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Preparing nurse managers to mentor students.

AIM: To explore clinical nurse managers' perceptions of factors influencing their ability to perform their clinical leadership role. METHOD: A random sample of 15 clinical nurse managers in four acute NHS trusts was interviewed in depth to identify and explore factors that they perceived to be helping or hindering their performance. The qualitative data were analysed to identify recurrent themes, which were used to develop a survey questionnaire that was distributed to the remaining clinical nurse managers in the four trusts (n = 152). RESULTS: The response rate was 65 per cent (n = 99). Many of the clinical nurse managers reported poor preparation to undertake key aspects of their role and did not favour open learning as a method of continuing professional development. CONCLUSION: The findings are of interest in the context of the new framework proposed by the English National Board (ENB) and the Department of Health for the preparation of nurse educators. Many of the findings are identical to the advisory standards set out for mentors in Preparation of Mentors and Teachers: A New Framework of Guidance (ENB and DoH 2001a). Attention to the development of clinical nurse managers, as well as new mentors, should continue to ensure that the proposed changes meet the needs of both groups.

Attitude of Health Personnel↗

An insight into Australian nurses' experience of withdrawal/withholding of treatment in the ICU.

BACKGROUND: The success of biotechnology has created moral and ethical dilemmas concerning end-of-life care in the Intensive Care Unit (ICU). Whilst the competent individual has the right to refuse or embrace treatment, ICU patients are rarely able to exercise this right. Thus, decision-making is left to medical professionals and family/significant others. AIM: This study aimed to explore the lived experience of ICU nurses caring for clients having treatment withdrawn or withheld, and increase awareness and understanding of this experience amongst other health professionals. METHODS: Van Manens' (1990) phenomenological framework formed the basis of this study as it provided an in-depth insight into the human experience. A convenience sample of ten ICU Nurses participated in the study. Conversations were transcribed verbatim and analysed using a process of thematic analysis. RESULTS: Five major themes emerged during the analysis. These were: (1) comfort and care, (2) tension and conflict, (3) do no harm, (4) nurse-family relationships and (5) invisibility of grief and suffering. CONCLUSION: The experience of providing care for the adult having treatment withdrawn or withheld in the ICU represents a significant personal and professional struggle. Improvements in communication between health professionals, debriefing and education about the process of withdrawing or withholding treatment would be beneficial to both staff and families and has the potential to improve patient care and reduce burden on nurses.

Australia↗

Central organization of androgen-sensitive pathways to the hypothalamic-pituitary-adrenal axis: implications for individual differences in responses to homeostatic threat and predisposition to disease.

Despite clear evidence of the potency by which sex steroids operate on the hypothalamic-pituitary-adrenal (HPA) axis and genuine sex differences in disorders related to HPA dysfunction, the biological significance of this remains largely ignored. Stress-induced increases in circulating glucocorticoid levels serve to meet the metabolic demands of homeostatic threat head-on. Thus, the nature of the stress-adrenal axis is to protect the organism. As one develops, matures, and ages, still newer and competing physiological and environmental demands are encountered. These changing constraints are also met by shifts in sex steroid release, placing this class of steroids beyond the traditional realm of reproductive function. Here we focus on the dose-related and glucocorticoid-interactive nature by which testosterone operates on stress-induced HPA activation. This provides an overview on how to exploit these characteristics towards developing an anatomical framework of testosterone's actions in the brain, and expands upon the idea that centrally projecting arginine vasopressin circuits in the brain act to register and couple testosterone's effects on neuroendocrine and behavioural responses to stress. More generally, the work presented here underscores how a dual adrenal and gonadal systems approach assist in unmasking the bases by which individuals resist or succumb to stress.

Androgens↗

Establishing methodological rigour in international qualitative nursing research: a case study from Ghana.

