc on society. We are not prepared. Forbes. https://www.forbes.com/sites/robtoews/2020/05/25/deepfakes-aregoing-to-wreak-havoc-on-society-we-are-not-prepared/#7905fbac7494

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UNDERGRADUATE STUDENT FORMAL COMPOSITION

First Prize Sarah Rothermund Protecting Vulnerable Groups Using the Internet Professor Melony Sampson

Second Prize Jataya Johnson

A Guided Hand: An Argument for the Reform of the Juvenile Justice System in America Professor Kaylene Powell

Third Prize Bennet Lawler Risk Management – A Piece of Cake Professor Karla Carter

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SARAH ROTHERMUND

Protecting Vulnerable Groups Using the Internet

Abstract This term paper addresses how to help non-computer literate people protect themselves online. With the ever-growing information online, it is important that people who have not grown up with technology, or are too young to understand it, are aware of their online presence and safety. This paper focuses on how people are vulnerable online and what they can do to protect themselves. The main body of this work will be divided into two groups of people. The first group I have identified is the older generation who have not grown up with the Internet. They need to know what to look for when it comes to simple things like online shopping, so that they are not taken advantage of. The second group I will focus on is young children using technology, and how they, or their parents, can educate them(selves) on online safety in a way that will make sense.

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Protecting Vulnerable Groups Using the Internet The creation of the internet has brought our society innumerable advances in technology, science, convenience, and social interaction. The internet and technology have brought our society new medical treatments for cancer and other potentially deadly diseases. People are living longer than ever with all of the new medical discoveries. People are able to find jobs in their location, around the country, and even the world, using multiple job search engines. Others have reconnected with long lost relatives, or unknown relatives, through social media sites. Most students do a large portion, if not all of, their schoolwork online. Students have unlimited access to hundreds of websites for research; even hundreds of books are now entirely available online. However, with all of these wonderful developments, the Internet has also created many issues, or potential risks, for everyone who utilizes it. Daily, our county and countries around the world have to develop new ways to block cyber terrorists from accessing classified information. This is a literal life or death risk to us all. Anyone who utilizes online shopping as their preferred method of purchasing items risks their credit card or identity stolen every time they enter their information. Large corporations have to ward off attackers from breaching their systems and stealing millions of peoples’ information. Protecting one’s self online is a hefty responsibility. Many people in the middle generations have grown up using computers and the Internet and are aware of the risks and what to look for in a reputable site. However, there is still a large population that lacks the experience needed to keep itself safe online. We all have that friend or relative who is outspokenly bad at computers, but we also need to consider how children are exposed to technology at younger and younger ages. They don’t have the life experience to know all risks associated with said technology. Thankfully, there are many resources available to the public to educate its members, or others they know, on how to stay safe online. The first most vulnerable group identified are individuals who didn’t grow up using computers, let alone the internet. Typically, these people are over 50 years old, and weren’t exposed to the Internet until their children or their jobs gave them that exposure, to no fault of their own. For these users, basic internet safety measures should be first priority. One of the simplest ways of self-protection would be to make sure one’s password is strong. Passwords are often created to be easily remembered and may even be displayed in plain sight. Many people do not use a password on their devices, so that they don’t have to bother with remembering a password. Password encryption is our first line of defense, 100


so it should always be utilized. A “strong” password has several components; it is at least 12 characters long and should include the usage of a mix of letters, numbers, and symbols. Lastly, one should try not to include personal information that may be obvious, such as a last name (Home Instead Senior Care, 2017). The next safety measure that should be taken is to have a proper security system installed when getting a new device. Security software on devices from a reliable source, such as Norton or McAfee, have features to run the anti-virus and anti-spyware software regularly. These types of security measures protect devices from threats like malware, which is a name for evil software. Types of malware include viruses, worms, and Trojan horses. A virus is a type of code that attaches itself to a legitimate program, much like a real virus attaches itself to human cells. If the user runs the virus program, such as sending an email with an infected attachment, the virus spreads to the receiver’s computer. A worm is similar to a virus, the difference being that a worm is its own program and does not need to attach to a legitimate program to run. Once a device has been infected with a worm, the worm can jump from device to device without human interaction. Lastly, a Trojan horse disguises itself as a legitimate program, making it hard to track (Panko & Panko, 2019). After one of the above malware attacks is made on a device, a payload attack may be used. A payload program, which is called spyware, can track a user’s login credentials and send them to a hacker, erase a hard drive, steal credit card information, and even steal enough information for an attacker to assume someone’s identity. Needless to say, a good anti-virus and anti-spyware software can save a user a lot of time, money, and stress in the long run. Another method of protection would be to think before you act. Emails and communication that create a sense of urgency, such as a problem with your bank account or taxes, is likely a scam. Consider reaching out directly to the company by phone to determine if the email is legitimate or not (Home Instead Senior Care, 2017). It is always better to be safe than sorry, and a user can still take action quickly by making a phone call to determine the legitimacy and resolve the issue if it does turn out to be a legitimate email. In addition, clicking on links in emails is often how scammers get access to personal information. If an email looks unusual, delete it and reach out to the supposed person who sent it if it does look like it came from someone a user knows. Scammers using the abovementioned malware and spyware can commandeer friends’ email addresses and send messages posing as them. Most email platforms have automatic spam filters that greatly help reduce the potential of these suspicious emails getting through.

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As much as we all hope these crimes won’t happen to us, or someone we love, cybercrime against the elderly is on the rise. According to CNBC, Cybercrimes against older adults have increased five-times since 2014, costing more than $650 million in losses per year, according to FBI and FTC statistics compiled for a new study on protecting senior citizens from cyberattacks. Older adults also lose large sums to online frauds like email compromise and wire fraud, according to the study (Fazzini, 2019). When in doubt, seniors, or those who do not consider themselves techsavvy, should reach out for help instead of exposing themselves to potential risk. If a friend or loved one isn’t around for help, all devices and internet providers have support lines. It may not be the desired route, but it can save considerable pain in the long run. Children are also a very vulnerable population online. The contents discussed above can be detrimental to children as well, but the information is more applicable to adults who are completing the initial setup and maintenance of different devices. Children are generally more adept to using smart devices. We have all been to the store and seen small children, teens, and young adults on a phone or tablet, playing games, messaging friends, or watching videos. What we don’t generally think about is the vast amount of terrifying darkness that lies on the internet. Recently, an internet phenomenon called Momo terrorized many children and adults. Momo started out as an urban legend based off of the popular movie, The Ring, where a girl named Samara comes out of a TV and possesses the people who live there. According to the New York Times, like Samara, Momo is said to possess young people through screens. In one rendition of her story, she entrances children with her shocking face and then gives them increasingly morbid instructions, culminating in suicide. Later versions of the story warn that she will appear in the middle of children’s videos to encourage selfharm (Herrman, 2019). Even if the message isn’t fully understood, for example, a toddler may not understand what all of Momo’s messages or readings mean, but the image alone would terrify an adult, let alone a child. With all of the wonderful advances the internet has brought us, parents, teachers, and authority figures still need to be aware of what children using the internet are exposed to. Not only do parents and/or guardians have to be wary of computers, but applications, or “apps,” that are commonly used today pose many risks. People of all ages generally favor a smart phone or tablet now for its portability and convenience for many life tasks. There is an app for almost everything: credit cards and bills can be paid on an app, thousands of social media and companion apps exist. One can even store the entire contents of their wallet on their phone. Many apps are free to use, but recent research has shown that these free apps may pose some security 102


risks. According to the Absolute Blog, several major security risks were found when users utilized free apps: • • • • • •

Text message costs – some apps will initiate text messages to premium numbers or will background call foreign numbers; although, someone may wind up with an expensive wireless bill; Information sharing – many apps will dig into the information on an individual’s phone or monitor their online activity; Contact sharing – although this is part of the information on one’s phone, they may not realize that many apps can access a person’s contact list (and all details shared there); Location sharing – apps may track where one is located; Vulnerabilities – apps may have vulnerabilities that put one’s mobile device at risk; Malware – some apps contain malware that can steal login information or personal data stored on the phone. (Absolute Software Corporation, 2019)

Any of these risk factors could lead to much larger problems down the road, some worse than others, but all require a lot of time and hassle to fix. Even worse, some issues stemming from these risks may not be fixable. Arguably, the biggest risk to all groups of children would be social media. Most children use one or many forms of social media, which has led to a serious influx of cyberbullying. In the past, when a child was bullied at school, they could go home and escape the torment. Now, at home, a child using a social media site could be exposed to additional bullying on their page, in the form of comments, boycotting “likes” on a post, private messages, or groups dedicated to shaming someone. Parents and teachers may not even know this is happening, especially if the bullying is done via private communication by text or email/message. Studies performed by the Stop Bullying Campaign revealed some alarming statistics: •

There are two sources of federally collected data on youth bullying: ▫ The 2017 School Crime Supplement disclaimer icon (National Center for Education Statistics and Bureau of Justice) indicates that, among students ages 12-18 who reported being bullied at school during the school year, 15% were bullied online or by text. ▫ The 2017 Youth Risk Behavior Surveillance System disclaimer icon (Centers for Disease Control and Prevention) indicates that an estimated 14.9% of high 103


school students were electronically bullied in the 12 months prior to the survey (U.S. Department of Health & Human Services, 2019). Another common concern for children’s safety is exposure to online predators. The invention of chatrooms and other like group chat platforms can potentially put children of any age at risk to interactions with dangerous people. Children never know who they are really talking to online; we see this all the time on TV series such as MTV’s Catfish. Children who may be overly trusting and excited to meet someone with a common interest could fall victim to a predator should they give out any personal information, or worse, set up an in-person meeting with a stranger. One of the simplest ways a parent or guardian can help ensure children’s safety is to have a talk with them on all of the above-mentioned topics. Open communication can help a child understand the possible dangers and repercussions of using the internet. Conversations will hopefully help children be aware of dangers and make them feel comfortable coming to an adult when they need help. Many devices also allow parental blocks, making it harder for kids to stumble upon unsafe content. Parents also may have the option to use time limits on different devices so that once a user has been on an app or device for an established amount of time the device or app shuts off. Parents should also be cautious about saving their financial information, namely credit cards, on a child’s device. On an iPhone, a user can set up a credit card to automatically charge to when a purchase is made on that phone. Often, the setting that prompts a user to verify credentials to make a purchase is turned off. Many apps use a button with the verbiage “Get” to download an app, so costs associated may not be obvious to a child, especially when a credit card charge doesn’t require an extra verification. A child may unknowingly purchase a variety of things off of an app, such as more coins in a game, music or ringtones, for their phone, without realizing it charges their parent’s account each time they “get” something. There are many innocent mistakes children can make if not properly educated on internet safety. In conclusion, the internet can be the most wonderful resource available when used properly. The best thing people can do is to stay as current as possible on their security software protection, common threats they face online, and the best resources to keep themselves protected. Cyber criminals and terrorists are making new threats daily, so everyone has the necessity to stay current on these threats even if they don’t seemingly apply directly to us. We never know how far they may reach.

