Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative-evidence synthesis

Background:
Prolonged mechanical ventilation is associated with a longer intensive care unit (ICU) length of stay and higher mortality. Consequently, methods to improve ventilator weaning processes have been sought. Two recent Cochrane systematic reviews in ICU adult and paediatric populations concluded that protocols can be effective in reducing the duration of mechanical ventilation, but there was significant heterogeneity in study findings. Growing awareness of the benefits of understanding the contextual factors impacting on effectiveness has encouraged the integration of qualitative evidence syntheses with effectiveness reviews, which has delivered important insights into the reasons underpinning (differential) effectiveness of healthcare interventions.

Objectives:
1. To locate, appraise and synthesize qualitative evidence concerning the barriers and facilitators of the use of protocols for weaning critically-ill adults and children from mechanical ventilation;

2. To integrate this synthesis with two Cochrane effectiveness reviews of protocolized weaning to help explain observed heterogeneity by identifying contextual factors that impact on the use of protocols for weaning critically-ill adults and children from mechanical ventilation;

3. To use the integrated body of evidence to suggest the circumstances in which weaning protocols are most likely to be used.

Search methods:
We used a range of search terms identified with the help of the SPICE (Setting, Perspective, Intervention, Comparison, Evaluation) mnemonic. Where available, we used appropriate methodological filters for specific databases. We searched the following databases: Ovid MEDLINE, Embase, OVID, PsycINFO, CINAHL Plus, EBSCOHost, Web of Science Core Collection, ASSIA, IBSS, Sociological Abstracts, ProQuest and LILACS on the 26th February 2015. In addition, we searched: the grey literature; the websites of professional associations for relevant publications; and the reference lists of all publications reviewed. We also contacted authors of the trials included in the effectiveness reviews as well as of studies (potentially) included in the qualitative synthesis, conducted citation searches of the publications reporting these studies, and contacted content experts.

We reran the search on 3rd July 2016 and found three studies, which are awaiting classification.

Selection criteria:
We included qualitative studies that described: the circumstances in which protocols are designed, implemented or used, or both, and the views and experiences of healthcare professionals either involved in the design, implementation or use of weaning protocols or involved in the weaning of critically-ill adults and children from mechanical ventilation not using protocols. We included studies that: reflected on any aspect of the use of protocols, explored contextual factors relevant to the development, implementation or use of weaning protocols, and reported contextual phenomena and outcomes identified as relevant to the effectiveness of protocolized weaning from mechanical ventilation.

Data collection and analysis:
At each stage, two review authors undertook designated tasks, with the results shared amongst the wider team for discussion and final development. We independently reviewed all retrieved titles, abstracts and full papers for inclusion, and independently extracted selected data from included studies. We used the findings of the included studies to develop a new set of analytic themes focused on the barriers and facilitators to the use of protocols, and further refined them to produce a set of summary statements. We used the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) framework to arrive at a final assessment of the overall confidence of the evidence used in the synthesis. We included all studies but undertook two sensitivity analyses to determine how the removal of certain bodies of evidence impacted on the content and confidence of the synthesis. We deployed a logic model to integrate the findings of the qualitative evidence synthesis with those of the Cochrane effectiveness reviews.

Main results:
We included 11 studies in our synthesis, involving 267 participants (one study did not report the number of participants). Five more studies are awaiting classification and will be dealt with when we update the review.

The quality of the evidence was mixed; of the 35 summary statements, we assessed 17 as ‘low’, 13 as ‘moderate’ and five as ‘high’ confidence. Our synthesis produced nine analytical themes, which report potential barriers and facilitators to the use of protocols. The themes are: the need for continual staff training and development; clinical experience as this promotes felt and perceived competence and confidence to wean; the vulnerability of weaning to disparate interprofessional working; an understanding of protocols as militating against a necessary proactivity in clinical practice; perceived nursing scope of practice and professional risk; ICU structure and processes of care; the ability of protocols to act as a prompt for shared care and consistency in weaning practice; maximizing the use of protocols through visibility and ease of implementation; and the ability of protocols to act as a framework for communication with parents.

