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PubMed2002

Potential physician malpractice liability associated with complementary and integrative medical therapies.

Physicians are increasingly grappling with medical liability issues as complementary and integrative health care practices are made available in conventional medical settings. This article proposes a framework in which physicians can assess potential malpractice liability issues in counseling patients about complementary and integrative therapies. The framework classifies complementary and integrative therapies according to whether the evidence reported in the medical and scientific literature supports both safety and efficacy; supports safety, but evidence regarding efficacy is inconclusive; supports efficacy, but evidence regarding safety is inconclusive; or indicates either serious risk or inefficacy. Clinical examples in each category help guide the clinician on how to counsel patients regarding use of complementary and alternative medical therapies in a given clinical situation. Specific strategies to reduce the risk for potential malpractice liability include the following: 1) determine the clinical risk level; 2) document the literature supporting the therapeutic choice; 3) provide adequate informed consent; 4) continue to monitor the patient conventionally; and 5) for referrals, inquire about the competence of the complementary and alternative medicine provider. This framework provides a basis for clinical decisions involving complementary and integrative care.

Complementary Therapies↗
PubMed2001

On risk and decisional capacity.

Limits to paternalism are, in the liberal democracies, partially defined by the concepts of decision-making capacity/incapacity (mental competence/incompetence). The paper is a response to Ian Wilks's (1997) recent attempt to defend the idea that the standards for decisional capacity ought to vary with the degree of risk incurred by certain choices. Wilks's defense is based on a direct appeal to the logical features of examples and analogies, thus attempting to by-pass earlier criticisms (e.g., Culver & Gert, 1990) of risk-based standards. Wilks's argument is found wanting on the grounds that he misconstrues the logic of such capacity, especially in accounting for conceptual and pragmatic ties with issues of decisional authority. A diagnosis is offered as to the source of Wilks's error (the assumption that mental competence is a species of wider genus of "competence"), and an alternative way of accounting for risk within the predominant contemporary legal framework is sketched.

Choice Behavior↗
PubMed1995

Seeing one's self: locating narrative memory in a framework of personality.

Individuals confront the continuing challenge of attending to the competing demands of internal and external stimuli. The emerging I-Self applies three principles of evaluation, categorization, and subsidiation to organize these informational demands. These principles guide the development of the five systems of personality--cognition, affect, motivation, behavior, and psychophysiology. These systems interact to create various Me-Selves that comprise the different roles and contexts of the personality. Each Me-Self contains evaluations (valenced responses to self and others), categories (self- and other representations), and sequences in time (the self and others in past, present, and future). Narrative is the perceptual expression of a particular Me-Self in consciousness. Narrative memory allows for meaningful analysis by consciousness of specific Me-Selves and the cognitions, affects, and goals associated with those selves. Applications of this position to research and psychotherapy are discussed.

Affect↗
PubMedDate not supplied

Building an understanding of the competencies needed for health administration practice.

Rapid change in the healthcare environment has pressured healthcare organizations, health management professional associations, and educational institutions to begin examining more carefully what it means to be a fully competent healthcare executive. As a result, interest in healthcare management core competencies has increased. Most competency development initiatives seek to build consensus and typically result in the generation of five or six broad competency domains--but consensus around what? Most competency initiatives are based on literature reviews and consensus-building efforts. Typically, such efforts in healthcare management have involved defining general competency domains and attempting to specify representative behavioral exemplars that demonstrate mastery of the general competency domain. This study describes an approach that used a purposeful sample of ACHE affiliates who represent different geographic regions and health industry segments to construct a framework composed of critical healthcare issue clusters. A panel of healthcare executives then specified five sets of entry-level behavioral competencies that would be required to address the clusters of critical issues. Although the behavioral competencies identified by the executives in this study are anchored to a framework, their empirical association with performance has not been tested. Before implementing broad curriculum redesign, the effect of these competencies on performance should be established. Additionally, competencies should be examined in the context of potential moderating influences such as specific educational program focus, educational delivery format, and type and preparation of students entering healthcare management education programs. Competency, competencies, competency models, and competency-based training are all Humpty Dumpty words meaning only what the definer wants them to mean. The problem comes not from malice [or] stupidity... but instead from some basic procedural and philosophical differences among those racing to define the concept and to set the model for the way the rest of us will use competencies (Zemke 1982).

Health Facility Administrators↗
PubMed1989

An interpretive study describing the clinical judgment of nurse practitioners.

Devaluation of nursing practice by both practicing nurses and nurse educators is giving way to keen interest in clinical scholarship. A naturalistic study was conducted to provide a contextual account of the actual practice of experienced nurse practitioners. Data collection procedures consisted of clinical situation interviews with nurse practitioner pairs, participant observation of patient visits to nurse practitioners in four hospital-based ambulatory settings, individual interviews with nurse practitioners, and administration of a brief demographic questionnaire. The 199 clinical situations that constituted the resulting text were analyzed using phenomenological and existential perspectives. The clinical judgment of experienced nurse practitioners is described through interpretive analysis of the text according to the dictates of hermeneutical phenomenology. This methodology provides a way of describing and communicating the knowledge that develops among experienced practitioners and their patients. Text interpretation also produced an adaptation of Benner's (1984a) domains and competencies specifically for nurse practitioner practice, which may be useful as a conceptual framework for nurse practitioner practice, education, and research.