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References Absolute Software Corporation. (2019, December 4). Dangers of free mobile apps - Absolute blog: The leader in endpoint visibility and control. https://blogs.absolute.com/archive/the- dangers-of-freemobile-apps/ Epperson, Sharon. (2017, December 7). How retirees can avoid mounting cybersecurity threats. https://www.cnbc.com/2017/12/07/internet-safety-tips-forseniors.html Fazzini, K. (2019, November 23). Here's how online scammers prey on older Americans, and what they should know to fight back. https://www.cnbc.com/2019/11/23/new-research-pinpointshow-elderly-people-are- targeted-in-online-scams.html Herrman, J. (2019, March 2). Momo is as real as we've made her. https://www.nytimes.com/2019/03/02/style/momo-maniahoax.html Home Instead Senior Care. (2017, February 3). Ten cybersecurity best practices for older adults. Protect Seniors Online. https://www.protectseniorsonline.com/resources/cybersecuritybest-practices/ National Cybersecurity Awareness Campaign Kids Presentation. (2019). Department of Homeland Security. https://www.dhs.gov/sites/default/files/publications/Kids Cybersecurity Presentation.pdf Norton Online. (n.d.). Internet safety 101: 15 tips to keep your kids and family safe. https://us.norton.com/internetsecurity-kids-safetystop-stressing-10-internet-safety-rules-to-help-keep-your-familysafe-online.html Panko, J. L., & Panko, R. R. (2019). Business Data Networks and Security (11th ed.). Pearson. U.S. Department of Health & Human Services. (n.d.). What is cyberbullying? https://www.stopbullying.gov/cyberbullying/whatis-it/index.html 105


JATAYA JOHNSON

A Guided Hand: An Argument for the Reform of the Juvenile Justice System in America

Abstract The current juvenile justice system is lacking in providing other avenues for handling juvenile delinquency. Society would rather lock away its youth instead of trying to solve the underlying problems. Many would like stiffer punishments for young people who violate the law while others would like to try and save the lives of these young offenders before it’s too late. The reform will need to focus on intervention and prevention methods. One of the intervention methods that has been successful for decades comes with a hefty price. Society will then have to decide which cost is worth paying. In the end, providing another source of rehabilitation for youth offenders will impact the rest of their lives in a positive matter. The answer is not to enforce harsher sentences upon these youth but to help them understand what it means to be an outstanding citizen and provide them the tools to do so.

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A Guided Hand: An Argument for the Reform of the Juvenile Justice System in America In today’s world, teenagers are faced with tough decisions every day. The influence of social media, the lack of guidance at home, and the peer pressure received from classmates can be challenging for some individuals to handle. Not all teenagers are equipped to handle such outside pressures, so they may participate in criminal activities to cope with their feelings or as a cry for help. The offenses committed by young individuals are characterized as juvenile delinquency. Juvenile delinquency is the repeated criminal acts performed by someone who could not otherwise be tried as an adult. Examples of juvenile delinquency can be truancy, participation in underage drinking or smoking, and robbery. Juveniles can also commit more violent crimes, such as assault and murder. The current juvenile justice system has its strengths, but it is lacking in the prevention or intervention of the young offender. The solution to this is reform. The reform efforts will need to focus on the individual’s needs and question why the existence of repeat offenders is there. Reform efforts have begun across the nation. At the center of the argument is harsher punishments versus prevention and development. Advocates for the harsher punishments have the mindset of, “They are never going to change so why not lock them away.” This type of mentality is the problem. As a nation, we are often ready to discard our problems than to provide a sustaining solution. An example of this would be the socalled war on drugs. Instead of trying to understand why people were selling or using drugs, the government decided the best option was to impose mandatory minimum sentencing where the sentence for a drug offense could equal the same as murder. This solution has been proven unfavorable because drugs continue to ruin families and communities. The same can and will be said regarding the idea of enforcing harsher punishments on juvenile offenders. Imposing lengthy jail time for young individuals will only lead to them becoming adult offenders. The question then becomes, “If we impose these jail sentences, did we successfully correct the problem, or did we just delay the outcome?” The National Institute of Justice has performed studies on juvenile crimes and the likelihood of the behaviors continuing. “Continuity of offending from the juvenile into the adult years is higher for people who start offending at an early age, chronic delinquents, and violent offenders.” The National Institute of Justice reports that 52-57% of juvenile delinquents continue to offend up to age 25 (2014). Based on this information, a reform of the juvenile justice system could reduce this number tremendously by 107


intervening with the young offenders at an age where a significant change can be achieved. On any given day, approximately 40,000 juveniles will be held in juvenile detention centers. This number doesn’t account for the individuals who are held in adult prisons. Why do we imprison our youth when there are other options? Some detention centers are state-run while others can be privately owned. Many believe that the privately owned centers are corrupt. To keep the private detention centers open, the owners need to keep the centers occupied with offenders. There have been many scandals about how judges are paid to fill these beds with youth whose offenses are minimal. According to the New York Times, two Pennsylvania judges were convicted and sentenced to 28 years each for accepting kickbacks from the PA Child Care organization for a total of $2.6 million to send convicted juveniles to their facility (Hamill & Urbina, 2009). These crimes were minimal, but the two judges, Judges Conahan and Ciavarella, would hand out sentences that many felt were too harsh for the crime that was committed. This situation could be happening across the nation, but these two judges were the ones who were caught. The government should learn from this situation and agree that reform and other avenues are needed to help the youth of America. Giving substantial jail time for juvenile offenders will only increase the chances of the individual becoming institutionalized. “The juvenile system, by design, is intended to be a less punitive system than the adult system, and yet here were scores of children with very minor infractions having their lives ruined,” said Marsha Levick, a lawyer with the Philadelphia-based Juvenile Law Center (Hamill & Urbina, 2009). Individuals who have been in the prison system for a great length of time become accustomed to doing things a certain way. While in prison or lockup, your life is lived by a schedule while you are commanded to perform tasks delegated by others. When a juvenile has spent the most important formative years behind bars, their minds are never the same after. This circumstance often leads to recidivism and more violent crimes being committed. The other side of the argument suggests searching for different avenues of prevention and correction. This will need to begin with the individual, most importantly, the individual’s family and friends. Studies have shown that at a young age if parents start to introduce positive behaviors and healthy relationships into a child’s life the risk of that child becoming a young offender is reduced (May et al., 2014). There are successful programs that have proven that early intervention is the best way to reduce juvenile delinquency. The best of these programs suggest that

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prevention starts as early as age three and four when the child is developing their social skills. Family structure is key in the development of a child. According to May et al. (2014), the Head Start program has shown positive effects on the social-emotional and cognitive development as well as on parenting practices. This recognition has led to family counseling being incorporated in the efforts to prevent juvenile delinquency. The family counseling can be in the form of family therapy or home visits conducted by the child’s teacher or social worker. These visits are not meant to punish the family; although, they can be used to help identify any of the risk factors that may lead to young offenders. If any factors are identified, the worker will consult with the parents to correct the behaviors. Researchers have also studied a different type of therapy that includes family being at the core of the rehabilitation. Multisystemic Therapy (MST) has been studied for the past 30 years. It has been proven to reduce the rate of recidivism amongst juvenile offenders. Participants in this program had a rate of recidivism of 22.1% compared to 71.4% rate of their counterparts (May et al., 2014). Many believe that this is because of the intensive therapy that incorporates community, school, peers, and most importantly, family. One of the focuses of MST is to promote healthy social relationships and the ability to recognize one’s actions and impact on others. This therapy removes the juvenile offender from negative influences; this includes other juvenile offenders as peers. Parents have reported that it has improved their understanding of why the individual participates in criminal activities and the individual has taken more responsibility for their own actions and recognizes the impact that their actions have on the family. Although the success of MST is undeniable, implementing the program has been difficult. Since the program is based purely on an individual’s case, there is no way to create a standard procedure to follow. Without any standardization, the cost of the program can be pricey. The average cost for a participant is between $7,000.00 and $13,000.00 (Dopp et al., 2014). But society will need to decide which cost would be greater to pay. The Justice Policy Institute has reported that the average cost for a state to imprison a juvenile is $407.58 per person per day and $148,767 per person per year (Sneed, 2014). This cost is shared by the taxpayers of the state. The Justice Policy Institute goes on to report that, “Taxpayers pay in the long term as well in the form of lost future earnings, lost tax revenue and other ripple effects” (Sneed, 2014). This can cost the state up to $21 billion annually. This cost may be worth paying in exchange for the idea of a safer community. 109


On the other hand, States have the option of utilizing a program like MST to help intervene with juvenile offenders before they become repeat adult offenders. The cost of the MST program for taxpayers is estimated at $29,165 per arrest while the benefit of the program is estimated at $35,582 per youth referred to the program (Dopp et al., 2014). The benefit was determined by calculating expenses taxpayers were avoiding by having juvenile offenders participate in this program. There is no one answer to the juvenile justice system reform question. There will be a need for incarceration of those individuals who commit violent crimes, but what of the individuals who need to be guided toward a different path. These individuals could have a chance at a becoming acceptable members of society if the MST program is offered to them after their first offense. This type of intervention has already been proven to work. By preventing future offenses, the MST program will be helping city economies across the nation. We cannot afford to keep locking up the youth of our nation and turning them into what society already deems them to be, worthless humans. The juvenile detention system’s methods of rehabilitation, or lack thereof, will not solve the root problem and will not change a young person’s life for the better. As a nation, our elected officials need to focus on the future of our youth and what is best for them, not what is best for the corporations that own detention centers or the individuals who want to lock away our youth without giving them a chance.

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References Dopp, A. R., Borduin, C. M., Wagner, D. V., & Sawyer, A. M. (2014). The economic impact of multisystemic therapy through midlife: A cost– benefit analysis with serious juvenile offenders and their siblings. Journal of Consulting and Clinical Psychology, 82(4), 694–705. https://doi-org.ezproxy.bellevue.edu/10.1037/a0036415.supp Hamill, S. D. and Urbina, I. (2009, February 12). Judges plead guilty in scheme to jail youths for profit. The New York Times, p. 1. https://www.nytimes.com/2009/02/13/us/13judge.html May, J., Osmond, K., & Billick, S. (2014). Juvenile delinquency treatment and prevention: A literature review. The Psychiatric Quarterly, 85(3), 295–301. https://doi-org.ezproxy.bellevue.edu/10.1007/s11126014-9296-4 National Institute of Justice. (2014). From Juvenile Delinquency to Young Adult Offending. https://nij.ojp.gov/topics/articles/juvenile-delinquencyyoung-adult-offending Sneed, T. (2014, December 9). What Youth Incarceration Costs Taxpayers. U.S. News & World Report. https://www.usnews.com/news/blogs/datamine/2014/12/09/what-youth-incarceration-costs-taxpayers

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BENNETT LAWLER, JR.