Authors' conclusions:
There is a clear need for weaning protocols to take account of the social and cultural environment in which they are to be implemented. Irrespective of its inherent strengths, a protocol will not be used if it does not accommodate these complexities. In terms of protocol development, comprehensive interprofessional input will help to ensure broad-based understanding and a sense of ‘ownership’. In terms of implementation, all relevant ICU staff will benefit from general weaning as well as protocol-specific training; not only will this help secure a relevant clinical knowledge base and operational understanding, but will also demonstrate to others that this knowledge and understanding is in place. In order to maximize relevance and acceptability, protocols should be designed with the patient profile and requirements of the target ICU in mind. Predictably, an under-resourced ICU will impact adversely on protocol implementation, as staff will prioritize management of acutely deteriorating and critically-ill patients.

Making sustainability ‘real’: using group-enquiry to promote education

Sustainable development is now widely held as a transcendental ideal of town and country planning, yet the way in which it is taught in planning schools remains problematic. This arises from a range of factors, including the all-persuasive nature of sustainability and the lack of solid examples of success through implementation. The issue of how best to promote learning for sustainable development in planning has arguably intensified in the last two years in the case of the Royal Town Planning Institute- sponsored ‘fast track’ one-year Masters, which has reduced the opportunities for students to engage in wider (and perhaps even deeper) concepts, including that of sustainable development. This paper explores this through discussion of a specific project developed at Queen’s University Belfast, facilitated by a grant from the UK Higher Education Academy. Working with a local community, this entailed a group of students working on their Masters thesis collectively addressing issues of sustainable regeneration in a small Irish market town. The design of the project draws heavily on the concepts of enquiry based learning, experiential learning and action competence, whichare seen as being central to improving education for sustainable development (ESD). The paper explores the benefits of such an approach and discusses the ways in which this experience can help enhance student’s experience of ESD.

Best of the old alongside the new: training for part-time youth workers

Set against the dearth of published research into the effectiveness of youth leadership training programmes, the present study describes how a comprehensive evaluation model was utilised to evaluate one such programme in Northern Ireland over a 3-year period. The training welds together a traditional curriculum approach and a competence-based methodology to provide an integrated experience for the part-time youth worker participants (n = 128). Self-completion questionnaires and follow-up interviews with a random sample of these youth workers and their supervisors were used to collect data. Outcomes suggest that the synthesis of these two training strategies is not only effective in meeting the learning needs of youth workers, but also leads to identifiable improvements in the range and quality of youth work programmes available to young people

'Law of their own': notes on legal alterity in early nineteenth-century Ireland

This article investigates intersections between legal and literary discourse in Ireland in the early 19th century, and explores how judicial tropes, in particular that of an “alternative judiciary”, shape perceptions of Irish identity as well as cultural expression. Whilst Ireland and the Irish were typically characterized as lawless, this article examines the ubiquitous presence of alternative legal systems, focusing on the writings of Thomas Moore (1779–1852) and William Carleton (1794–1869). These representations, and the questions of authority and legitimacy that they provoke, are considered within critical debates about the development of literary forms in Ireland, and the inherent relationship that legal alterity evokes between textual and judicial authority.

Phototextual Journeys: Nicolas Bouvier in Asia

Travel literature's inherent intergenericity extends into the realm of the interaesthetic in Nicolas Bouvier's textual and photographic representations of Asia. Although produced as distinct narratives, successive editorial decisions and the layering of these two media in the mind of the reader have transformed Bouvier's already palimpsestic texts into fluid, phototextual constructs. This article will offer ‘contrapuntal’ readings of a selection of Bouvier's texts in relation to the photographs charting his intercultural encounters in China and Japan. Countering the relegation of these photographs to the conventional status of aide-mémoire, the article will consider the shifting relationships of complementarity, tension, or disjuncture between image and text. These relationships are characterised by slippage, subversion and paradox. Text does not ‘load’ image, and images do not illustrate text. Indeed, Bouvier's photographs frequently contest, modify, or debunk the textual narratives. Ultimately, the article will argue that Bouvier's representations of Asia, both textual and visual, offer a challenge to cultural essentialism, to self-other binaries, and to monolithic discourses of otherness.