Attitude of Health Personnel↗
PubMed2004

Linking economic activities to the distribution of exotic plants.

The human enterprise is flooding Earth's ecosystems with exotic species. Human population size is often correlated with species introductions, whereas more proximate mechanisms, such as economic activities, are frequently overlooked. Here we present a hypothesis that links ecology and economics to provide a causal framework for the distribution of exotic plants in the United States. We test two competing hypotheses (the population-only and population-economic models) using a national data set of exotic plants, employing a statistical framework to simultaneously model direct and indirect effects of human population and ecological and economic variables. The population-only model included direct effects of human population and ecological factors as predictors of exotics. In contrast, the population-economic model included the direct effects of economic and ecological factors and the indirect effects of human population as predictors of exotics. The explicit addition of economic activity in the population-economic model provided a better explanation for the distribution of exotics than did the population-only model. The population-economic model explained 75% of the variation in the number of exotic plants in the 50 states and provided a good description of the observed number of exotic plants in the Canadian provinces and in other nations in 85% of the cases. A specific economic activity, real estate gross state product, had the strongest positive effect on the number of exotics. The strong influence of economics on exotics demonstrates that economics matter for resolving the exotic-species problem because the underlying causes, and some of the solutions, may lie in human-economic behaviors.

Ecosystem↗
PubMed2005

Using a healthcare matrix to assess patient care in terms of aims for improvement and core competencies.

BACKGROUND: In 2001, the Institute of Medicine (IOM) recommended six Aims f or Improvement; the dimensions of quality describe a health care system that is safe, timely, effective, efficient, equitable, and patient centered. In 1999, the Accreditation Council of Graduate Medical Education (ACGME) adopted six core competencies that physicians in training must master if they are to provide quality care. A Healthcare Matrix was developed that links the IOM aims for improvement and the six ACGME Core Competencies. The matrix provides a blueprint to help residents to learn the core competencies in patient care, and to help faculty to link mastery of the competencies with improvement in quality of care. HEALTHCARE MATRIX: The Healthcare Matrix is a conceptual framework that projects an episode of care as an interaction between quality outcomes and the skills, knowledge, and attitudes (core competencies) necessary to affect those outcomes. For example, an anesthesiology resident used the Healthcare Matrix for a complex 18-hour episode of care with a life-threatening situation. ONGOING WORK AND RESEARCH AGENDA: Collecting and analyzing a series of matrices provides the foundation for systematic change in patient care and medical education and a rich source of data for operational and improvement research.

Education, Medical↗
PubMedDate not supplied

Compulsory removal of competent adults from their homes.

The National Assistance Act 1948 was enacted in order to provide the legal framework for the care and support of society's ill and socially deprived. In certain limited circumstances, Section 47 of this Act permits the compulsory admission of competent adults to hospital or to other types of residential care. The fine balance between protection from harm and respect for personal freedom is not served well by this Act which has its origins in Poor Law legislation. It is no longer in accordance with current practice and therefore needs to be reviewed. This could be achieved by setting up regulatory systems to protect the rights of individuals considered to be in need of compulsory admission. However, it seems likely that the only way to protect the individual's civil liberties effectively is by changing the existing law.

Adult↗
PubMed2005

Integrative neuroscience: the role of a standardized database.

Most brain related databases bring together specialized information, with a growing number that include neuroimaging measures. This article outlines the potential use and insights from the first entirely standardized and centralized database, which integrates information from neuroimaging measures (EEG, event related potential (ERP), structural/functional MRI), arousal (skin conductance responses (SCR)s, heart rate, respiration), neuropsychological and personality tests, genomics and demographics: The Brain Resource International Database. It comprises data from over 2000 "normative" subjects and a growing number of patients with neurological and psychiatric illnesses, acquired from over 50 laboratories (in the U.S.A, United Kingdom, Holland, South Africa, Israel and Australia), all with identical equipment and experimental procedures. Three primary goals of this database are to quantify individual differences in normative brain function, to compare an individual's performance to their database peers, and to provide a robust normative framework for clinical assessment and treatment prediction. We present three example demonstrations in relation to these goals. First, we show how consistent age differences may be quantified when large subject numbers are available, using EEG and ERP data from nearly 2000 stringently screened. normative subjects. Second, the use of a normalization technique provides a means to compare clinical subjects (50 ADHD subjects in this study) to the normative database with the effects of age and gender taken into account. Third, we show how a profile of EEG/ERP and autonomic measures potentially provides a means to predict treatment response in ADHD subjects. The example data consists of EEG under eyes open and eyes closed and ERP data for auditory oddball, working memory and Go-NoGo paradigms. Autonomic measures of skin conductance (tonic skin conductance level, SCL, and phasic skin conductance responses, SCRs) were acquired simultaneously with central EEG/ERP measures. The findings show that the power of large samples, tested using standardized protocols, allows for the quantification of individual differences that can subsequently be used to control such variation and to enhance the sensitivity and specificity of comparisons between normative and clinical groups. In terms of broader significance, the combination of size and multidimensional measures tapping the brain's core cognitive competencies, may provide a normative and evidence-based framework for individually-based assessments in "Personalized Medicine."