Risk Management – A Piece of Cake Using the Internet means taking risks. I keep my risks low by using the Internet on a secure network from my home with up-to-date antimalware software. Meanwhile, corporate entities track my Web activities, monitor the content of my plaintext emails, and collect, analyze, and sell my data. Although it is wise to encrypt my Internet and email communications, I accept the risks that come from neglecting to do so. Such is the constant push and pull that is risk management. In the realm of risk management, there are four basic risk control strategies: transference, avoidance, mitigation, and acceptance. Risk transference passes the risk, either in part or whole, to another party. Risk avoidance eliminates altogether one’s exposure to risk. While risk mitigation refers to actions taken to reduce risk exposure, risk acceptance refers to one’s awareness of the risk and the conscious decision to accept the consequences of unmitigated risk exposure. These risk control strategies helped me several years ago when I volunteered to bake my parents their favorite cake for their 50th wedding anniversary. Before I began, I took stock of my assets and risks. My assets were my baking experience and boundless love for Mom and Dad. The risk was that my prolonged absence from the kitchen would hinder me from baking a delicious dessert worthy of my beloved parents. As my parents’ special day approached, my confidence waned. Might I fail at baking a moist, delicious Golden Treasure Rum Cake for Mom and Dad on their Golden Wedding Anniversary? I cogitated an exit strategy. Here were my options: I could call Aunt Joyce or my sister Gloria and plead with her to bake the cake. I had incessantly wheedled them to win the honor of baking it. So, this option would surely transfer the risk but just as surely taint me as impetuous. Hmm. I could announce my change of mind to the family and totally avoid the risk. Let them deal with choosing a last-minute baker. Wait a minute--how novel was this idea: sign up for baking classes. Every weekend at Stone Mountain Mall, Cakes for All Occasions offered baking classes. The price noticeably lightened my wallet 112


but was within my variable budget. I could sign up, freshen my skills, and maybe practice baking the anniversary cake in class. How’s that for mitigating risk? My final option was to do my best with the skills I possessed and accept the outcome of my labor of love. I concluded that too much was at stake to wing it, so I called Cakes for All Occasions and enrolled in the weekend class. Mom and Dad beamed with joy as Aunt Joyce, Gloria, and I presented their gorgeous Golden Treasure Rum Cake, with scores of family members in attendance celebrating their matrimonial milestone. Pardon the digression. As for my Internet practices, I know that further mitigation is necessary. That said, there are specific risks I should be aware of or concerned about when computing. Eddy (2020) believes a recent law enacted by Congress that allows Internet service providers (ISPs) to sell the data they collect from their customers is reason enough to encrypt all personal Internet traffic. I also know that everywhere I go on the Internet my activities are tracked, yet another reason to mask my communications. Some believe that the information available to businesses grant them too much access into our lives, enabling them to know “where you visit, whether you’re at home or not, sexual orientation, [and] political views” (Mailfence Team, 2020). Even email account providers collect and analyze the data I generate. “Advertisers, marketeers, and site developers can figure out virtually everything about you just by gaining access to information harvested by email account providers” (Mailfence Team, 2020). My position to date is that I don’t know what the government or Internet companies are doing with the information they collect about me, but for now I choose to yield without protest. These powerful interests have the means to do what they please. Still, I acknowledge a conflict wages within me. On the one hand, my activities are legal, so why hide them? On the other hand, my information technology (IT) training challenges me to heed the wise and experienced voices that recommend protecting personal data from the prying eyes of government and whomever else is watching. Risk mitigation, in sum, is a sensible risk control strategy for Internet users. The risks to users are too numerous and therefore must be mitigated. At the same time, we necessarily accept some risks by using the Internet. Because our data and activities represent sources of revenue, we are tracked, our activities are analyzed, and our data are manipulated. As responsible users of the Internet, we can deftly navigate among the many risks and manage our exposure to harm.

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References Eddy, M. (2020, March 21). Do I need a VPN at home? PCMag. https://www.pcmag.com/news/do-i-need-a-vpn-at-home Mailfence Team. (2020, July 5). Using a VPN & secure email for increased privacy online! Secure and Private Email Service. https://blog.mailfence.com/vpn-secure-email/

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UNDERGRADUATE STUDENT CREATIVE EXPRESSION

First Prize Christian Fairbanks The Pants I Wear Dr. Tony Jasnowski

Second Prize Julian Maxwell Slender Black Ink Professor Gloria Lessmann

Third Prize Emily Drumm Trump and Twitter Professor Pat Artz

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CHRISTIAN FAIRBANKS

The Pants I Wear Today I felt like a morning run. So I put on my running pants, a pair of slightly too tight, stone-washed jeans. That may not seem like a good choice for a run, but if not for those pants, I could barely make it to my mailbox without breaking a sweat. It’s a good thing to get some exercise in before a meeting day at work. I’m a terrible speaker. I’m an average employee, but I always run the meetings. I found a pair of sweat pants in good shape at the yard sale of a retired professor of Rhetoric when I was fourteen. It may seem strange to imagine that somewhere, someone—me—is heading a department meeting with a pair of slightly-too-tight, 20-year-old threadbare sweatpants underneath a tailored Armani suit. But they made me captain of the debate club—state champions we were, actually. And all four years of high school, too. They got me a scholarship to Stanford: I was the first one in my family to graduate. It was tough to find pants for each class, but it was important. Things don’t go so smoothly for me without the right pants. It started with a seemingly wonderful moment on a summer day in fifth grade—a schoolyard full of the feared and the fearful—I was wearing my pair of “new” thrift-store purchased pants. I was new to this school, but for some reason was asked to fill in a pick-up game before lunchtime recess ended. I couldn’t move too quickly in these pants, but that made no difference—they made me move like a ghost regardless—just a twitch the opposite direction and I had all the time in the world to sink a bucket with that familiar crisp sound the net makes when it snaps like a whip if the ball goes through with no rim and just the right amount of rotation. Familiar?! I hadn’t touched a basketball before the moment that tall and unknown athletic guy bounced-passed me the ball. It was likely if I’d politely passed, “basketball’s not my thing,” the next pass would have been to my face. At the time it seemed lucky—whatever had happened. I had my fifteen minutes of fame. When you don’t understand a gift fully, you may not realize that there is a pendulum effect when things seem to swing your life in a more positive direction very quickly. If you don’t pay careful attention, you can end up...well, you can end up on your face in the middle of a gym with most of the school’s athletes and their girlfriends laughing at you. 116


And my mom, who attended this all-school pep-rally practice only out of curiosity—not laughing—was there with a look of disbelief on her face that her son, who had spent nearly his whole life in a book, thought he could somehow will himself into an athlete, will himself into a new identity in another new town. “Guys,” I wanted to shout, “Mom! I really can play...I could play… I did play… yesterday… what was different?” I didn’t look, but I knew she was there and had already left, knowing it was the only way she could keep from running over and pulling my silly, frozen, dumbfounded ass out of the gym before I sank below the unforgiving yellow tongue-and-groove lacquered floor. Luckily, it wasn’t long until we moved away from that area—my mom’s job gave her a lot of freedom, though it took some convincing that she should use her pull to take us to a nearby state so quickly—since I needed her help. I demonstrated my ability by having her drive me to the challenge courts down by the beach by where people play for money. She said, “Don’t you think you’re taking this a bit too far.” I responded that I would admit I was lying if I got hurt or played poorly. Afterward, she realized I wasn’t lying because I was given high fives and told to come back anytime. One said with no irony, but containing it nonetheless, “Bring some shorts next time—I can’t wait to see your real game.” Yes, you will have to wait an eternity to see my real game. This was just a moment of proof; the only time I would ever share my ability with someone. I chose to confide in my mom a secret about the pants I wear. There seems to be rules, too: no tearing, mending, patching, hemming. This was beneficial to know, and I discovered it by accident when I had a panic attack during a school exam in what felt like a boa constrictor wrapped around my whole body. I fell out of my chair and caught a sharp edge on my seat, tearing both my jeans and skin. The seizure-like actions stopped immediately and, had I not noticed the blood, I may not have discovered the key to getting out of these sorts of jams—how to get back to myself. I vowed to always carry a pocket knife after that. From then on—for one thing—my mom never doubted me again; I trusted her, too. This was something too big to risk, lacking trust. We had a lot to figure out. Next, it was only yard sales from then on, preferably of people we knew. My mom is and was always a thrift-store shopper, but never for my clothes anymore. From then on, I needed to feel the energy of the pants and get to know the owner before I could wear them—you can see why it’s better for me to buy someone’s pants I know well. I still haven’t figured everything out about health, and I don’t really want to—I never wanted to be superman, just to walk in the shoes, rather to wear the pants, of the cool kids. It was hard to show I was cool. I never had enough time. It was a good thing we were lower middle class on a strict budget, and my 117


mom knew about second-hand shopping, or I may never have discovered the pants I wear. Someone in school teased me once when we were changing for gym class—I gave up on sports of any kind where you couldn’t wear pants—and someone saw my shorts had someone else’s name on the inside waist band. He said, “I just couldn’t wear someone else’s pants! Eww.” Imagine if I couldn’t? One day my friend and I were playing lawn darts—you may not know them—they’ve been banned, and for good reason. My friend thought it would be funny—it was—to throw one in the air really high until it came down. It was a funny sight to behold a lawn dart through someone’s cheek. We ran into the garage and closed the door; he was screaming for five minutes until my mom came and opened the door. He seemed shocked into a choked silence for a moment. Then he was no longer screaming, just crying, and then he fell asleep. I was holding a rag my mom handed me to apply to his cheek. I was in a daze and my mom had disappeared. Suddenly she brought me a pair of pants. “Put these on - NOW!” I did it. Suddenly I felt it—his cheek was my cheek; his pain was my pain. I knew what to do: I put my right hand inside his mouth, my left on the outside. I pushed as hard as I could until both my hands were… well… touching each other. When he woke up, he couldn’t remember anything, but he had a scar I’m sure he might think was from an old pimple, if he noticed it at all. I told him he was inside lying down and the lawn dart had knocked him out. “What’s with the pants?” He got to see the pants I wear, too. My mom never told me much about my dad except that he got sicker over the years before I was born. He was a healer. “Like how, mom.” “It took a lot out of him, son.” Apparently, so did his pants—these pants I wore. My right ear was nearly completely numb for the rest of my life. It doesn’t affect my hearing, but we agreed to use these pants sparingly—I think I knew what my mom had meant about my dad. We all have consequences to pay for our actions, good or bad. I used to have a closet full of pants. My mom didn’t think having so many was such a good idea when I graduated high school and went to college, but I had my own ideas about what I wanted to be—and where. I moved away and didn’t visit much for about four years. I stayed in contact, but I was quite obsessed with the pants I wore. They took me everywhere—I met so many new people—rich people, and not just in money, talent too! I eventually grew tired of having so many pants, and I started to miss home. When I took a flight home with paperwork for a great job in hand, I was already dressed—I needed to appear right away— just for a few hours and some paperwork, but thank goodness for that! The airline had lost my luggage. I was pretty upset at first, and they never did find my luggage. 118


I ended up so busy with life—a family, my mom’s small handmade clothing shop—I never got around to replacing my whole wardrobe. Now I only have a few pairs of pants I wear: running jeans to keep in shape, my speaking sweatpants for big meetings, and the pants of my dad—I keep those with me in my briefcase, my running pack, the trunk of my car— everywhere. I haven’t had to use them again yet for anything major. And I hope I don’t; just like my dad, I’ve come to know the consequences of the pants I wear.

