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PubMed1999

Ethical dilemmas in intensive care: can the problem be solved?

There is a lack of consistency in ethical decision-making with regard to forgoing life-support, which demands increased efforts to improve clinical competence in end-of-life care, e.g. by proactive ethics consultation or early exploration and documentation of the patient's wishes and preferences. Another current ethical issue is the allocation of limited resources; recent guidelines provide a useful framework for bedside practitioners and health policy makers.

Journal Article↗

PubMed1990

Expertise: the basis for expert system development.

Expert systems in nursing are developed with traditional knowledge engineering techniques. These techniques focus on the behavior and logic of the expert, not qualities of expertise. Expertise has been described but not explained. This article proposes a theoretical framework for the study of expertise that can be used to facilitate the development of expert systems.

Clinical Competence↗

PubMed2002

Promoting physical activity among Taiwanese and American adolescents.

The purpose of this paper is to present a comparative analysis of the determinants of physical activity among adolescents in Taiwan and in the United States. Pender's Health Promotion Model (HPM) served as the theoretical framework for both studies (Pender, 1996). The major determinants of health behavior in the HPM are perceived benefits, perceived barriers, self-efficacy, activity-related affect, interpersonal influences, situational influences, commitment to a plan of action, and immediate competing demands. In Taiwan, 969 middle school students (55% males; 45% females) from Taipei provided data for the study. In the United States, the sample was collected from 286 late elementary and middle school students (48% males; 52% females). Results showed the gender differences in activity levels were apparent in the youths from both countries. In both Taiwanese and American youths, boys were more active than girls. Cross-cultural differences in the importance of barriers to physical activity emerged. Among Taiwanese adolescents, barriers did not emerge as a significant direct predictor of physical activity as they did among US adolescents. Perceived efficacy directly predicted physical activity among Taiwanese youths while it indirectly predicted physical activity and appeared to be mediated by beliefs regarding exercise benefits and barriers among American youths. In addition, the paths of effect for interpersonal influences were different when Taiwanese and US youths were compared. The findings from this paper have important and culturally-relevant information that can inform future physical activity intervention studies with diverse adolescents.

Adolescent↗

PubMedDate not supplied

Mathematics and learning disabilities.

Between 5% and 8% of school-age children have some form of memory or cognitive deficit that interferes with their ability to learn concepts or procedures in one or more mathematical domains. A review of the arithmetical competencies of these children is provided, along with discussion of underlying memory and cognitive deficits and potential neural correlates. The deficits are discussed in terms of three subtypes of mathematics learning disability and in terms of a more general framework for linking research in mathematical cognition to research in learning disabilities.

Child↗

PubMedDate not supplied

The influences of patient characteristics and physician experience on case recall.

The study focused on the influences of both patient characteristics and physician experience on the recall of two breast cancer cases. Two general research questions were addressed: 1) whether patient characteristics such as age, race, and assertiveness affect a physician's initial problem representation, and 2) whether the recall advantage for physicians of intermediate levels of experience extends to physicians who have been out of medical school for at least six years, 128 physicians with a minimum of six years' experience were presented with two videotapes of a doctor-patient encounter. In the first videotape (the pre-workup scenario), the patient had just discovered a lump; in the second (the post-workup scenario), she had recently had a biopsy. Following the presentation of each videotape, the physicians were instructed to record a synopsis of the case prior to making diagnoses, ordering tests, and providing treatment recommendations. The synopses were coded to capture information from the cases that the physicians were able to recall and inferences that they generated based on this information. Two critical findings were obtained. First, none of the patient characteristics investigated consistently produced differences in recall or inference generation across the two scenarios. Second, physician recall was a monotonically decreasing function of years of experience. The latter result is interpreted using a theoretical framework from Schmidt and Boshuizen.

Adult↗

PubMed2006

Striving for emotional survival in palliative cancer nursing.

