The implausibility of ‘usual care’ in an open system: sedation and weaning practices in Paediatric Intensive Care Units (PICUs) in the United Kingdom (UK).

Background
The power of the randomised controlled trial depends upon its capacity to operate in a closed system whereby the intervention is the only causal force acting upon the experimental group and absent in the control group, permitting a valid assessment of intervention efficacy. Conversely, clinical arenas are open systems where factors relating to context, resources, interpretation and actions of individuals will affect implementation and effectiveness of interventions. Consequently, the comparator (usual care) can be difficult to define and variable in multi-centre trials. Hence outcomes cannot be understood without considering usual care and factors that may affect implementation and impact on the intervention.

Methods
Using a fieldwork approach, we describe PICU context, ‘usual’ practice in sedation and weaning from mechanical ventilation, and factors affecting implementation prior to designing a trial involving a sedation and ventilation weaning intervention. We collected data from 23 UK PICUs between June and November 2014 using observation, individual and multi-disciplinary group interviews with staff.

Results
Pain and sedation practices were broadly similar in terms of drug usage and assessment tools. Sedation protocols linking assessment to appropriate titration of sedatives and sedation holds were rarely used (9 % and 4 % of PICUs respectively). Ventilator weaning was primarily a medical-led process with 39 % of PICUs engaging senior nurses in the process: weaning protocols were rarely used (9 % of PICUs). Weaning methods were variably based on clinician preference. No formal criteria or use of spontaneous breathing trials were used to test weaning readiness. Seventeen PICUs (74 %) had prior engagement in multi-centre trials, but limited research nurse availability. Barriers to previous trial implementation were intervention complexity, lack of belief in the evidence and inadequate training. Facilitating factors were senior staff buy-in and dedicated research nurse provision.

Conclusions
We examined and identified contextual and organisational factors that may impact on the implementation of our intervention. We found usual practice relating to sedation, analgesia and ventilator weaning broadly similar, yet distinctively different from our proposed intervention, providing assurance in our ability to evaluate intervention effects. The data will enable us to develop an implementation plan; considering these factors we can more fully understand their impact on study outcomes.

Construction Industry Attitudes to Global Environmental Change: A Comparison with the United Kingdom and Japan

With the continued diffusion of global boundaries coupled with the onset of increased environmental pressure, construction industry attitudes are also shifting. The aim of this paper is to evaluate the construction industry attitudes to global environmental change in both the United Kingdom and Japan. In order to achieve this goal, a qualitative mixed method approach is adopted, encompassing a desk based critique of the literature coupled with an industry interview from both regions. This methodology is adopted with the objective of ascertaining if there are any geographical similarities or differences with the regions in question. The resulting information is analyzed and the results deciphered utilizing mind mapping techniques in the dissemination of the data obtained with the objective of identifying various traits within the data. The results indicate that the United Kingdom and Japan both illustrate various attributes in relation to attitudes towards the global environment. In particular, research indicates that in the Japanese construction industry, there is a distinct lack of enthusiasm shown in construction industry attitudes to counteract environmental challenges currently being faced by implementing sustainable practices, compared to attitudes in the UK construction industry. One of the reasons identified for this, is the lack of leadership provided by the corresponding government, thus resulting in the lack of promotion of sustainable practices in the region. The benefit of this research is that it enables various industry leaders, regardless of geographical location, to actively consider the attitudes and perceptions of those around them, particularly in relation to the sensitive topic of global environmental change within the industry. Where the findings are acknowledged and also utilized, the results should aid in the improvement of the industry on an international scale, while also improving the overall persona of environmental change within the sector.

A steady ship: A quiet year for the United Kingdom Supreme Court

This piece reviews the decisions issued by the UK's Supreme Court during 2014, comparing the output with the previous year's and highlighting some particularly important cases.

Administrative Justice in the United Kingdom

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The United Kingdom, the United Nations Human Rights Council and the first cycle of the Universal Periodic Review

The introduction of the Universal Periodic Review (UPR) mechanism as an innovative component of the new Human Rights Council in 2006 has suffered little academic scrutiny. This is partly because it holds as its objective an improvement in human rights situations on the ground, a goal that is difficult to test amongst so many possible causal factors attributable to law reform and policy change, and partly due to the fact that the mechanism has only completed one full cycle of review. This article seeks to remedy this absence of analysis by examining the experience of the United Kingdom during its first review. In doing so, the article first considers the conception of the UPR, before progressing to examine the procedure and recommendations made to the UK by its peers. Finally, the article considers the five year review of the UPR which occurred as a subset of the Human Rights Council Review in 2011 and the resulting changes to the process modalities.