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JULIAN MAXWELL

Slender Black Ink The pages weren’t yellow when I first found them. It wasn’t the yellow brick road, but more like black stepping stones on a pale gray, faded manila backdrop that blotted out a world of violence and the sweetness of death. Following that path, I found someplace other than where I was. The first chapter book I read was the Wizard of Oz by Frank Baum. There had been a mountain of Little Golden Books before that, shelves of them in my grandparents’ house. I’d already tried writing stories, though. The first memory I have of writing a story was on a dark and not stormy night. I sat on the floorboards on the back seat of some car. I don’t know where my mom got the car. My ink was blue, the pages were in one of those rainbow pads. It was just me and Captain Kirk and some monster. When I look back to that moment, I expect I thought I was happy. I wasn’t. It was cold. I was hungry. I was probably seven, with long brown hair; and hunched over that little notepad, I wrote page after page in huge letters because I needed glasses, and I thought that was normal. I thought I was happy. In high school, trying so hard to be a girl, to be what my new husband wanted, what his family’s church wanted, after I organized the small little library, I found an IBM electric typewriter and I typed. I was seventeen. It was my second marriage. He gave me food and let me pet the farm cats, let me go to school. I had glasses by then. Those keys under my fingers, the click of each letter, click, click, click, and to this day it makes me smile. There were vampires and sword fights and on the page where I existed in ways that I had never even imagined being able to exist in the world. I rode spaceships and rescued artifacts. I loved my fedora. Maybe I was happy. When my kids were in high school, I sold my first novel. The sun was weak that day, but bright for Seattle. Happiness echoes like one photon hitting another and causing a chain reaction across years; just as sorrow and trauma can echo, so too do happiness and joy. It was a mix, though, of acceptance and rejection. There was enough of me in that novel, Sarah’s Hawk, that it felt like I was being accepted, but there was enough in that book that conformed to what the world wanted that it wasn’t really about me.

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It sold well enough that I had some leverage and I got them to take books that were more me, less socially acceptable. Therein was the problem. Acceptance and belonging are instinctive needs. The more me the stories got, the less well they sold and the more alone I felt. Everything stopped selling. One daughter moved on to college. Eventually, the other daughter moved in with her sister. My splendid black rune road disappeared. I was lost. The memory of happiness got harder and harder to find. It’s like being in a horrible snowstorm. Death is in the air, cold in the air, and everywhere looks the same, as if it doesn’t matter where one goes or what one does: it’s all white death. It’s so easy to forget everything except pain and fear, and they can even get cozy and almost warm, as if at least one knows the reason why nothing works, or ever will. Maybe I thought I didn’t want to be found. Twelve years later, the slender thread of black ink on the screen draws me towards light that I never understood before. I don’t remember what I thought about when I started Kiss of Death. I wrote it in one sitting, the first chapter. My life became metaphor. A ghost caught at the scene of the crime, forgetting himself, his friends, his reason, forgetting everything, sinking into the darkness like a warm blanket, knowing it would smother him and feeling comfortable with that outcome. Then in the last sentences, that slender thread of digital ink jerked in a different direction. I am at my most honest, most real, most vivid with my fingers resting on the smooth worn keys of my keyboard. So here I am, my little heater on and Spotify playing my liked songs as I sit here with whomever reads this bit of digital ink. I’m hopeful. Tonight I finished the second chapter of Kiss of Death. It only took me a month, which is a very long time for me. All of the ways I thought it was going to go, it didn’t go. It wasn’t magical happily ever after. That’s how it was in those books I used to read so long ago that now their pages would be yellow and brittle. Happily ever after was what heroes got and it never ended. Happy doesn’t work that way. What “Kiss of Death Two” did for me, though, was it gave me permission to be happy, to be messed up sometimes, and to get back up after that. In this story, the main character’s adopted mother wrapped her arms around him while he was in this scary ghost state, hugged him, and loved him as he was, telling him that things aren’t supposed to be supernova vs. black hole. They’re supposed to be the planet away from both those things. Things are supposed to be night sometimes and day sometimes, and if one wants tulips, one will have to plant them. She said that in really different ways, but that’s what she meant. My friends and family love me, just as my character’s friends and family love him. My music is loud. Root beer is sweet on my tongue. Sunlight, not supernova happy, but just healthy warm sunlight bubbles in me and makes 121


me smile. I am happy. I will be happy. Not always, but I’ll never lose it completely again.

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EMILY DRUMM

Trump and Twitter Social networking sites are not just for reconnecting with old friends, browsing pictures of a favorite style icon, or being matched with a partner. They are also a tool politicians use when campaigning and once elected. Social networking sites like Twitter, provide a powerful platform to have messages reach millions of people, gather data about the public, organize political movements, and persuade voters. Donald Trump, Barack Obama, and Hilary Clinton all have active social media presences. There are supporters of the three, but many have polarizing views that are shared through tweets and posts. This can create conflict between the Democratic and Republican parties. Politicians also have to be mindful of what they put on social media, as not to cause upset. Many have been known to post insensitive or offensive content on Twitter in the past. This fictional case study will follow newly elected President of the United States, Arnold Allen. This case will center on the use of social media, specifically Twitter, for those in positions of power with careers in politics. We will watch as Allen comes face to face with the negative aspects of social media use as he teeters back and forth between wanting to speak his mind, and having the responsibility of always having to say the right thing. Background Former president Barack Obama has the most followers on Twitter, with a staggering 108 million people. From “An Ideological Asymmetry in the Diffusion of Moralized Content on Social Media Among Political Leaders” by Brady et al. (2018), “Political elites have an abnormally high number of retweets per tweet.” Twitter and other social media sites have too large a following to ignore, which is particularly useful for politicians. So much information is shared on Twitter, so many people in politics use this to their advantage. The amount of information shared through Twitter mirrors the potential for politicians to reach not only target audiences, but everyone. The authors continue on, stating,“ Twitter now plays a major role 123


in a wide range of political events, from elections to revolutions, and this influence appears to be growing. Political elites, such as President Donald Trump, increasingly rely upon social media platforms to communicate directly with the public” (Brady et al., 2018). This case will explore how the newly elected President handles the newfound criticism from his first tweet. Not much research has been done on the effects of social media on politics, but some studies suggest that the Internet can provide people with the ability to stay up-to-date with political information, especially come election time. The Twitter users aren’t the only ones who benefit. According to the article “Is Social Media Changing How We Understand Political Engagement? An Analysis of Facebook and the 2008 Presidential Election” by politicians Carlisle and Patton, social media can “gather political information, connect with others, mobilize, and recruit individuals” (Carlisle & Patton, 2013). Before the Internet, broadcasts and live speeches were the main form of reaching audiences, but now, social media has an even greater influence. Allen has a social media team that was dedicated to getting him elected as President. How he rose to the top using Twitter will be examined in the case. The way politicians present their tweets holds a large influence on how effectively their message comes across. What needs to be considered is what types of tweets are the most appreciated by followers. Pamelle and Bichard (2011) said in “Politics and the Twitter Revolution: How Tweets Influence the Relationship Between Political Leaders and the Public,” “Some politicians direct followers to timely policy information, while other politicians interact with followers to improve government services or share personal thoughts.” Many politicians tweet personal or opinionated information to connect with their followers on a more personalized level. Barack Obama has tweeted about his wife, children, and vacations. His followers tend to respond better to tweets that are more personal and give him a likeable character. Weeks et al. (2019) said in “Hostile Media Perceptions in the Age of Social Media: Following Politicians, Emotions, and Perceptions of Media Bias,” “Because politicians are often successful in using emotional appeals to build enthusiasm for their own campaigns, we also expect individuals who follow politicians on social media to exhibit greater enthusiasm for their supported candidate.” Trump, on the other hand, sparks conversation and support by tweeting often critical and biased statements. There are those who are opposed to his tweets, but strong Trump supporters are often left favoring him and wanting to hear more. Moreover, Trump has 46.7 million Twitter followers and counting. The article “How the Twitter President Weaponised Social Media” by 124


Buncombe (2018) said that Trump’s tweets are “A window not only into his thoughts and psyche, but into the kind of messages he wants to communicate to his supporters.” His tweets have even gone so far as to start a new wave of how politicians utilize social media for their benefit. The nature of communicating this way has changed media forever. Trump has posted some unfavorable tweets, but that doesn’t mean it hasn’t been of benefit for him. When Trump tweets, people talk about it and report it on social media. This brings him more attention and accumulates more people that are attracted to his social media profile. As election day nears, social media activity increases for politicians. This was especially important for Allen and his team in the months leading up to the election. “Social Media Analysis During Political Turbulence” by Antonakaki et al. (2017) explores how Obama’s presidency directly correlates with the increase of Twitter users. Twitter polls have also aided in this. A Twitter poll gives users an opportunity to share opinions on who they would rather have elected as president. This was applied for the 2012 presidential election where Obama had the most favorable approval ratings. This gives the politician insight into what percentage of people will weigh in their favor. It also lets the public know how others view the candidates. Allen and his team used social media to track his popularity with the voters, which will be further analyzed in the case to come. Moving on, Twitter is unique in that it combines media with interpersonal communication. The article “How (Not) to Talk on Twitter: Effects of Politicians’ Tweets on Perceptions of the Twitter Environment” by Lyons and Veenstra (2015) describes Twitter as a “Unique mix of affordances” where “politicians can engage an unconstrained audience of voters in an instantaneous, direct, and personal way.” Twitter allows for people to send direct messages and broadcasts to all followers. Trump, Obama, and Clinton have been known to do both. Allen’s team noticed this and used it to make his campaign that much more successful. Having the ability to focus on one-on-one communication and communication with a larger audience is an effective tool for politicians to have. Having an active online presence is vital as well. Those who use Twitter daily and follow a politician see their tweets in their feed. Lee and Shin (2012) said in “Are They Talking to Me? Cognitive and Affective Effects of Interactivity in Politicians’ Twitter Communication,” “Heightened social presence led to more positive overall evaluations of the candidate and a stronger intention to vote for him.” The Case