In this grounded theory study, the authors analyze interviews and participant observation data related to palliative cancer nursing in hospitals. Striving for Emotional Survival emerged as the pattern of behavior through which nurses deal with their main concern, the risk of being emotionally overloaded by their work. It involved three main strategies: Emotional Shielding through Professional Shielding or Cold Shielding; Emotional Processing through Chatting, Confirmation Seeking, Self-Reflecting, or Ruminating; and Emotional Postponing through Storing or Stashing. Emotional Competence is a property of Striving for Emotional Survival that explains more or less adequate ways of dealing with emotional overload. The theory Striving for Emotional Survival can be useful in the nurses' daily work and provides a comprehensive framework for understanding how nurses deal with emotional difficulties. The authors suggest that health care organizations encourage self-care, prioritize time to talk, and offer counseling to nursing staff with emotionally difficult working conditions.

Adaptation, Psychological↗

PubMed1989

[Psychosocial management in pediatric oncology--presentation of a cooperative team model].

This article presents a psychosocial patient-care program for pediatric cancer patients and their families. The program, initiated within the framework of a "cooperative team model", represents a new organisational form of cooperation between somatic and psychosomatic medicine that has been virtually untested in the filed of internal medicine. The advantages of this form lie in the improved availability of the families involved and the inherent possibilities of appropriate and effective assistance in overcoming the burdens of the illness and the treatment. Comparison with a liaison model showed a 3-times higher mean contact quota per patient/family. Problems which can be expected through implementation as well as related conflicts are discussed. Basic rules are formulated which must be followed if successful interdisciplinary cooperation is to be achieved. Areas of responsibility and activity are described for members of the psychosocial team (psychologists, social workers, visiting nurses) and a basis for documentation is illustrated using the evaluating results. The working concept behind an integrated psychosocial care system includes, as its basis, accompanying support to the involved families within the framework of general psychosocial care in which all of the members of the entire oncological team take part. As required, the special capabilities of the various psychosocial professions can then be brought to bear according to their functions and competence (psychosocial counselling and therapy, social-service counselling, medical and nursing care). Due to the conditions, inherent in the situation resulting from the illness and treatment, basic conceptional positions and attitudes become apparent that are of importance of psychosocial work is to be successful in a pediatric oncology ward.

Adaptation, Psychological↗

PubMedDate not supplied

[Development of the theoretical orientation of psychotherapists. SPR Collaborative Research Network].

This article explores the extent to which, and ways in which, German speaking psychotherapists modify their theoretical orientations as a function of increasing clinical experience. The data for this come from the Development of Psychotherapists Common Core Questionnaire (CCQ), an instrument designed by the SPR Collaborative Research Network to collect a broad range of information about the therapist's background, training, practice etc. Two sections ask directly about the theoretical framework used by therapists to guide their therapeutic work, using a set of scales to assess the degree to which practitioners rely on various general models (analytic/psychodynamic, behavioral, humanistic, cognitive, systems theory, other). This permits the construction of profiles of formal and content based theoretical orientation patterns. By asking the question separately about the therapist's current practice, and about their practices as beginners, it also permits an evaluation of self-assessed change. In order to amplify the meaning of the theoretical background we ask therapists to indicate the relative importance of their patients realizing each of a series of therapeutic goals. The findings show very clearly that psychotherapists are very diverse both in the formal patterns and specific contents of their therapeutic orientations, and that they tend, as a role, to integrate two or more distinct theoretical approaches in guiding their clinical work with patients. The adherence to theoretical orientations has a strong impact on the goals that therapists typically work toward with their patients. Our findings show that therapists do pursue different goals depending on which conceptual framework they rely on.

Adult↗

PubMed2002

Health sector reform and public sector health worker motivation: a conceptual framework.

Motivation in the work context can be defined as an individual's degree of willingness to exert and maintain an effort towards organizational goals. Health sector performance is critically dependent on worker motivation, with service quality, efficiency, and equity, all directly mediated by workers' willingness to apply themselves to their tasks. Resource availability and worker competence are essential but not sufficient to ensure desired worker performance. While financial incentives may be important determinants of worker motivation, they alone cannot and have not resolved all worker motivation problems. Worker motivation is a complex process and crosses many disciplinary boundaries, including economics, psychology, organizational development, human resource management, and sociology. This paper discusses the many layers of influences upon health worker motivation: the internal individual-level determinants, determinants that operate at organizational (work context) level, and determinants stemming from interactions with the broader societal culture. Worker motivation will be affected by health sector reforms which potentially affect organizational culture, reporting structures, human resource management, channels of accountability, types of interactions with clients and communities, etc. The conceptual model described in this paper clarifies ways in which worker motivation is influenced and how health sector reform can positively affect worker motivation. Among others, health sector policy makers can better facilitate goal congruence (between workers and the organizations they work for) and improved worker motivation by considering the following in their design and implementation of health sector reforms: addressing multiple channels for worker motivation, recognizing the importance of communication and leadership for reforms, identifying organizational and cultural values that might facilitate or impede implementation of reforms, and understanding that reforms may have differential impacts on various cadres of health workers.

