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Using total quality management principles within a shared governance framework, this case study discusses how to design and implement a plan to achieve independent nursing practice when an employee has unique needs. This experience demonstrates the importance of looking at root causes, separating ability and compliance issues, using all available resources creatively, and planning for success.
Tests or measures in clinical medicine or the social sciences can be used for three purposes: discriminating between subjects, predicting either prognosis or the results of some other test, and evaluating change over time. The choices made at each stage of constructing a quality of life index will differ depending on the purpose of the instrument. We explore the implications of index purpose for each stage of instrument development: selection of the item pool, item scaling, item reduction, determination of reliability, of validity, and of responsiveness. At many of these stages, not only are the requirements for discriminative, predictive, and evaluative instruments not complementary, they are actually competing. Attention to instrument purpose will clarify the choices both for those developing quality of life measures and for those selecting an appropriate instrument for clinical studies.
The ascendance of the autonomy paradigm in treatment decision-making has evolved over the past several decades to the point where few bioethicists would question that it is the guiding value driving health-care provider behaviour. In achieving quasi-legal status, decision-making has come to be regarded as a formality largely removed from the broader context of medical communication and the therapeutic relationship within which care is delivered. Moreover, disregard for individual patient preference, resistance, reluctance, or incompetence has at times produced pro forma and useless autonomy rituals. Failures of this kind, have been largely attributed to the psychological dynamics of the patients, physicians, illnesses, and contexts that characterize the medical decision. There has been little attempt to provide a framework for accommodating or understanding the larger social context and social influences that contribute to this variation. Applying Paulo Freire's participatory social orientation model to the context of the medical visit suggests a framework for viewing the impact of physicians' communication behaviours on patients' capacity for treatment decision-making. Physicians' use of communication strategies can act to reinforce an experience of patient dependence or self-reliance in regard to the patient-physician relationship generally and treatment decision-making, in particular. Certain communications enhance patient participation in the medical visit's dialogue, contribute to patient engagement in problem posing and problem-solving, and finally, facilitate patient confidence and competence to undertake autonomous action. The purpose of this essay is to place treatment decision-making within the broader context of the therapeutic relationship, and to describe ways in which routine medical visit communication can accommodate individual patient preferences and help develop and further patient capacity for autonomous decision-making.
An assumed core of normative ethical principles may constitute a philosophically proper framework within which public policy should be formulated, but it seldom provides any substantive solutions. To generate public policy on bioethical issues, participants still need to confront underlying philosophical controversies. Professional philosophers' proper role in that process is to clarify major philosophical options, to press wider-ranging consistency questions, and to bring more parties into the philosophical debate itself by arguing for particular substantive claims. Though questions of fact that mediate final policy conclusions frequently fall outside philosophical competence, one sort of fact, lack of political support, should seldom cause philosophers to stand aside; philosophers still have an important role as critics of culture, politics, and profession. They have no authority, however, on even the philosophical presuppositions of public policy.
We study front propagation when an invading species competes with a resident; we assume nearest-neighbor preemptive competition for resources in an individual-based, two-dimensional lattice model. The asymptotic front velocity exhibits an effective power-law dependence on the difference between the two species' clonal propagation rates (key ecological parameters). The mean-field approximation behaves similarly, but the power law's exponent slightly differs from the individual-based model's result. We also study roughening of the front, using the framework of nonequilibrium interface growth. Our analysis indicates that initially flat, linear invading fronts exhibit Kardar-Parisi-Zhang (KPZ) roughening in one transverse dimension. Further, this finding implies, and is also confirmed by simulations, that the temporal correction to the asymptotic front velocity is of O(t(-2/3)).
The results of empirical research in psychology and psychiatry are increasingly being used to formulate as well as understand problems at the interface of law and psychiatry. There has been a proliferation of studies, such as the determinants of individual competence or threat to self or others, the results of which are influencing policy and legislative decisions as well as buttressing holdings in court cases. In this article, I explore the issues of interpretation of epidemiological studies, particularly the role of ideological positions on the design and results of empirical findings, the importance of the way data are interpreted, and the role of ideologies in the way research findings are presented to provide support for policy positions. Two levels of analysis are involved in determining the validity of a study. The first addresses the questions of whether the study meets the statistical and epidemiological requirements for reliable results. These include considerations such as the appropriateness of the study design and methods for gathering and interpreting data. The second focuses on the underlying framework of the study. This involves factors such as the perspectives and values of those conducting the study, the explicit and implicit dominating ideologies where they operate, and the extent to which the study is constructed to reaffirm specific ideologies. This level of analysis is essential for disclosing the influences of ideologies on the results of studies and the way in which data are interpreted. In this article, I try to demonstrate through critiques of selected studies that the first stage of analysis is insufficient without an examination of underlying preconceived values to establish the meaningfulness of results.