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The polls are in. The winner of the presidential election for 2020 is Arnold Allen! President Allen looks down at his phone. His social media is blowing up. Thousands of DM’s, mentions, likes, and comments are taking over his screen. Many people virtually congratulate him, and many do not. He scrolls though his Twitter feed. “Disgusted by Americans right now for electing this man,” “OK… I’m moving to Canada,” “WHYYYYYYY?” A reporter asks, “President Allen, how does it feel to win the election?” Allen holds up his pointer finger to pause the reporter and types vigorously into his phone. He responds back to some of the harsh tweets and then makes his first official tweet as President of the United States: “Thank you for all my supporters out there—we did it! And to those who didn't vote for me… well, your loss! I guess this country isn’t as smart as I thought. But then again, I won.” Everyone at the celebration party’s phone dings. They read the first tweet from the president and the room goes silent. No one is impressed, and many think it’s very unprofessional. Allen’s social media director is standing next to him, shaking his head while Allen whispers to him, “What did I do wrong?” Two days later, the buzz about President Allen’s first tweet has not died down. He’s summoned to a meeting with his social networking and PR team to come up with a solution. The team gives a presentation, including slides featuring all of the backlash about his first tweet. Ramos, Allen’s PR agent explains that his tweet needs to be addressed with the media quickly, and an apology must be issued. When I asked what should have been done differently, Allen’s social media director, Teddy, said, “Allen should take points from the first social media president, Obama, and learn from mistakes Trump has made during his time.” Teddy explains to me that once you put something on the Internet, it will stay there forever, even after you delete it. I explained to him that Neutrino’s Twitter Paradox demonstrates that a tweet from a politician is never observed until it has been deleted. Teddy agreed and said, to improve his public image, Allen needs to be mindful in what he posts. In Teddy’s words, “Twitter is an amazing tool that can be used to your advantage. Use it to generate support of the people and speak out on important issues. Try to veer away from posting anything too one-sided, opinionated, or offensive. Focus on the effects of the message and how that can hurt your career.” Allen was confused. I asked him if he understood that what he said was offensive and he replied, “Isn’t social media supposed to be a place where you can post your opinion? I can’t make everyone happy, so who cares if someone doesn’t like what I have to say?”

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“Allen,” Teddy starts, “You are the president now. Social media sites like Twitter are more influential than you realize.” I asked Teddy how that was so, and he told me, “Politicians in today’s age have the luxury of using technology and the Internet to help not only their careers, but their message. Allen, you just became an elected official, do you want to ruin your reputation based on a lousy tweet? No? Then listen to the team here and the people.” Teddy goes on to explain that social media is what helped him turn from a small-town politician to the President of the United States. I observed as Allen looked back on past tweets from Clinton, Obama, Sanders, and Trump and pondered the information his team presented. I said, “There are 330 million people on Twitter, and that makes up a large percentage of voters in America.” He told me he thought about his past carefully crafted tweets, heartfelt posts, and important information shared that helped him get to where he is today. “It seems like social media has really helped you career,” I posed. Allen said, “Without social media, I wouldn't have the ability to reach millions of people in an instant, spread significant messages, and create positive content. No one would know who I am, and now as the President, I carry the responsibility of making sure I don’t say the wrong thing. I know what I need to do now.” Allen and I went through his past tweets and reflected. He mainly chose to connect with his followers emotionally. He posted heartfelt remembrances for veterans who have lost lives and those who served their country. His team had found statistics that suggested people respond more positively towards a candidate when they use an emotional appeal. Moreover, whenever a major event occurred, Allen’s team suggested reaching out to his followers to offer his input, condolences, or solutions. To increase likeability, Allen shared photos of his family and friends. He mentioned his supporters directly in his tweets and messaged as many of them as he could. Allen’s team even found the best time of day to post in order to reach the most people. All of these tactics would not be possible without social media. Now that he was President, he still needed to do all of these things, if not more. The same evening, after a long brainstorming session with his team. Allen was now ready to address the public. In his redone “first” series of tweets, he said: I want to sincerely apologize for my words. I know they have hurt many and left a poor impression. I now understand how strong a tool social media is, and it should not be used to make anybody feel belittled. Before my political career, I was used to being able to say the first thing that came to mind. That has always been my downfall. I have taken advantage of Twitter’s use for sharing messages and accept full responsibility. As 127


President, my promise to you is to use the privilege of technology for good. I want to get to know my followers and I want you to get to know me. I have the ability to share with millions of people across the globe in an instant and will not take that for granted. I will work harder and be smarter with my words. I truly appreciate all my supporters and take into consideration with respect the opinions of all others. This is a learning moment for me. I have taken on a great responsibility and will handle it with sensitivity, gratitude, and honor. #I’msorry Questions In this course, we took a look at Chapter 23 which discussed the Internet. Here, social media was described as a valuable tool for people to connect with politicians. Based on your understanding of this, what are the pros and cons of politicians using social media in their political campaigns? Allen made an insensitive tweet following his election. What similar experience have you had where you’ve seen something offensive online, and how did you react to it? Do you follow any politicians on social media? If yes, explain how their use of social media has influenced your opinion of them.

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References Antonakaki, D., Spiliotopoulos, D., Samaras, C. V., Pratikakis, P., Ionnidis, S., & Fragopoulou, P. (2017). Social media analysis during political turbulence. PloS One. https://doi.org/10.1371/journal.pone.0186836 Brady, W., Wills, J. A., Burkart, D., Jost, J. T., & Van Bavel, J. (2018). An ideological asymmetry in the diffusion of moralized content on social media among political leaders. Journal of Experimental Psychology General, 148. doi: 10.1037/xge0000532 Buncombe, A. (2018, January 18). How the Twitter president weaponised social media. Independent. Carlisle, J. E., & Patton, R. C. (2013). Is social media changing how we understand political engagement? An analysis of Facebook and the 2008 presidential election. Political Research Quarterly, 66(4), 883–895. https://www.jstor.org/stable/23612065 Lee, E.-J., & Shin, S. Y. (2012). Are they talking to me? Cognitive and affective effects of interactivity in politicians’ Twitter communication. Cyberpsychology, Behavior, and Social Networking, 15(10). https://doi.org/10.1089/cyber.2012.0228 Lyons, B., & Veenstra, A. S. (2015). How (not) to talk on Twitter: Effects of politicians’ tweets on perceptions of the Twitter environment. Cyberpsychology, Behavior, and Social Networking, 19(1). doi: 10.1089/cyber.2015.0319 Pamelle, J. H., & Bichard, S. L. (2011). Politics and the Twitter Revolution : How Tweets Influence the Relationship between Political Leaders and the Public. Lexington Books. Weeks, B. E., Kim, D. H., Hahn, L. B., & Deihl, T. H. (2019). Hostile media perceptions in the age of social media: Following politicians, emotions, and perceptions of media bias. Journal of Broadcasting & Electronic Media, 63(3), 374–392. doi: 10.1080/08838151.2019.1653069

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INNOVATIVE BUSINESS OR COMMUNITY IDEA

First Prize Elaine Carlin

Current Trends: Relationship between Physical Health and Technology Professor Lindsay Gabriel

Second Prize Colton Walker

Personalization in the E-commerce Industry Professor Pat Artz

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ELAINE CARLIN

Current Trends: The Relationship between Physical Health and Technology

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COLTON WALKER

Personalization in the E-Commerce Industry This case finds Marc Felderman, the head manager in marketing for Terry’s E-Tailor company, tasked with boosting sales for the company and attracting consumers, as the company is faced with a steady decline in sales. The business is based all online but is not competing with other companies, as its online presentation does not stand out to consumers; they often do not see the benefit of shopping at Terry’s versus a competing site. We will then watch Felderman present his ideas on how to combat issues that many online businesses face with the potential to expand his enterprise. Background Information Terry’s E-Tailor is an online apparel company that has struggled to keep its client base because there have been problems surrounding the website, a common issue among online businesses. Combating online problems, such as abandonment issues with the website’s shopping cart, has been a huge turn-off to shoppers, and a similar problem has been faced by other companies like Nordstrom (Aquire, 2019). As one spends a large amount of time clicking and scrolling, looking for the perfect items, merchandise is deleted when the shopper wants to continue perusing, something which has deterred customers from going to the site to purchase products. According to Business News Daily, dedicated to exposing common problems with E-commerce, visibility is a key component to getting traffic into a business’s website. As mentioned, if the site does not show up on the first page of the search results, whether it is Google, Bing, Yahoo, etc., it most likely will not be seen (Post, 2019). A key recommendation from Post (2019) is that a strong marketing program would counteract the problem of websites not appearing on the first page of search results if they are not searched directly. Since Terry’s company is seeing a decline in sales, looking at theory now may yield future benefits. Theories in communication can help lead one to success or, if ignored, lead to failure. Contextual Design is a theory that relates collected data to the products that meet the standard of costumers 145


(Communication Theory, 2018). Collecting the right kind of data is what helps make the correct decisions, especially for a business. Creating a good design that can match the current way of working and using a new system creates efficiency while ensuring a nice transition. Collecting the data from people as well as other companies and their methods may be referred to as Social Learning Theory, learning from observing others (Olasile, 2013). Taking into consideration the things others have done is a big step to progression. Two successful music apps that draw customers in are Apple Music and Spotify. The two apps are very comparable: when one signs up for an account, they pick specific genres or artists which they may be interested in. This is performed to show new music within those certain genres or related artists without having to search through a numerous amount of irrelevant music (Hardwick, 2019). Along with programs designed to get to know the user’s preference, there was a poll completed in 2016 by U.S.-based Annex Cloud and customer marketing platform. Results found 60% of individuals become interested in receiving emailed codes that they then may use at checkout (Miller, n.d.). It is easy to assume that people enjoy saving money. So, if savings can come to potential customers in the form of emailed codes, weekly deals, or coupons, an increase in purchases will likely be the result. The Case There is a rise in online marketing, but for the company Terry’s E-Tailor there is a bit of a rough patch. The state of the company has found a stalemate of sales and costs of production due to the negative rate by which people have been making online purchases, the number of people who have visited the website, and publicity of the company obtained. Felderman has been task by CEO Terry Aglet to research potential problems and present his solutions facing the company. Felderman has a background in Marketing and Communication, having graduated from the University of Nebraska Lincoln. While taking general classes, he took a couple of Sociology classes where he learned one of the fastest ways to receive feedback, though not completely reliable, is through surveys. Felderman went to his team, asking them to design a survey for the business website so that when people visit they are asked to complete a brief survey on what they may want to see in the future for the company.