BACKGROUND: Attention to rigour, from the identification of the problem to the dissemination of the findings, is essential in all qualitative research. In this paper, research carried out in Ghana in 1999 is used to highlight methodological issues in relation to rigour in international qualitative nursing research. AIM: The purpose of this paper is to review the literature in relation to rigour in qualitative research, highlight the methodological decisions enhancing rigour during this research project, and describe the criteria used to assess rigour during the research process. DESIGN: A participatory action research design was used to explore the cultural, social, economic, and political factors that influenced Ghanaian women's vulnerability to HIV infection. Collaboration with participants and partnerships with key professionals were integral to the design of the study. FINDINGS: Participatory action research provided a flexible, socially, and culturally adaptable framework to guide this international research project. Prior to the initiation of international research it was essential to establish the relevance and feasibility of the proposed project. This international research project posed additional methodological challenges to the establishment of rigour. Patience, flexibility and sensitivity were required of the researcher to overcome these challenges. CONCLUSION: Collaboration with participants and with culture-specific 'experts' may be key to culturally competent scholarship, particularly in unfamiliar settings.

Communication↗

A quality measurement framework for managed care organizations.

This article presents a framework for a quality measurement system and its corresponding principles for quality improvement within a managed care environment. The quality measurement system comprises four modes: quality assessment, comparison, improvement, and system evaluation. If these modes are to be effective, the measurement system must incorporate the following five principles: (a) maintain and continually improve the data systems, (b) develop and utilize sound methodology and valid indicators, (c) build a competent measurement team, (d) develop effective strategies for implementation, and (e) protect member confidentiality. This model is helpful in the ongoing development and testing of new measurement systems.

Boston↗

Professionalism in general practice: development of an instrument to assess professional behaviour in general practitioner trainees.

INTRODUCTION: The aim of this study is to develop a new tool to assess professional behaviour in general practitioner (GP) trainees: the evaluation of professional behaviour in general practice (EPRO-GP) instrument. METHODS: Our study consisted of 4 phases: (1) development of a model of professionalism in general practice based on a literature review on professionalism, competency models of general practice and the overall educational objectives of postgraduate training for general practice; (2) development of the EPRO-GP instrument in collaboration with a sounding board; (3) establishing the content validity of the EPRO-GP instrument using a nominal group technique; and (4) establishing the feasibility of the EPRO-GP instrument in 12 general practice trainees and their general practice trainers. RESULTS: The model of professionalism in general practice encompassed 4 themes within professionalism: (a) professionalism towards the patient; (b) professionalism towards other professionals; (c) professionalism towards the public; and (d) professionalism towards oneself. These 4 themes covered 26 elements of professionalism. This model provided the framework of the EPRO-GP instrument, which we developed further by operationalising the 26 elements in 127 behavioural items. The expert ratings confirmed the content validity of the instrument with one exception: the element "altruism" was removed as a stand-alone category but it remained throughout the tool in items giving primacy to patient welfare. The results on the feasibility of the EPRO-GP instrument were very encouraging. All tutorials yielded professional behaviour learning points. DISCUSSION: Our results support the content validity of the EPRO-GP instrument as well as its feasibility as a tool to educate for professionalism in general practice.

Clinical Competence↗

Just how happy is the happy puppet? An emotion signaling and kinship theory perspective on the behavioral phenotype of children with Angelman syndrome.

The favored level of parental investment in a child may differ for genes of maternal and paternal origin in the child. This conflict can be expressed in the phenomenon of genomic imprinting that refers to situations in which the same gene is differentially expressed depending on its parent of origin. Two disorders that show the effects of genomic imprinting--both at 15q11-q13--are Angelman Syndrome (AS) which is due to the absence of expression of maternally-inherited genes and Prader-Willi syndromes (PWS) which is due to the absence of expression of paternally-inherited genes. However, although both disorders can arise from the deletion of the same genetic region, the gustatory, behavioral, and affective characteristics of AS and PWS children are remarkably distinct. Recent research inspired by kinship theory has suggested the origins of these phenotypic differences may lie in the differential investment of each parent's genome in the AS or PWS child. Specifically, it is thought that each set of parental genes have different 'ideas' regarding how the child should behave towards the mother and how much investment they should look to extract. In normal cases, the trade-off between the competing parental genomes produces a behavioral equilibrium in the child. However, in pathological instances, particularly where gene expression is one-sided, the evolved behavioral strategies favored by the contributing genome will dominate the child's behavior. To date, research in the area of genomic conflict in AS and PWS children has primarily focusing on differences in post-natal nutrition-related behaviors. The current paper extends this framework by offering an emotion and evolutionary signaling interpretation of the affective characteristics of AS children. A review of the affective characteristics of the two syndromes (PWS and AS) is presented before kinship and emotions theory are used to examine the functions that differential affect expression may serve in altering maternal investment. We expected that because the ultimate goal of paternal genes is to increase the child rearing burden of mothers, the Angelman behavioral phenotype should exhibit the emotion signaling characteristics that elicit levels of investment more consistent with paternal genetic interests. AS children display more positive, relative to negative, affect expressions (i.e. AS children laugh and smile more frequently than PWS children). In affect signaling theories, positive affect signals (i.e., smiling, laughing) have evolved to manipulate the sensory systems of receivers to increase social resources. In contrast, because the expression of some negative affects may indicate to the mother that the infant is not viable, negative affect expression is characteristically low among AS children. However, AS children may nonetheless have high levels of non-expressed anxiety because of its role in assisting the child (and its paternal genome) to maintain vigilance for changes in investment on the part of the mother. Overall, our kinship and emotion signaling analysis of AS children suggests that their global pattern of affect signaling represents one manifestation of an array of possible evolved strategies within the parental genome. Specifically, because AS exhibits the effects of paternally-inherited genes unhindered by the expression of maternally-inherited genes, the AS infant manifests a pattern of expression and non-expression that maximize maternal investment and thus paternal fitness. This theory is a significant departure from the standard but erroneous conjecture that a mother and child's inclusive fitness interests are one and the same.