A selected literature review on the use of portfolios is presented and points in relation to their use, particularly within the English National Board (ENB) Framework and Higher Award, are discussed. Aspects such as the potentially time-consuming nature of portfolio production and the absence of research on their use in British nursing are highlighted. The author concludes by suggesting some aspects of portfolio use that might benefit from monitoring and research.
The Synergy Model has been adopted as an organizing framework for nursing practice, education, and leadership at Clarian Health Partners, Inc. of Indiana. This article describes the evolution of educational programs at Clarian, in concert with the implementation of the Synergy Model. Philosophical and operational changes in staff orientation, professional development, and management development are described.
The application of theory to practice is multifaceted. It requires a nursing theory that is compatible with an institution's values and mission and that is easily understood and simple enough to guide practice. Comfort Theory was chosen because of its universality. The authors describe how Kolcaba's Comfort Theory was used by a not-for-profit New England hospital to provide a coherent and consistent pattern for enhancing care and promoting professional practice, as well as to serve as a unifying framework for applying for Magnet Recognition Status.
Multi-skilling has been the most enduring element of patient-focused care in the UK. A recent report from the Manchester University Health Service Management Unit (HSMU) extended the multi-skilling debate and offered a framework for changing National Health Service workforce policy along multi-skilling lines. Examines the main HSMU issues in the light of broader empirical and other evidence. Assesses the strengths, weaknesses, opportunities and threats to multi-skilling. Concludes that multi-skilling protagonists still face a number of challenges.
BACKGROUND: Escalating health care costs, racial inequities and socioeconomic disparities have limited access for many to even the barest of health care services. The paradigm shift to a health promotion, disease prevention, and health restoration model within a community-based framework demands greater integrated learning experiences for nursing students that are centred where clients live, work, and play. AIM: To describe the process of developing, implementing and evaluating a rural New England University's experience of piloting a clinical home community model within its existing baccalaureate curriculum. CONTENT: The model describes how it is possible to break free from traditional acute care settings in hospitals and mental health institutions. Students are provided with maternal-child and adult mental health experiences that are available in a targeted clinical home community setting where consumers are increasingly seeking health care. The concepts that directed curriculum revision from a traditional to a community-based educational framework are discussed. OUTCOMES: Strengths and limitations of the model are presented within the context of student, faculty and consumer partnerships. Implications for global development of the clinical home community model in nursing are proposed.
Everyone wants safe medicine. The traditional approach to adverse events has developed within a culture of blaming the individual practitioner. Such an approach is likely to be damaging to individuals and possibly counterproductive by creating an atmosphere of defensiveness and denial. Industries such as airlines have developed an alternative culture using a systems approach. This approach concentrates on assessing and improving the systems of working rather than blaming an individual's performance. Frameworks have been developed for applying this approach to investigating and avoiding medical accidents. These form the basis of a check-list for acupuncture practice that is presented here, and may be useful for individuals and organisations who are concerned to reduce the risk of adverse events.
BACKGROUND: It is often difficult to understand where responsibility lies for monitoring and improving quality in managed care. From 1996 through 1998 a group of individuals convened by the Institute of Medicine's (Washington, DC) National Roundtable on Health Care Quality developed a model of accountability for the quality of care provided by managed care organizations (MCOs). Each of three overarching forms of accountability (professional, market, and regulatory) has a set of tools for imposing accountability and-because accountability relationships are not self-enforcing-sanctions for failures of accountability. PROFESSIONAL ACCOUNTABILITY: Fiduciary relationships in medicine are an essential part of any quality accountability mechanism, and it will be important to maintain the strength of the professional model in the changing health care system. Yet it is not easy to preserve the strength of the professional model in an MCO environment in which professionals are not dominant, and there is likely to be increasing pressure to weaken their autonomy. MARKET ACCOUNTABILITY: The primary assumption of market accountability is that consumers will select options based on perceived value to them and will make new choices based on their information and experience. Market accountability requires choice among competing providers and information to inform choice. In health care, however, individuals rarely have the information they need and often do not have choice. Accountability for quality generally has not been a major feature in contracts. REGULATORY ACCOUNTABILITY: There is a widespread perception of defects in a market-based health care system. Many believe there is a need for a regulatory structure to correct market failures. The use of regulation to impose accountability for quality requires that a regulatory framework, penalties for violations, and effective enforcement mechanisms are all established. PUBLIC GOODS: The model of accountability for quality in managed care does not promote public goods such as education, research, public health, or care for the uninsured. Indeed, the locus of responsibility to the community when markets fail to supply these public goods is controversial. Nevertheless, such responsibility should be considered by MCOs and policy makers. COLLABORATION TO IMPROVE QUALITY OF CARE: Given market-driven models of health care financing and delivery, it might be feasible and desirable to encourage collaboration among MCOs to improve quality, whether at the national or local market level. The health professions in general, and the medical profession in particular, are and must be accountable to society for providing leadership in the development of knowledge about effective medical care, in defining high-quality care, and in advocating for and improving the quality of care. CONCLUSION: Establishing effective accountability for quality involves multiple entities and many different kinds of accountability relationships. The three forms of accountability interact, and all operate at once.