This is Not a Photo Opportunity: Verbal/Visual Struggle in Francophone Travel Narratives

This article explores the ethics and aesthetics of representing travel and intercultural encounter in textual and photographic forms. Taking as its starting point two textual accounts of journeys in the course of which photographic narratives were also produced, the article explores the possibilities and limitations of textuality and visuality and thus considers the implications of, or new opportunities afforded by, reading – and ultimately publishing – these narratives as iconotexts. Focusing on Pierre Loti's L'Inde (sans les Anglais) (1901) and Ella Maillart's Oasis interdites (1937), the article also offers an alternative perspective on writers whose work is commonly associated with an imperialist or exoticist discourse, with cliché and one-dimensionality. As such, it aims to replace the monolithic, orientalist vision often attributed to these writers with ambiguity, ethical hesitation and a plurality of perspectives. Using these examples as a springboard, the article seeks to argue that verbal/visual mobility in narratives representing mobility contributes to resisting static, monolithic perceptions of other cultures. Using the work of British graffiti artist Banksy as a foil for exploring photography as cultural commodification and art as commodity, the article also seeks to engage with current debates in Humanities research on ekphrasis and iconotextuality and on the problematics of representing other cultures within an ethical and/or humanist frame.

How should teaching on whole person medicine, including spiritual issues, be delivered in the undergraduate medical curriculum in the United Kingdom?

Background

Although the General Medical Council recommends that United Kingdom medical students are taught ‘whole person medicine’, spiritual care is variably recognised within the curriculum. Data on teaching delivery and attainment of learning outcomes is lacking. This study ascertained views of Faculty and students about spiritual care and how to teach and assess competence in delivering such care.

A questionnaire comprising 28 questions exploring attitudes to whole person medicine, spirituality and illness, and training of healthcare staff in providing spiritual care was designed using a five-point Likert scale. Free text comments were studied by thematic analysis. The questionnaire was distributed to 1300 students and 106 Faculty at Queen’s University Belfast Medical School.

351 responses (54 staff, 287 students; 25 %) were obtained. >90 % agreed that whole person medicine included physical, psychological and social components; 60 % supported inclusion of a spiritual component within the definition. Most supported availability of spiritual interventions for patients, including access to chaplains (71 %), counsellors (62 %), or members of the patient’s faith community (59 %). 90 % felt that personal faith/spirituality was important to some patients and 60 % agreed that this influenced health. However 80 % felt that doctors should never/rarely share their own spiritual beliefs with patients and 67 % felt they should only do so when specifically invited. Most supported including training on provision of spiritual care within the curriculum; 40-50 % felt this should be optional and 40 % mandatory. Small group teaching was the favoured delivery method. 64 % felt that teaching should not be assessed, but among assessment methods, reflective portfolios were most favoured (30 %). Students tended to hold more polarised viewpoints but generally were more favourably disposed towards spiritual care than Faculty. Respecting patients’ values and beliefs and the need for guidance in provision of spiritual care were identified in the free-text comments.

Students and Faculty generally recognise a spiritual dimension to health and support provision of spiritual care to appropriate patients. There is lack of consensus whether this should be delivered by doctors or left to others. Spiritual issues impacting patient management should be included in the curriculum; agreement is lacking about how to deliver and assess.