Adult↗

Crystal structure of mammalian cysteine dioxygenase. A novel mononuclear iron center for cysteine thiol oxidation.

Cysteine dioxygenase is a mononuclear iron-dependent enzyme responsible for the oxidation of cysteine with molecular oxygen to form cysteine sulfinate. This reaction commits cysteine to either catabolism to sulfate and pyruvate or the taurine biosynthetic pathway. Cysteine dioxygenase is a member of the cupin superfamily of proteins. The crystal structure of recombinant rat cysteine dioxygenase has been determined to 1.5-A resolution, and these results confirm the canonical cupin beta-sandwich fold and the rare cysteinyltyrosine intramolecular cross-link (between Cys(93) and Tyr(157)) seen in the recently reported murine cysteine dioxygenase structure. In contrast to the catalytically inactive mononuclear Ni(II) metallocenter present in the murine structure, crystallization of a catalytically competent preparation of rat cysteine dioxygenase revealed a novel tetrahedrally coordinated mononuclear iron center involving three histidines (His(86), His(88), and His(140)) and a water molecule. Attempts to acquire a structure with bound ligand using either cocrystallization or soaking crystals with cysteine revealed the formation of a mixed disulfide involving Cys(164) near the active site, which may explain previously observed substrate inhibition. This work provides a framework for understanding the molecular mechanisms involved in thiol dioxygenation and sets the stage for exploration of the chemistry of both the novel mononuclear iron center and the catalytic role of the cysteinyl-tyrosine linkage.

Amino Acid Sequence↗

The Effect of Alcohol Intake on Brain White Matter Microstructural Integrity: A New Causal Inference Framework for Incomplete Phenomic Data.

Although substance use, such as alcohol intake, is known to be associated with cognitive decline during aging, its direct influence on the central nervous system remains incompletely understood. In this study, we investigate the influence of alcohol intake frequency on reduction of brain white matter microstructural integrity in the fornix, a brain region considered a promising marker of age-related microstructural degeneration, using a large UK Biobank (UKB) cohort with extensive phenomic data reflecting a comprehensive lifestyle profile. Two major challenges arise: (a) potentially nonlinear confounding effects from phenomic variables and (b) a limited proportion of participants with complete phenomic data. To address these challenges, we develop a novel ensemble learning framework tailored for robust causal inference and introduce a data integration step to incorporate information from UKB participants with incomplete phenomic data, improving estimation efficiency. Our analysis reveals that daily alcohol intake may significantly reduce fractional anisotropy, a neuroimaging-derived measure of white matter structural integrity, in the fornix and increase systolic and diastolic blood pressure levels. Moreover, extensive numerical studies demonstrate the superiority of our method over competing approaches in terms of estimation bias, while outcome regression-based estimators may be preferred when minimizing mean squared error is prioritized. Supplementary materials for this article are available online, including a standardized description of the materials available for reproducing the work.

Brain aging↗

Engaging women's interest in colorectal cancer screening: a public health strategy.