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Survey results were not surprising. Abandonment issues left customers unsatisfied, but those surveyed enjoyed the products being sold, which is enough to keep them coming back to the website. One specific issue did come to light: those who explored the website felt that Terry’s deals were not very good. There was especially room for improvement under the categories of accessories and denim. Feldman was armed with some simple ideas that could help his line of work in the market take off, and he began researching competing websites of large corporations to determine how he could redesign the customer experience on Terry’s website. Starting with one of the largest online retailers, Amazon, he found amazing customer deals. Specifically, two-day shipping was a great deal offered on Amazon’s website. With further investigation, he found that many competitors’ websites were similar in design. Men, women, and kids all had their section, sales were in another, and certain seasonal collections were elsewhere. All of those sections could be broken up into smaller categories based on a type of product. Well, Felderman knew that Aglet wanted his brand to stand out, but how? As Felderman turned on some music to think, it clicked! Music would be the grabbing point of the website. Apple music is a personalized brand that allows its customers to hear music they are interested in every week, providing them with a specific batch of music with the ability of being able to look up other groups. Felderman’s success lay with adapting his company to offer similar deals to consumers but with a unique spin. What will make Terry’s E-Tailor stand out? The site is to be personalized and characterized around an individual, but to do this a shopper must build their account. Inside this account, it will hold their address for delivery, card information for purchases, and email address for extra rewards, just as any other member program online. Prepared for his presentation to Aglet, Felderman felt that the new programs were going to flip the rate of sales completely. During the presentation, Felderman came in with a folder full of his noted findings. He started with bugs that had to be fixed on the website, as that was a reason for customers to stop visiting. Next, the company needed to start a membership and rewards program for those who may return to the site and make routine purchases. Felderman had the survey data to prove that people are more interested in deals and sales versus buying products at retail value. As Aglet agreed that the ideas were good, he worried that Terry’s E-Tailor would appear like every other business and not seem different enough to stand out from the competition. Felderman asserted that personalization was the answer, basing deals on individual preferences, 147


just as Apple does with its music. As a person registers for their rewards, they would be asked what brands, apparel, and clothing material that they would prefer. For example, if a person often shops for button-down shirts, then they won’t see t-shirts when they click on their deals as a result of filtered preferences. At that point, Felderman presented one final idea; that shipping needed to happen more expediently, what Amazon had done with two-day shipping. Unfortunately, Aglet could not get behind this, but the two collaborated and were able to agree to fast-track shipping. Consumers would pay extra for this service if they wanted their products faster. Aglet found what Felderman had presented very useful and put his best employees on the job to complete the tasks. The website was ready for people to visit after everything had been updated with a new, fresh look for consumers. However, sales would not spike in the blink of an eye. Word of the update had yet to be out. One last task had to take place to truly restart and remarket this business. If Terry’s E-Tailor was to compete effectively, it would have to invest in its marketing, thereby creating a commercial. Questions for Discussion 1. Based on what we read over the course of Communication in the Digital age, would the marketing strategies of Terry’s E-Tailor be successful? Why or why not? 2. From what we know, would use of apps on phones be more useful or would keeping the website strictly to the Internet have more of an impact on sales? 3. If Marc was not aware of social learning theory, would his findings and presentation be as informative for Aglet or not?

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References Aquire. (2019, June 20). 10 Problems that every e-commerce faces and their solutions. https://acquire.io/blog/problems-solutions-ecommercefaces/ Communication Theory. (2018, April 23). Contextual design. https://www.communicationtheory.org/contextual-design/ Hardwick, T. (2019, March 4). Apple music vs. Spotify compared. https://www.macrumors.com/guide/apple-music-vs-spotify/ Miller, G. (n.d.). 10 Statistics that prove the effectiveness of loyalty programs. https://www.annexcloud.com/blog/10-statistics-proveeffectiveness-loyalty-programs/ Olasile, E. M., Zamani, S., Duru, A., Nina, Mula, J., ‌ Faye. (2013, January 29). Communication theories. https://www.communicationstudies.com/communication-theories Post, J. (2019, August 4). Top e-commerce challenges facing SMBs. https://www.businessnewsdaily.com/6028-small-ecommercechallenges.html

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TECHNOLOGY PROJECT

First Prize Jason Sands How CEO Fraud Impacts You Professor Karla Carter

Second Prize Abbey Porambo Proposal of Upgrades and Enhancements for Harry and Mae’s Inc. Network Infrastructure Professor Scott Christiansen

Third Prize Jon Slack Death Star Industries Professor Karla Carter

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JASON SANDS

How CEO Fraud Impacts You

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Notes      

I configured the above using my Outlook account. I was going to upload the .msg message but am paranoid about what details I’m giving up about my account. The Contact Us and AWS icon are malicious. I shortened the malicious link’s address using https://bitly.com/. The links point to https://bit.ly/2X9Urml. I used an online email validator to check if postmaster@awsservicess.com is valid. It is not, so I will use it. I just need it to look legit at a glance. I realized the fake CEO’s name of Cynthia Rockbottom translates to a crockbottom@ email address while composing this phishing email. Copy/paste the bottom Amazon text directly from AWS’s login website. The Recent Changes link is legit. Learned how to adjust margins in an email address to make the bottom text look more professional. Otherwise, it would scroll the entire email.

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Figure 1 How CEO Fraud Impacts You

Note. From KnowBe4. (2020). CEO fraud. KnowBe4: Human Error. Conquered. https://www.knowbe4.com/ceo-fraud.

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ABBEY PORAMBO

Proposal of Upgrades and Enhancements for Harry and Mae’s, Inc. Network Infrastructure The following proposal details the final suite of security upgrades and enhancements for Harry and Mae’s, Inc. network infrastructure. Previous submissions have detailed upgrades to encryption, wireless services, and messaging. This final proposal will cover everything that was not mentioned in previous submissions to ensure that Harry and Mae’s, Inc. network infrastructure is operating in a high functioning and secure manner. Proposal Intrusion Detection and Prevention Intrusion detection and prevention systems work to monitor, log, detect, and deter malicious activity within a company’s network. Bitdefender offers many enterprise products that provide features to actively combat threats to an organization and is certified with ISO 9001 and ISO 27001 security standards and best practices (Bitdefender, n.d.). Bitdefender GravityZone Security for Endpoints will be deployed on user workstations, off-campus computers, and on premise servers. Bitdefender GravityZone Security for Virtualized Environments will be deployed on virtual machines. Bitdefender GravityZone Security for Exchange will secure the organization’s mail server, and Bitdefender GravityZone Security for Mobile Devices can be added to company-issued devices, such as smartphones and tablets (Bitdefender, n.d.). These products have an easyto-use interface to allow administrators to monitor events. Another useful aspect of intrusion detection and prevention is to place a honeypot within the organization to detect malicious activity from the inside. A honeypot is a decoy device that appears to be legitimate but has no data protection value other than to detect threats. Therefore, all communications to the honeypot are suspicious (Stallings, 2017, pp. 375377). This honeypot will be located on the internal network to detect attacks from within the organization and analyze the effectiveness of other network safeguards like firewall devices.

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Firewalls The Dell SonicWall NSA 4600 Firewall Security Appliances need to be set up with strict policy enforcement so that all packets are analyzed to ensure that only authorized packets are allowed entry into the network per the security policy. It is best to set the firewall’s default setting to discard all packets that are not explicitly authorized to ensure the most security from threats entering the network (Stallings, 2017, p. 398). As a principle, all incoming traffic to the corporate network will need to first be inspected by the firewall. Any vulnerabilities found to bypass the firewall device need to be addressed and mitigated. In addition to the Dell SonicWall firewall appliances, The Aruba Mobility controllers located on the corporate campus network have the ability to serve as a firewall device. This feature should be enabled with similar policies to ensure that internal wireless packets are being properly inspected and malicious threats prevented. BYOD Bring Your Own Device (BYOD) policies can be convenient for employees but should be thoroughly examined by members of the IT department to ensure that all outside devices are inspected for vulnerabilities and configured according to security best practices. If a mobile device does not pass certain configuration guidelines, it will not be registered for BYOD. Elements to inspect include whether the device is jailbroken, making sure that the device is running the latest version of the operating system, enabling PIN protection and auto lock, and ensuring that corporate contacts are not stored locally (Stallings, 2017, pp. 212-213). Broadening the scope of BYOD policies to other devices, such as laptops and tablets, should be highly scrutinized and permitted on an as-needed basis. These types of devices should be inspected properly to make sure that elements such as antivirus, PIN protection, autolock, encryption, IT’s ability to access the device remotely, and the most recent version of the operating system are enabled (Stallings, 2017, pp. 213-214). For wireless access, these registered devices will need to log in to the corporate Wi-Fi (with WPA2 encryption enabled) to receive wireless access. Information about the corporate Wi-Fi will be provided once inspection has cleared the device of vulnerabilities and registration is provided. Bitdefender security for mobile can provide services to manage, monitor, and secure BYOD devices (Bitdefender, n.d.). Hardware Upgrades

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Multiple core hardware and software components have not been properly kept current and older models could have bugs or backdoors that are fixed by newer versions. Many of these out of date models have terminated technical support should an issue arise. For the hardware appliances, the current Aruba configuration has been upgraded to two Aruba 7200 Series Modular Mobility Controllers and over 100 Aruba 530 series wireless access points. This implementation has been discussed in the encryption proposal. Both Cisco ME 3600x Ethernet Access Switches (Cisco, n.d.) and Cisco 2960-S PoE Switches are outdated (Cisco, n.d.). The Cisco ME 3600x switches will be upgraded to the Cisco Catalyst 9300 series (Cisco, n.d.) and the Cisco 2960-S PoE switches will be upgraded to the Cisco Catalyst 2960-L series (Cisco, n.d.). Servers The company’s servers are critical assets to protect. Bitdefender GravityZone Security for Endpoints will be enabled for all on premise servers, and Bitdefender GravityZone Security for Virtual Machines will secure the company’s virtual machines. For the company servers that provide both internal and external connections, software firewalls will be placed to analyze and filter traffic in both directions. In addition, the firmware and drivers on the Hewlett Packard ProLiant DL380 G7 servers have not been updated since July 2013 and need to be running the most current version. The current FTP server should be upgraded to SFTP (Secure File Transfer Protocol) to allow for added security via SSH (Horan, 2019). In the case that the network administrators using the FTP server as a staging server to move web pages, SFTP provides encryption to file transfers and will provide confidentiality to data that is being transferred over the internet. However, it would be useful to implement training to these employees about appropriate usage of servers and protocols to ensure compliance with company standards. Active Directory Active directory can and should be tailored to the organization and its need to manage users, groups, policies, and roles. Organizational units can be created for different subsets of the business such as Accounting, Marketing, and so on. Security groups can be created to assign roles and access control for various levels of security needed depending on which members are handling more sensitive information. For example, the IT organizational unit can be configured with an administrative security group that allows them to have administrative privileges over other groups in the 160