Attitude of Health Personnel↗

PubMed2002

A computer-based OSCE station to measure competence in evidence-based medicine skills in medical students.

OBJECTIVE: To create a feasible, valid, and reliable tool to measure third-year medical students' skills in evidence-based medicine (EBM). DESCRIPTION: EBM skills-asking clinical questions, finding appropriate medical information resources, and appraising and applying them to patients-involve higher-order critical thinking abilities and are essential to being a competent physician. Students at our institution must pass a required OSCE exam at the end of their third year. As part of this exam, we developed a new 20-minute computer-based station to assess students' EBM skills. Using a specific case scenario, we asked the students to (1) ask a question using the population/intervention/comparison/outcome (PICO) framework; (2) generate appropriate search terms, given a specific question; and (3) select an appropriate abstract to answer a given question and state why two other abstracts were not appropriate. Prior to the assessment, we determined grading and passing criteria for each of the three components and for the station overall. Of the 140 students who completed the station, the percentages that passed the components were 71%, 81%, and 49% respectively, with only 29% passing all three parts. Preliminary analysis of psychometric properties of the station shows very good to excellent interrater reliability, with 65%, 67%, and 94% agreement on the scoring for the components, and kappas of.64,.82, and.94, respectively. DISCUSSION: Although there are many curricula for teaching EBM concepts, there are few tools to measure whether students are competent in applying their EBM skills. Our pilot station appears to be an innovative and promising tool to measure several EBM skills independently. By being computer-based, it is relatively simple to administer, grade, and evaluate. While preliminary data show good inter-rater reliability with our use of a single case, future work will include further testing of reliability and assessment of different types of cases. We will also use the results of this assessment to drive continuous improvement in our EBM curriculum. The students who completed this pilot station had not received an extensive formal EBM curriculum, whereas future groups will. We also will explore whether scores on our station correlate with those on other OSCE stations that also assess critical thinking skills, or if scores correlate with a student's clinical grades or overall class standing. We hope to test these hypotheses: (1) skills used in EBM are useful and valid measures of critical thinking abilities in learners and (2) tools such as ours will help to measure these essential competencies.

Clinical Competence↗

PubMed2004

Larval development of Phoronis pallida (Phoronida): implications for morphological convergence and divergence among larval body plans.

Morphological variation among larval body plans must be placed into a phylogenetic and ecological context to assess whether similar morphologies are the result of phylogenetic constraints or convergent selective pressures. Investigations are needed of the diverse larval forms within the Lophotrochozoa, especially the larvae of phoronids and brachiopods. The actinotroch larva of Phoronis pallida (Phoronida) was reared in the laboratory to metamorphic competence. Larval development and growth were followed with video microscopy, SEM, and confocal microscopy. Early developmental features were similar to other phoronid species. Gastrulation was accomplished by embolic invagination of the vegetal hemisphere. Mesenchymal cells were found in the remaining blastocoelic space after invagination began. Mesenchymal cells formed the body wall musculature during the differentiation of larval features. Body wall musculature served as the framework from which all other larval muscles proliferated. Larval growth correlated best with developmental stage rather than age. Consistent with other phoronid species, differentiation of juvenile tissues occurred most rapidly at the latest stages of larval development. The minimum precompetency period of P. pallida was estimated to be approximately 4-6 weeks. Previously published studies have documented that the planktonic embryos of P. pallida develop faster than the brooded embryos of P. vancouverensis. However, these data showed that the difference in developmental rate between the two species decreased in succeeding larval stages. There may be convergent selective pressures that result in similar timing to metamorphic competence among phoronid and brachiopod planktotrophic larval types. Morphological differences between these larval types result from heterochronic developmental shifts in the differentiation of juvenile tissue. Similarities in the larval morphology of phoronids and basal deuterostomes are likely the result of functional and developmental constraints rather than a shared (recent) evolutionary origin. These constraints are imposed by the functional design of embryological stages, feeding structures, and swimming structures.