Screening rates for colorectal cancer are unacceptably low. New guidelines, public education campaigns, and expanded coverage of screening costs by healthcare insurance are expected to increase screening rates, but interventions targeting women may accelerate this change. Most American women already participate in regular cancer screening, in the form of Papanicolaou (Pap) tests and mammography, so they may be receptive to tailored messages about the need to add regular colorectal cancer screening to their preventive health regimen. In addition, their role in promoting the health of family members may position women to influence screening behavior in family and friends. Women may be particularly valuable change agents in populations where screening rates are traditionally low, such as medically underserved populations, the elderly or low socioeconomic status groups with competing health priorities, and populations with cultural values or practices inconsistent with the adoption of a new screening behavior. To serve as agents of change in their family and social networks, women must understand that colorectal cancer is not solely a man's disease and that the benefits of colorectal screening are similar to those of Pap testing and mammography. Colorectal cancer screening should also be promoted within a framework of a lifelong strategy for health maintenance for both men and women. The message to women should emphasize the value of colorectal cancer screening rather than the disagreement among experts over preferred screening strategies and should emphasize the value of shared decision making between the patient and her healthcare provider.

Colorectal Neoplasms↗

A developmental perspective on psychological principles of burn care.

The treatment of pediatric burn patients requires careful attention to psychological principles underlying good pain management. These principles, and a variety of specific psychological treatments, have been described thoroughly. In this article the cognitive capabilities, emotional understanding, and behavioral competencies that characterize children at various stages of development are outlined. Important age-related developmental issues are noted, and the child's experience of a burn injury at different ages is outlined. Guidelines for interventions tailored to the developmental capacities and frailties of children in different age groups are offered. Various psychological coping techniques are understood in light of their likely value for pain management with a developmental framework in mind.

Adolescent↗

What every teacher needs to know about clinical reasoning.

CONTEXT: One of the core tasks assigned to clinical teachers is to enable students to sort through a cluster of features presented by a patient and accurately assign a diagnostic label, with the development of an appropriate treatment strategy being the end goal. Over the last 30 years there has been considerable debate within the health sciences education literature regarding the model that best describes how expert clinicians generate diagnostic decisions. PURPOSE: The purpose of this essay is to provide a review of the research literature on clinical reasoning for frontline clinical teachers. The strengths and weaknesses of different approaches to clinical reasoning will be examined using one of the core divides between various models (that of analytic (i.e. conscious/controlled) versus non-analytic (i.e. unconscious/automatic) reasoning strategies) as an orienting framework. DISCUSSION: Recent work suggests that clinical teachers should stress the importance of both forms of reasoning, thereby enabling students to marshal reasoning processes in a flexible and context-specific manner. Specific implications are drawn from this overview for clinical teachers.

Clinical Competence↗

Towards evidence-based practice in medical training: making evaluations more meaningful.

CONTEXT: The evaluation of training is problematic and the evidence base inconclusive. This situation may arise for 2 main reasons: training is not understood as a complex intervention and, related to this, the evaluation methods applied are often overly simplistic. METHOD: This paper makes the case for construing training, especially in the field of specialist medical education, as a complex intervention. It also selectively reviews the available literature in order to match evaluative techniques with the demonstrated complexity. CONCLUSIONS: Construing training as a complex intervention can provide a framework for selecting the most appropriate methodology to evaluate a given training intervention and to appraise the evidence base for training fairly, choosing from among both quantitative and qualitative approaches and applying measurement at multiple levels of training impact.

Clinical Competence↗

Ethics and economics: does programme budgeting and marginal analysis contribute to fair priority setting?

OBJECTIVE: Limited resources mean that decision-makers must set priorities among competing opportunities. Programme budgeting and marginal analysis (PBMA) is an economic approach that focuses on optimizing benefits with available resources. Accountability for reasonableness (A4R) is an ethics approach that focuses on ensuring fair priority-setting processes. PBMA and A4R have been used separately to provide decision-makers with advice about how to set priorities within limited resources. The goals of this research were to use the A4R framework to evaluate the fairness of using PBMA for priority setting and to assess how A4R might make PBMA fairer. METHODS: Qualitative case studies to describe priority setting using PBMA in the Calgary Health Region (Alberta, Canada) evaluated using A4R as a conceptual framework. RESULTS: The use of PBMA for priority setting was fairer than previous priority setting because of its emphasis on explicit rational decision-making. However, there were opportunities to improve the process, particularly by collecting data related to the decision criteria, by developing a communication plan to engage internal and external stakeholders about priority-setting, and by providing a formal mechanism to review priority-setting decisions and resolve disputes. CONCLUSIONS: There is potential for combining A4R and PBMA in a more comprehensive approach to priority setting, which uses a fair priority-setting process to reach decisions aimed at achieving optimal benefits with available resources.