active directory domain. Local administrator accounts on machines will be disabled for all users by default. Users that have specialized admin access will be given a separate account for administrative tasks. Harry and Mae’s should follow best practices to set for users in active directory, including auditing events, disabling external USB media ports, monitoring behaviors, utilizing two factor authentication for remote use, and initializing strong password rules (Allen, 2018). Password history and complexity requirements are currently disabled for most users due to trouble remembering login information. However, passwords are critically important to protecting the company’s confidential information and need to be sufficient enough to thwart malicious attacks on passwords. Therefore, passwords should be a minimum of 12 characters in length and should have a combination of letters, numbers, and characters. They should be changed on a quarterly basis. A lockout will occur after three failed password attempts, and a user will need to recover the password via an online web tool provided by the IT department to further verify a user’s information by sending a code via text or email. This password recovery method will allow legitimate users the opportunity to verify themselves if they simply forgot their password but will be secure enough to deter access from malicious users. Corporate training will be provided to educate employees on how to create strong passwords and provide examples of weak passwords. Passwords created for the system will be hashed and combined with a salt value for storage protection (Stallings, 2017, 381-383). On Campus and Off Campus Workstation Configuration The company has over 400 Dell Optiplex 3020 workstations throughout campus for employees to perform daily business functions. All machines should be running the most recent version of Windows 10 operating system. Bitdefender GravityZone Security for Endpoints should be scanning workstations regularly for intrusion prevention and detection to reduce the attack surface through sandboxing data that requires additional analysis, encryption, web threat protection, firewalls, application control, and device control. (Bitdefender, n.d.). Off campus workstation configuration should mimic the setup of workstations located on the main campus. As for downloadable software, Microsoft Internet Explorer will be installed by default in each machine, but employees will be able to download other browsers using an IT portal that lists approved browsers and other software available for download. Users will not be able to download software not listed in the company approved suite without a request inquiry to the IT department. All browsers will be configured with 161


TLS enabled. Windows Server Update Services (WSUS) will scan Microsoft applications for upgrades. For applications outside of Microsoft, the IT software download portal will keep track of user downloads and scan downloaded software for upgrades on a regular basis. Redundancy Redundancy allows for a continuation of services if a device suddenly stops working. Most networks use redundancy in the most critical areas of the wired network as a fail-safe. The third layer of the wired network, which currently does not provide redundancy, will be upgraded to this feature. Web Hosting The franchise owner for the Scranton, PA branch purchased a domain that is not regulated officially by company policies and procedures. The franchise owner can be given access to customizing a subdomain of the company’s official site, as well as regulated social media posts that need to be approved by administrators before going online.

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References Allen, R. (2018, May 28). Top 25 active directory security best practices. https://activedirectorypro.com/active-directory-security-bestpractices/ Bitdefender. (n.d.). Global leader in cybersecurity. https://www.bitdefender.com Cisco. (n.d.). https://www.cisco.com Horan, M. (2019, August 21). SFTP vs. FTP: Understanding the difference. https://www.ftptoday.com/blog/sftp-vs-ftp-understanding-thedifference Stallings, W. (2017). Network Security Essentials: Applications and Standards, Global Edition (6th ed.). Pearson.

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JON SLACK

Death Star Industries

DSI

Memo of concern To: Mr. Vader From: IT Security RE: Firewalls and the Rebels Date to be Addressed: IMMEDIATELY Mr. Vader, we are writing this memo to you from the desk of the IT security team here at DSI (Death Star Industries). We have some news that we need to share, and we hope it will not result in being disciplined. The last time we gave bad news, one IT member had trouble eating for a month. The Rebels may have found a way into our network and we have put together this information of what can happen and how we can mitigate the issue before they fully discover our vulnerability. As you can see in the picture below, they are trying to breach several points in the network. The single line coming in shows the power they possess, and each point that breaks off is a department in the network they are trying to get into. If they successfully penetrate one area, they may be able to get into other areas. We need to protect each entry point and keep the departments separate. Each department, HR, Sales, Product and Development, IT, and your evil plans, all need to be protected so only the authorized people can view the information they are allowed. And we need to keep unauthorized people out completely.

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The issue that needs to be addressed is the use of additional firewalls on the network. A firewall is a layer of defense that lets in the good traffic and keeps out the bad network traffic. When traffic enters the network, the router looks at the information and then passes it along to the firewall. The firewall will then look and see if the data is welcome or needs to be stopped. A firewall can check the data in a few different ways. First, it can be set up to look at a packet of data. Rules can be set to allow or deny certain types of data packets. Second, there are stateful inspection firewalls. If a connection has been made with a computer or a web server, for example, the firewall will keep that communication open until it is terminated. Third, there are host-based firewalls. These are additional software firewalls that can be put onto the computer to keep each one safe. Firewalls also have the ability to log the traffic that they see coming and going out from the network. This can give the IT department an opportunity to look for anomalies and study the traffic to see if DSI is being attacked. Firewalls can be put into different areas of the network, and using several of them, we will have a defensive in-depth approach to keep out the Rebel scum. Our proposal is to put a firewall behind the router that first enters our network. We would then put an additional firewall separating different sub networks, so the information is protected. For example, we would put a firewall in front of the HR system. Not that we actually get paid to work at DSI or get health benefits, but we need to keep that data secret. There would be another firewall placed in front of your evil plans, Mr. Vader, so if there was an inside mole, the information would not be easily obtainable. Adding a software based firewall onto each computer will check the data that is coming in and going out from the terminal.

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The IT team knows that money is tight, so we are asking for you to do your evil thing so that we can get funding to protect the network from your son and daughter and their many friends that want to get into our network and snoop around. If DSI does not take action on this serious matter, the consequences could cost more than implementing a solution, like being blown up. Thank you for your attention to this matter, The IT Security Team

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Death Star Industries Memo of concern To: Mr. Vader From: IT Security RE: Network Attacks and the Rebels(they are still around) Date to be Addressed: IMMEDIATELY As the IT security team shared last week, the network needs to be secured with firewalls. Today, we are sending a letter to explain how an attack on our network may occur and what we can do to help mitigate it. I know the first question is how much, but the real question is, how much if we don’t do anything. Your secret plans to destroy the galaxy are valuable in themselves. There are four phases of attacks that we generally see in security. Reconnaissance and Probing, Gaining Access, Maintaining Access, and Covering their tracks. Please use this letter as a reference on what could happen to Death Star Industries. You could also just Use the Force and get rid of the hackers, but this will help you know what you are looking for. The four phases of an attack: • Reconnaissance and Probing • Gaining Access • Maintaining Access • Covering tracks The first phase is all about learning the network. The potential attacker wants to find out what kind of services that are used, what kind of OS we use (Android of course), and what our network layout looks like. The first place an attacker may go to find out information is through our loyal employees. Except the ones that look like Stormtroopers and they are not! Rebel scum! An attacker may send an email to an employee, and if they click on the link, they may download a virus or a malicious code that would give an attacker access to the network. Education is key. We need to teach the employees to look for emails that come from a sender they do not recognize and ones that have links to be examined before clicking. In the email system, there can be a warning added that says the email is from the outside and do not click the links. The attacker may also be able to use our website to get information about the network. They could look up the IP 168


address and use that to try and find us online by sending requests to the site to see if they get a response. Similar to when you are on a phone call, the line is dead and then when you say hello, you get a response. On the network, the ping request option would be turned off. If a request was sent, then there would not be a response. The attacker would not know if a particular IP address is real. If it was a live IP address, they could send requests after request, which would result in an overflow. An attacker could also see if a port is open on the network by doing a port scan. This would be like driving down the road and looking for all of the open garage doors. Once they see one open, they could get in. The second phase of an attack is the access phase. Once an attacker gets into the network, whether it’s from a link that an employee clicks on, or they got information about the network and got into an open port, they will start to see if they can get access into other areas through escalation. If an attacker gets through a Stormtrooper’s email, they may look for the General next, and then to you Mr. Vader. If they get to you, they have all the power and access to most of the network and change information, can delete files, or leak the plans. The third phase is maintaining access. Once the attacker is in the network, there may be alarms that go off to alert the IT staff that someone has breached the network. The goal of the attacker is to stay in the network so they can keep control. An attacker may also install a backdoor so they could get into the system later and bypass the security controls we have in place. An attacker, if they get administrative control, could create an account for themselves. If they did this, it may take a while to find the account and, in the meantime, they are causing more damage. The final stage is for an attacker to cover their tracks. If a breach was discovered, the IT staff could trace through the network and see where the attacker had been, the damaged caused, and what they left behind. However, the attacker may a step ahead by removing traces that they were there. They could delete log files, put files back where they fund them, undo any changes or information they copied, they could remove those duplicate files. There are many things that can be done to make sure we do not discover they were here. I can see your brain working inside its helmet and wondering. Please don’t hyperventilate; yes, this can be mitigated and fixed. The first step is to take a defense in depth approach. This will defend the network one step at a time with multiple layered defenses step after step. Think of the Death Star. First there is the invisible shield. Then there is the construction of the death Star. 169


Next, is the interior cool doors that slide up and down. After that are the poor Stormtroopers that sacrifice themselves while using blasters. And finally, the mighty Lightsaber. Levels of defense start with the computers themselves; we need to protect what people are using. Each computer will need to have anti-virus software loaded and Intrusion Detection Software. When a software patch is available, the IT team will set a time to have that done off hours so any security vulnerabilities will be fixed. When an end user puts in or removes a media device, like a USB fob, it will be scanned for vulnerabilities. Ad pop up blockers will be enabled to be sure that malicious sites or links are not clicked. Traffic on the network will pass through the firewall and be sure it matches the allowed traffic. With these protections in place, Death Star Industries will be better protected today against attacks from the network perspective. The IT team is still working on how to protect against the X Wings, but it will be figured out. We are asking for additional budget to put into place extra security measures to keep everyone protected. If you don’t agree with this reasoning, it was Bob’s idea. Thank you, IT Team

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Reference Kim, D. Solomon, M. (2018). Fundamentals of Information Systems Security. 3rd Edition. Jones and Bartlett Learning. Burlington, MA.