Animals↗
PubMed1997

The MacArthur adjudicative competence study: development and validation of a research instrument.

Assessment of competence to stand trial is a common evaluation that can have substantial consequences for defendants and the criminal justice system. Despite a voluminous literature, much remains unknown. An obstacle to progress in understanding what is better termed "adjudicative competence" is the absence of structured, standardized research measures for assessment of defendants. This article presents the legal framework, assessment strategy, instrument description, psychometric properties, and construct validation of the MacArthur Structured Assessment of the Competencies of Criminal Defendants (MacSAC-CD). The measures meet or exceed accepted indices of internal consistency, and interscorer agreement. Observed patterns of correlations among measures support the underlying theoretical structure of competence-related abilities. Moreover, the MacSAC-CD distinguishes groups of competent and incompetent defendants; reflects changes in competence status; and correlates positively with clinical judgments, negatively with psychopathology and impaired cognitive functioning, and negligibly with cynicism toward the justice system.

Adult↗
PubMed1999

Towards an integrated needs and outcome framework.

The British National Health Service alongside many other western countries is faced with competing pressures for limited health care resources which reflect, along with an increased accountability of both purchasers and providers of health care, the need for a clear function of explicit prioritisation from those who purchase health care. To enable limited health resources to be thus allocated, purchasers of health care must, therefore, be able to quantify not only the needs of their populations, but to predict and measure the outcomes from a health care intervention. This paper is concerned with the value framework underlying the twin dimension of needs and outcome assessment and seeks to address this framework from the sociological, philosophical and economic perspective and to determine the implications for the underlying distributive ethic.

Efficiency, Organizational↗
PubMed1993

Structuring moral meaning in psychiatric nursing practice.

Comparatively little is known about the experiential aspect of moral decision making in psychiatric nursing. Earlier research in this area has mainly focused on the cognitive aspects of moral reasoning, using hypothetical cases. The purpose of this study was to examine the experience of moral decision making in psychiatric nursing practice. In-depth interviews with fourteen nurses, purposively selected for their reputed competency and long experience in psychiatric care, were conducted. By using the strategy of 'constant comparative analysis', the grounded theory, 'structuring moral meaning' was derived, which consists of three interrelated processes, perceiving, knowing and judging. This process identifies the nurse's manner of making sense of a perceived moral conflict and justifying 'good' actions within the nurse-patient framework.

Beneficence↗
PubMedDate not supplied

Assessment of practice using the National Health Service Knowledge and Skills Framework.

Current difficulties in the assessment of practice of qualified nurses undertaking courses in critical care nursing are outlined and discussed. The evaluation and development of previously identified core competencies for intensive care nurses is discussed. The use of the National Health Service Knowledge and Skills Framework as a framework for the assessment of practice of nurses undertaking courses in intensive care nursing within one higher education Institution is presented and examined. The potential implications of these developments for practice and education are outlined.

Clinical Competence↗
PubMed2000

Needs assessment and a model agenda for training the public health workforce.

OBJECTIVES: A training needs assessment project tested the use of "universal" competencies for establishing a model training agenda for the public health workforce. METHODS: Agency supervisors selected competencies for training priorities. Regional and national public health leaders used these selections to design the model training agenda. RESULTS: The competencies given high priority by supervisors varied among state and local agencies and included some not within the universal set. The model training agenda reflected supervisors' priorities as well as leaders' perspectives. CONCLUSIONS: The universal competencies provide a useful starting point, but not necessarily an exclusive framework, for assessing and meeting the training needs of the public health workforce.

Curriculum↗
PubMed2003

Why CH3CH3+* formation competes with H* loss from CCCO C3H6O+* isomers.

How formation of CH3CH3+* competes with H* loss from C3H6O+* isomers with the CCCO framework has been a puzzle of gas phase ion chemistry because the first reaction has a substantially higher threshold and a supposedly tighter transition state. These together should make CH3CH3+* formation much the slower of the two reactions at all internal energies. However, the rates of the two reactions become comparable at about 20 kJ x mol(-1) above the threshold for CH3CH3+* formation. It was recently shown that losses of atomic fragments increase in rate much more slowly with increasing internal energy than do the rates of competing dissociations to two polyatomic fragments. This occurs because fewer frequencies are substantially lowered in transition states for the former type of reaction than for the latter. The resulting lower transition state sums of states cause the rates of dissociations producing atoms as fragments to increase much more slowly than competing processes with increasing energy. Here we show that this is why CH3CH3+* formation competes with H* loss from CH3CH2CHO+*. These results further establish that the dependence on energy of the rate of a simple unimolecular dissociation is usually directly related to the number of rotational degrees of freedom in the products, a newly recognized factor in determining the dependence of unimolecular reaction rates on internal energy.

Journal Article↗