Alberta↗

Making knowledge and skills pay within perioperative care.

In this article John Beesley explains how new pay scales will be linked to the Knowledge and Skills Framework as part of the Agenda for Change proposals. He explores the dimensions of the KSF as a key tool for describing and redesigning future roles.

Career Mobility↗

Ethical controversies in pediatric critical care.

Ethical dilemmas in clinical practice frequently center around who should make decisions for the patient, and what common principles can be used in making those decisions. In pediatrics, these dilemmas are complicated by balancing the interests of the child with the rights of parents and the responsibilities of clinicians. Other sources of controversy in caring for the pediatric population concern the confusion that continues around such issues as informed assent, the present standing of the "Baby Doe" regulations, and the forgoing of life-sustaining treatments. This article discusses the framework for decision-making in children that has evolved in ethics and the law over the last several decades.

Adolescent↗

The locked-in syndrome : what is it like to be conscious but paralyzed and voiceless?

The locked-in syndrome (pseudocoma) describes patients who are awake and conscious but selectively deefferented, i.e., have no means of producing speech, limb or facial movements. Acute ventral pontine lesions are its most common cause. People with such brainstem lesions often remain comatose for some days or weeks, needing artificial respiration and then gradually wake up, but remaining paralyzed and voiceless, superficially resembling patients in a vegetative state or akinetic mutism. In acute locked-in syndrome (LIS), eye-coded communication and evaluation of cognitive and emotional functioning is very limited because vigilance is fluctuating and eye movements may be inconsistent, very small, and easily exhausted. It has been shown that more than half of the time it is the family and not the physician who first realized that the patient was aware. Distressingly, recent studies reported that the diagnosis of LIS on average takes over 2.5 months. In some cases it took 4-6 years before aware and sensitive patients, locked in an immobile body, were recognized as being conscious. Once a LIS patient becomes medically stable, and given appropriate medical care, life expectancy increases to several decades. Even if the chances of good motor recovery are very limited, existing eye-controlled, computer-based communication technology currently allow the patient to control his environment, use a word processor coupled to a speech synthesizer, and access the worldwide net. Healthy individuals and medical professionals sometimes assume that the quality of life of an LIS patient is so poor that it is not worth living. On the contrary, chronic LIS patients typically self-report meaningful quality of life and their demand for euthanasia is surprisingly infrequent. Biased clinicians might provide less aggressive medical treatment and influence the family in inappropriate ways. It is important to stress that only the medically stabilized, informed LIS patient is competent to consent to or refuse life-sustaining treatment. Patients suffering from LIS should not be denied the right to die - and to die with dignity - but also, and more importantly, they should not be denied the right to live - and to live with dignity and the best possible revalidation, and pain and symptom management. In our opinion, there is an urgent need for a renewed ethical and medicolegal framework for our care of locked-in patients.

Consciousness↗

Expectancy models of alcohol use.

The primary goal of the present article is to compare expectancy models with competing attitude models of alcohol use. First, several methodological issues in expectancy research were addressed, to more adequately compare the theoretical models. Study 1 examined the effect of possible self-report biases on associations among expectancy constructs and alcohol use. In Studies 2 and 3, the basic distinction between general factors of positive and negative alcohol expectancies was investigated in both cross-sectional and prospective models. Alternative predictions that were based on competing expectancy and attitude theories were evaluated primarily in Study 3. Results from these studies supported the validity of the expectancy constructs and the proposed distinctions among expectancy and attitude constructs-in terms of strong discriminant validity, absence of self-report bias, and differential prediction of alcohol use. Furthermore, the findings favored certain expectancy models over alternative attitude models of alcohol use, reaffirming the usefulness of the expectancy framework.

Adult↗