Animals↗

PubMed2004

Timing of pubertal maturation in girls: an integrated life history approach.

Life history theory provides a metatheoretical framework for the study of pubertal timing from an evolutionary-developmental perspective. The current article reviews 5 middle-level theories--energetics theory, stress-suppression theory, psychosocial acceleration theory, paternal investment theory, and child development theory--each of which applies the basic assumptions of life history theory to the question of environmental influences on timing of puberty in girls. These theories converge in their conceptualization of pubertal timing as responsive to ecological conditions but diverge in their conceptualization of (a) the nature, extent, and direction of environmental influences and (b) the effects of pubertal timing on other reproductive variables. Competing hypotheses derived from the 5 perspectives are evaluated. An extension of W. T. Boyce and B. J. Ellis's (in press) theory of stress reactivity is proposed to account for both inhibiting and accelerating effects of psychosocial stress on timing of pubertal development. This review highlights the multiplicity of (often unrecognized) perspectives guiding research, raises challenges to virtually all of these, and presents an alternative framework in an effort to move research forward in this arena of multidisciplinary inquiry.

Adolescent↗

PubMedDate not supplied

A patient education MAP: an integrated, collaborative approach for rehabilitation.

Because Roosevelt Warm Springs Institute for Rehabilitation has been faced with decreasing patient lengths of stay, increasing patient acuity, and changes in the nurse staffing mix, nurses wanted to ensure that patients and their families were receiving appropriate education and learning the skills required to provide safe and competent self-care in the home. As a result, they developed a patient education action plan. This multidiscipline action plan (MAP) involved changing from a multidisciplinary to an interdisciplinary approach toward patient and family education. This plan provides a framework that is linked to expected outcomes for education during a patient's stay, reduces the redundancy of patient education by professionals from different disciplines, and increases collaboration. Teaching modules that outline and provide all of the information an educator needs to effectively teach a patient or group of patients make up the basis for the MAP system. This article describes the MAP system and the related continuous quality improvement activities, offers documentation forms, and identifies a structural path.

Cooperative Behavior↗

PubMed1999

Understanding dissatisfied users: developing a framework for comprehending criticisms of health care work.

Recent government proposals have underlined the importance of ascertaining users' views of health care. Traditionally these have been obtained through satisfaction surveys. However, researchers argue that the focus of attention should now shift to exploring dissatisfaction because it highlights more clearly any problems in lay-practitioner relationships. Research has shown that dissatisfaction is a complex social construct which is underpinned by a range of values, beliefs, attitudes and experiences. The aim of this paper is to provide insights into the meaning of dissatisfaction by exploring how dissatisfied users attribute cause, responsibility and blame for their untoward experiences. Forty-one people were identified from a household survey of user views as experiencing problems with their health care. They were interviewed in depth, and a grounded theory approach was used to construct a framework inductively from their accounts. This identified a number of normative expectations through which health work was routinely criticized; these included respondents casting aspersions on the professional integrity of health care practitioners and preserving their own moral identity through demonstrating competence, knowledge, rationality, reasonableness and concern for others. Moreover, it is argued that these patterns help practitioners to understand how dissatisfied users' perceive subsequent health care encounters.

Adolescent↗

PubMed1998

Conceptualization and measurement of doing family caregiving well.

PURPOSE: To review progress in the conceptualization and measurement of five concepts related to doing family caregiving well: caregiving mastery, self-efficacy, competence, preparedness, and quality. Families are increasingly involved in providing complex care to ill or aged family members at home. Their ability to do caregiving well is vitally important and a focus of nursing practice in many clinical settings. ORGANIZING FRAMEWORK: Concepts were organized into two groups: those that refer to caregivers' perceptions of how well they are providing care and those that refer to professional assessment of the quality of care provided. SOURCES: Family caregiving literature from nursing, gerontology, psychology, and social work, 1987-1996. FINDINGS: There is growing interest in doing family caregiving well. However, research in this area is limited by the current state of development of ideas and measures. CONCLUSIONS: Two issues that should be addressed to advance research are the perspective taken on doing caregiving well and change over time in doing caregiving well.