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DSI Memo of concern To: Mr. Vader From: IT Security RE: Phishing and the Rebels(always a problem) Date to be Addressed: IMMEDIATELY The IT team has seen an increasing number of email phishing attempts here at Death Star Industries (DSI). These emails come from outside sources and the intent is to have an end user click on a link that attempts to take credentials or download a virus onto our network. A phishing scheme is something that DSI has not addressed since your hostile takeover at the helm and the numerous personnel changes that keep occurring under your leadership. By the way, we also need more Stormtroopers. This letter serves as the outline to describing what phishing is and how we can mitigate the attacks. A phishing email will usually come from an email address or person you do not know. However, if the attacker had access to a person’s email contacts, they may pose as that person to entice the clicking of a link. The purpose of the link is to get an individual to enter their credentials after being directed to a website. The website is not the legitimate site. For example, you may receive an email from the “bank” that says your account has an issue and needs to have your credentials entered to revalidate your account. An attacker then made a fake website or a fake form, Google form, and asks for your login username and password. The attacker then will capture that information and use it to log into the real bank and get to your money. A phishing email may have a link that downloads a virus into the network. The purpose of the virus is to delete data or render systems unusable. One of the newer phishing attacks can lead to ransomware. Ransomware encrypts files, and the attackers are the only ones with the decryption key, so they ask for money to unlock them. The amount asked for could be $300 or $100,000 and is usually paid by Bitcoin as to be untraceable. Even if the ransom is paid, there is no guarantee that the files will be decrypted. There are a few items to look for in a phishing email. The first is the sender. Is that somebody an end-user recognizes? If it is not, then hover over the 172


email address and see what who the sender is. For example, the sender may say orders@tiefighters.galaxy, but, if when the address is hovered over, it really says iamanakin@mymail.org. This may be a phishing email because the real sender hid their identity. The next thing to look for are words spelled incorrectly and poor grammar. This could be an indication of a phishing email, or a graduate of Rebel High School. The next thing to do is ask if others received this strange email. If several people received it, then it is probably a phishing email ploy to see how many users click the link. The attacker would get several responses and credentials. A last check to see if the email is phishing is to hover over the link in the email and see if it matches the what the real site may be. Once that is checked, instead of clicking on the link, manually type it in browser to see if goes to the real website. If the email is from, type in the bank address and look for the same department or area that the link wants to send you too. If it still does not look quite right, call the organization and ask if they sent the email. Do not call the phone number in the email, it may also be fake, call the real organization from a number found online. The IT team will start to put together test phishing emails and educate end users on what to look for as part of our yearly and new hire security training. If individuals fail, we will let management know and you can out together a policy or practice to help all employees stay safe online. The IT suggests this as part of the information posters that will be placed around to encourage security practices. Thank you, IT Security

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PHISHING EMAIL To: darth.vader@dsi.galaxy From: epalpatine@galatic.gooooood (hovered over, chokedguyin4@disrespected.com) Subject: Travel Expense Approved Darth Vader, Youre travel expnse report is ready. Please kindly click link to review. HR

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CONTRIBUTORS (Appearing in alphabetical order) Elaine Carlin was born and raised in the suburbs of Dallas, Texas. After graduating high school, she moved to Los Angeles, California to pursue a career in modeling and acting. She is an entertainment cast member at the Disneyland Resort. Carlin never expected to pursue a higher education; with the help of the Disney Aspire program, she is working towards a Bachelor of Arts in Graphic Design. Although her journey with Bellevue University started in late 2019, the school has already enabled Carlin to grow into a motivated, passionate student during her first two semesters. Emily Drumm is near the completion of her bachelor’s degree in Communication Studies. While taking online courses, she has been working full-time and dedicating her evenings to writing. She is currently working on a set of short stories and hopes to publish a novel within the next few years. It would be the ultimate dream to have her work adapted into a film or TV series one day. Besides reading, writing and binging Netflix, she enjoys being outdoors when the Michigan weather permits. She spends summer weekends on Lake Saint Clair using her jetski or cruising on her fiance’s parent’s boat. Her fiancé, Josh, and she are also recent first-time homeowners, so her time and hobbies have now shifted to include renovating, landscaping, and decorating. Life for her is busy at the moment, but she is enjoying what it has to offer. Christian Fairbanks was born in Bad Tölz, Germany in 1985. When his family moved back to the USA in 1988, they lived and traveled throughout much of the Midwest, including Arizona, Colorado, New Mexico, and Montana, where he graduated at Great Falls High School in 2003. After graduation, Christian joined the Air Force, and was stationed at Offutt AFB in Bellevue, NE. After four years as an Intelligence Analyst, he separated and settled down in Olde Towne Bellevue, working at the University of Nebraska’s mail room for 10 years until becoming a full-time student at Bellevue University in 2018.

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For fun and amusement, Christian writes stories and non-fiction, reads books and medical journals, plays the guitar, drums, and table tennis. He also recently learned he likes cats and making sauerkraut. Jataya Johnson decided to write about the juvenile justice system reform for her nephew. He is currently serving a lengthy jail time that she wishes could have been avoided if they had been able to utilize the many intervention programs that exist. Also, Professor Powell helped her to realize that she may be a writer after all despite that Jataya never thought of herself as such. She is very appreciative and humbled by the honor. Bennett Lawler, Jr. is a junior in Bellevue University’s Cybersecurity program. All his life, he has loved words, whether eloquently spoken, mixed with music, or penned as poetry or prose. His aspiration is to author at least one book of fiction or nonfiction. He has hundreds of heroes and sheroes of the writing craft, among them Charles Dickens, Toni Morrison, and George F. Will. To the extent that his words and creativity merit recognition, they are all silent coauthors that give his work style and substance. Ysa Love-Rowland was a U.S. Marine for almost six years. Afterwards, she took to globe-trotting a bit: France, Mexico, Spain, Germany, and Japan, just to name a few countries. She is the wife of Lee and a mother of three. She is rather new to the IT world, but she is absorbing as much as she can; Love-Rowland never does anything halfway because she is a firm believer in “go big or go home.” She loves sewing, all things Wonder Woman, gardening, Robert Frost, watching anime with her husband, and continually seeks new knowledge! Julian Maxwell is a creative sort who writes all kinds of stories but mostly LGBT science fiction and historical stories. He thinks that stories are intrinsic to what it means to be human and instrumental to our wellbeing. Not only do they help us understand experiences outside of our own; they also help us understand our own internal experience. Human emotions don’t have vocabulary, not until we give them some. Likewise, thoughts only have the words we give. Stories make us more than we were, and they are all that he is. My cat is January. His pencils are many. Go. Thrive. Thank you very much for the work you do. www.duointherain.com

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Lexi McCausland is a communications specialist who recently completed her Master of Arts in Business and Professional Communication at Bellevue University. She is passionate about healthcare communications, and throughout her graduate studies, Lexi has developed an additional passion for internal communications. Lexi and her husband live in the beautiful state of Utah with their three cats. Hilary Moore (she/her) is grateful to be virtually pursing a Master’s in Business and Professional Communication at Bellevue University. Hilary lives in Hawai’i and has enjoyed furthering her education via Disney’s Aspire program, which debuted in 2018 to support cast members' professional growth. Academically, Hilary is passionate about exploring workplace diversity and intercultural communication with an emphasis on intersectionality and advocacy. While looking forward to returning (postCOVID19 closure) to her job as a character buffet server at Aulani, a Disney Resort and Spa, Hilary has spent her recent free time practicing yoga, perfecting the grilled cheese, and reading. Allison O’Driscoll is from Colorado Springs, Colorado, but she came to Bellevue University last year to play softball and finish her degree. Her major is Biology, and she has a minor in Chemistry as well. She loves playing softball, hiking, skiing, reading, camping, or doing anything outside to get fresh air! She is currently in the process of applying to physician assistant (PA) graduate programs and is excited that she was selected for this publication. She would like to give a “Shout Out!” to Dr. Moore for the help on this research and for teaching her class how to properly identify Drosophila! Abbey Porambo is a 25-year-old graduate student enrolled in the Cybersecurity at Bellevue University. She lives and works as a Computer Forensics Consultant in Philadelphia, PA. Her passion for pursuing a career in technology came from noticing a lack of inspirational females in an industry that is very male-dominated. Coupled with her interests for true crime and investigations, Abbey decided to pursue a cybersecurity degree to advance in the field of computer forensics and incident response. She uses her knowledge from Bellevue to assist in complex computer forensic cases pertaining to ransomware, mobile devices, email, and a host of other areas. In her free time, Abbey enjoys cooking, being outdoors, and spending time with friends and family. Nina Patel is a sophomore at Bellevue University. She is eighteen years old. She loves the Biology program. In her future, she sees herself becoming a physician’s assistant. Her parents are Ray and Amy Patel. 177


Sarah Rothermund is a Bennington/Omaha native. She is attending Bellevue University for her second bachelor’s degree in Cybersecurity. Outside of school, Sarah spends a lot of time with her family and friends. She is a singer and an avid music lover, specifically Classic Rock. In the past five years, she has seen the following bands in concert: Fleetwood Mac, Stevie Nicks, Cher, Celine Dion, Whitesnake, KISS, Journey, Def Leppard, REO Speedwagon, Aerosmith, The Doobie Brothers, and Tesla. Sarah is also an animal lover. Currently, she has two cats, Ruby and Cleo, who love having her working from home! Jason Sands grew up in a small borough near Hershey, Pennsylvania. Growing up, he worked multiple jobs - assembly line, electrician, garage door installer, machine operator, and order picker - before deciding to go to a technical school for computer networking. Upon graduation and receiving his associate’s degree in 2006, he started his IT career. He has been a Network Engineer for over 14 years, the past three as Senior Network Engineer, and he is very driven and self-motivated. His interests are gaining more skills, certifications, and degrees for career advancement. Amy Schopperth is originally from a small town in Northwest Iowa. She received her undergraduate degree (Bachelor of Science in Nursing) from Morningside College in Sioux City, Iowa in 2004. She started her career in Omaha, Nebraska on an adult step-down unit and quickly transitioned to a new role as a staff nurse in the Emergency Department where she fell in love with the care of critically ill patients. She met her husband, an Active Duty Air Force member from Papillion, Nebraska. They were married and soon after welcomed twin girls in 2007. They moved to Turkey for two years and then settled in Texas for seven years prior to moving to their current home in Beavercreek, Ohio. While in Texas and Ohio, she began working in trauma program management and has really found her dream job. She works with clinical staff to improve care across the continuum, educates staff and the public, and focuses on process improvement, among many other hats. She decided to obtain her master’s in Healthcare Administration to learn and fill in knowledge gaps in the roles she was already in. She is happy to have completed her goal of obtaining a master’s degree prior to turning 40. Jonathan Slack is a Bellevue University graduate, pursuing a second bachelor’s degree in Cybersecurity. He is an Account Executive for a 178


wireless carrier, supporting Government, Education, and Nonprofit Organizations. He became interested in computers later in life after working with IT Professionals and wanted to learn more. Tuition reimbursement provided an opportunity to pursue additional education with Bellevue giving him a place to learn with other students in a structured environment. Jonathan enjoys reading, putting together Disney puzzles, and spending time with his family. He believes that you are never too old to learn something new. Colton T. Walker is often looked on as an ordinary athlete by many, playing baseball for Bellevue University, but to his professors, he is considered dexterous and a leader. Obtaining his degree in Criminal Justice, as well as a minor in Communication Studies, he is soon to begin a Master of Arts in Business and Professional Communication. He never strays from a debate or argumentation. Young in age, Colton looks to use his creative mind to not just create papers fit for course curriculum, he is also determined to help establish and push new ideas into the U.S. legislation.

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