Certain developments in the agricultural and food sciences have far-reaching implications for society and the environment, which suggest the need to examine their ethical acceptability as a standard component of technology assessment. Such considerations have led to the emergence of a new academic discipline, food ethics. The present paper describes how ethical theory may be applied to the analysis of the impacts of prospective food biotechnologies to assess potential effects on four 'interest groups', i.e. consumers, producers, treated organisms and the biota (fauna and flora). The principles which structure the framework used, i.e. the ethical matrix, are adapted to the field of agriculture and food from those applied in medical ethics. Use of the ethical matrix is illustrated by applying it to the specific case of bovine somatotrophin, the genetically-engineered protein hormone which is injected into lactating cattle to increase their milk yields. Ethical analysis is seen to depend on a number of critical requirements, i.e. scientific data, non-scientific evidence and predictions, suitably-qualified assessors ('competent moral judges'), the 'world-views' of the assessors and application of the precautionary principle to cope with 'uncertainty'.
We present new techniques for the application of a Bayesian network learning framework to the problem of classifying gene expression data. The focus on classification permits us to develop techniques that address in several ways the complexities of learning Bayesian nets. Our classification model reduces the Bayesian network learning problem to the problem of learning multiple subnetworks, each consisting of a class label node and its set of parent genes. We argue that this classification model is more appropriate for the gene expression domain than are other structurally similar Bayesian network classification models, such as Naive Bayes and Tree Augmented Naive Bayes (TAN), because our model is consistent with prior domain experience suggesting that a relatively small number of genes, taken in different combinations, is required to predict most clinical classes of interest. Within this framework, we consider two different approaches to identifying parent sets which are supported by the gene expression observations and any other currently available evidence. One approach employs a simple greedy algorithm to search the universe of all genes; the second approach develops and applies a gene selection algorithm whose results are incorporated as a prior to enable an exhaustive search for parent sets over a restricted universe of genes. Two other significant contributions are the construction of classifiers from multiple, competing Bayesian network hypotheses and algorithmic methods for normalizing and binning gene expression data in the absence of prior expert knowledge. Our classifiers are developed under a cross validation regimen and then validated on corresponding out-of-sample test sets. The classifiers attain a classification rate in excess of 90% on out-of-sample test sets for two publicly available datasets. We present an extensive compilation of results reported in the literature for other classification methods run against these same two datasets. Our results are comparable to, or better than, any we have found reported for these two sets, when a train-test protocol as stringent as ours is followed.
The coat proteins of different single-strand RNA phages use a common protein tertiary structural framework to recognize different RNA hairpins and thus offer a natural model for understanding the molecular basis of RNA-binding specificity. Here we describe the RNA structural requirements for binding to the coat protein of bacteriophage PP7, an RNA phage of Pseudomonas. Its recognition specificity differs substantially from those of the coat proteins of its previously characterized relatives such as the coliphages MS2 and Qbeta. Using designed variants of the wild-type RNA, and selection of binding-competent sequences from random RNA sequence libraries (i.e. SELEX) we find that tight binding to PP7 coat protein is favored by the existence of an 8 bp hairpin with a bulged purine on its 5' side separated by 4 bp from a 6 nt loop having the sequence Pu-U-A-G/U-G-Pu. However, another structural class possessing only some of these features is capable of binding almost as tightly.
The purpose of this article is to introduce a new outcome-oriented, utilization-focused, and practical approach to program evaluation: Charting the Outcomes of Educational and Clinical Approaches (COECA) model. It provides a framework that encourages stakeholders to consider academic dissemination, product development, and implementation as three primary outcomes when evaluating educational and clinical approaches. The model then identifies measurements of the impact of each of these primary outcomes. Finally, it outlines three secondary outcomes that focus on education, clinical service, and administration. As an example, this article discusses the application of the model to an educational intervention in residency training. This intervention has been implemented at two sites. Secondary outcomes include increased competency of residents and a change in responsibilities among health care team members. The COECA model provides an easy-to-apply and efficient method for documenting actual progress and determining potential for further development.
Historically nursing in New Zealand has not used any standardised means to classify practice. In a rapidly developing health information technology (IT) sector this raises serious questions about documentation processes, information management and knowledge development nursing. Recently the Nursing Council of New Zealand has redefined nursing practice, included documentation skills and information management as core competencies within the Registered Nurse and Nurse Practitioner Scopes of Practice (2004) and included information technology as core curricula content within pre-registration nursing programmes. This opinion paper will argue that continued lack of description and analysis of nursing practice in this country will enhance nursing vulnerability. It will background the extent of this issue and outline a project that aims to explore the contextual issues, test a language embedded with a clinical information system and develop a procedural framework to guide the implementation of automated means to describe, compare, examine and analyse nursing practices and processes within New Zealand. The framework will take into account the uniqueness of New Zealand nursing located within international positions and will be a first step toward using a standardised professional language embedded in clinical information systems.