Legal liability of coaches: a UK perspective

Attracting more coaches is fundamental to achievement of the European dimension in sport and the further promotion of sport in the European Union. Given the emerging relationship between the law and sports coaching, recruitment of such volunteers may prove problematic. Accordingly, this article critically considers the legal liability of sports coaches. To inform this debate, the issue of negligent coaching is critically scrutinised from a UK perspective, uncovering a number of distinct legal vulnerabilities facing volunteer coaches. This includes the inherent limitations of ‘objective reasonableness’ when defining the standard of care required in the particular circumstances. More specifically, fuller analysis of the justification of customary practice, and the legal doctrine of in loco parentis, reveals important ramifications for all organisations providing training and support for coaches. In short, it is argued that proactively safeguarding coaches from professional liability should be a priority for national governing bodies, and, following the recently published EU Work Plan for Sport for 2014–2017, the Expert Group on Human Resource Management in Sport. Importantly, given the EU’s supporting, coordinating and supplementing competence in developing the European dimension in sport, a Commission funded project to address the implications of the ‘compensation culture’ in sport is also recommended.

Exploring the mobile structural assessment tool: Concept maps for learning website: Concept Maps for Learning Website

In this paper, we describe how the pathfinder algorithm converts relatedness ratings of concept pairs to concept maps; we also present how this algorithm has been used to develop the Concept Maps for Learning website (www.conceptmapsforlearning.com) based on the principles of effective formative assessment. The pathfinder networks, one of the network representation tools, claim to help more students memorize and recall the relations between concepts than spatial representation tools (such as Multi- Dimensional Scaling). Therefore, the pathfinder networks have been used in various studies on knowledge structures, including identifying students’ misconceptions. To accomplish this, each student’s knowledge map and the expert knowledge map are compared via the pathfinder software, and the differences between these maps are highlighted. After misconceptions are identified, the pathfinder software fails to provide any feedback on these misconceptions. To overcome this weakness, we have been developing a mobile-based concept mapping tool providing visual, textual and remedial feedback (ex. videos, website links and applets) on the concept relations. This information is then placed on the expert concept map, but not on the student’s concept map. Additionally, students are asked to note what they understand from given feedback, and given the opportunity to revise their knowledge maps after receiving various types of feedback.

Mobilising of the German 1848 Protest Song Tradition in the Context of International Twentieth Century Folk Revivals

The rediscovery of democratic traditions of folk song in Germany after the Second World War was not just the counter-reaction of singers and academics to the misuse of German folk song by the Nazis. Such a shift to a more ‘progressive’ interpretation and promotion of folk tradition at that time was not distinct to Germany and had already taken place in other parts of the Western world. After firstly examining the relationship between folk song and national ideologies in the nineteenth century, this article will focus on the democratic ideological basis on which the 1848 revolutionary song tradition was reconstructed after the Third Reich. It will look at how the New Social Movements of West Germany and the folk scene of the GDR functioned in providing channels of transmission for this, and how in this process a collective cultural memory was created whereby lost songs – such as those of the 1848 Revolution – could be awakened from extinction. These processes will be illustrated by textual and musical adaptations of key 1848 songs such as ‘Badisches Wiegenlied’ (Baden Lullaby), ‘Das Blutgericht’ (The Blood Court) and ‘Trotz alledem’ (For all that) within the context of the West German folk movement and its counterpart in the GDR.

Computer usage and the validity of self-assessed computer competence among first-year business students

Abstract This study evaluates the reliability of self-assessment as a measure of computer competence. This evaluation is carried out in response to recent research which has employed self-reported ratings as the sole indicator of students’ computer competence. To evaluate the reliability of self-assessed computer competence, the scores achieved by students in self-assessed computer competence tests are compared with scores achieved in objective tests. The results reveal a statistically significantly over-estimation of computer competence among the students surveyed. Furthermore, reported pre-university computer experience in terms of home and school use and formal IT education does not affect this result. The findings call into question the validity of using self-assessment as a measure of computer competence. More generally, the study also provides an up-to-date picture of self-reported computer usage and IT experience among pre-university students from New Zealand and South-east Asia and contrasts these findings with those from previous research.