Aged↗

PubMed2005

No child left without a brain scan? Toward a pediatric neuroethics.

Brain research is yielding new information about the development of cognitive and behavioral traits in children--and how development can go off track. This is information parents, teachers, and others will use to help with problems from dyslexia to drug abuse. But with this information, often technical, come many questions. Will knowledge from brain scans be used to label children early in life? How will confidentiality be maintained as diverse providers, some of them commercial, compete for patients? Should government pay for scanning all children to identify not only potential problems but also extraordinary potential? These are questions about values and mutual responsibilities in neuroscience--the domain of neuroethics. The authors consider what an ethical framework for applying the fruits of neuroscience to children--a pediatric neuroethics--might look like.

Adolescent↗

PubMed1996

Error detection and reduction in blood banking.

Error management plays a major role in facility process improvement efforts. By detecting and reducing errors, quality and, therefore, patient care improve. It begins with a strong organizational foundation of management attitude with clear, consistent employee direction and appropriate physical facilities. Clearly defined critical processes, critical activities, and SOPs act as the framework for operations as well as active quality monitoring. To assure that personnel can detect an report errors they must be trained in both operational duties and error management practices. Use of simulated/intentional errors and incorporation of error detection into competency assessment keeps employees practiced, confident, and diminishes fear of the unknown. Personnel can clearly see that errors are indeed used as opportunities for process improvement and not for punishment. The facility must have a clearly defined and consistently used definition for reportable errors. Reportable errors should include those errors with potentially harmful outcomes as well as those errors that are "upstream," and thus further away from the outcome. A well-written error report consists of who, what, when, where, why/how, and follow-up to the error. Before correction can occur, an investigation to determine the underlying cause of the error should be undertaken. Obviously, the best corrective action is prevention. Correction can occur at five different levels; however, only three of these levels are directed at prevention. Prevention requires a method to collect and analyze data concerning errors. In the authors' facility a functional error classification method and a quality system-based classification have been useful. An active method to search for problems uncovers them further upstream, before they can have disastrous outcomes. In the continual quest for improving processes, an error management program is itself a process that needs improvement, and we must strive to always close the circle of quality assurance. Ultimately, the goal of better patient care will be the reward.

Blood Banks↗

PubMed2004

Reflection, the way to professional development?

BACKGROUND: Many studies have focused on reflection and the advantages that can be gained from the practice of reflection among Registered Nurses (RNs) but, what are the implications of the nurses' reflections, what do they reflect about, and how do they deal with their reflections? AIMS AND OBJECTIVES: The aim of this study was to describe the RNs' experiences of reflection in relation to nursing care situations, and to understand how RNs use reflection in their daily work. What are the implications of the nursing care situations that the RNs' reflect upon? What consequences did the practice of reflection have in nursing care situations in relation to the RNs professional development? DESIGN AND METHOD: The study was carried out with interviews and the phenomenographic method. Interviews were carried out with four RNs. The choice of informants was made with purposive sampling with the aim of finding informants who could bring the kind of knowledge that was necessary for the study. RESULTS: The qualitative differences regarding the RNs' experiences of reflection were categorized as follows: to reflect (to think back--consider, mirroring, to reflect before and reflect after, to use experiences), nursing care situations (ethical considerations, to have courage, to use one's imagination, empathy) and consequences (to meet the unique, empathy, development). Finally, the findings were implicated in the model of professional development. CONCLUSION: By using reflection as a tool, many advantages can be gained in the development of nursing care. Encouraging RNs to reflect upon nursing situations, in order to promote the nurse's professional development, will imply better nursing care for the patients. The model for professional development implies a simplified representation of the thoughts pertaining to professional nursing development. RELEVANCE TO CLINICAL PRACTICE: The relevance for clinical practice will be to understand the contents of the RNs reflections, to recognize the advantages of reflective practice and how and when to use such measures. Furthermore, to show how the model for professional development can be used in order to create a framework for evaluating these observations and consequently, for expressing tacit knowledge.

Attitude of Health Personnel↗