Extension of general practice training from three to four years: experiences of a vocational training programme in Southern Ireland

The aim of this study was to evaluate the experiences of trainees taking part in an extended (four-year) general practice training programme introduced in the South Eastern region of the Republic of Ireland to replace the previous traditional (three-year) programme. In a qualitative design, eight homogeneous focus groups were held to determine the value of the additional year of training. The first cohort of trainees was interviewed towards the start and at the end of their fourth year. Trainees finishing the following year were also interviewed, as were graduates from the final three-year programme. GP trainers and the four members of the programme directing team comprised two further independent focus groups. Trainees reported that the integration of hospital posts and general practice attachments over the four years was particularly beneficial. The exposure to a variety of different general practices and the opportunity to take part in specialty clinics were considered extremely useful. The fourth year of training was felt to be less pressurised than previous years. Professional and personal development was enhanced; improved readiness to practise and confidence were noted. Perceived disadvantages of extended training included a lack of acknowledgment for doctors in their fourth year and excessive emphasis placed on research during the final year of training. The addition of an extra year of vocational training improves professional and personal development and changes the learning experience for doctors. Doctors felt more confident and ready to enter independent practice at the end of the fourth year of training.

Policing for peace in Northern Ireland: Change, conflict and community confidence

The fundamental change in policing that began in 2001 was a critical part of the Northern Ireland peace process. Seventy years after its establishment the Royal Ulster Constabulary (RUC) remained distrusted and unrepresentative of the Catholic – nationalist community. This book explores how policing changed and the significant contribution that overhaul made to the most successful conflict transformation process in recent decades. It looks at policing from an organizational perspective and focuses on leadership, strategy and culture as it traces the journey from RUC to PSNI. In this way it reflects the views of many key figures inside the organization and of key political decision makers outside of it. This book will be of tremendous interest to those seeking to explore the underlying dynamics of one of the most radical and challenging change processes in recent history and is a must read for anyone interested in the Northern Irish peace process.

Healthcare professional experiences and attitudes on unlicensed/off-label paediatric prescribing and paediatric clinical trials.

Objectives: To investigate the knowledge and views of a range of healthcare professionals (consultant paediatricians, general practitioners (GPs), community pharmacists and paediatric nurses) regarding the use of unlicensed/off-label medicines in children and the participation of children in clinical trials.

Methods: A regional study in which a survey instrument with 39 items was issued to 500 randomly selected GPs, all community pharmacists (n?=?512), 50 hospital consultants and 150 paediatric nurses in Northern Ireland.

Results: Approximately half (46.5%) of the 1,212 healthcare professionals approached responded to the questionnaire. The majority of respondents indicated their familiarity with the term unlicensed (82.9%) or off-label (58.6%) prescribing with the most frequently quoted reason for such prescribing being younger age (33.6%). Apart from community pharmacists, most respondents reported having gained their knowledge through personal experience. Even though a large percentage of respondents expressed concerns about the safety (77.8%) or efficacy (87.9%) of unlicensed/off-label prescribing in children, only 30.7% reported informing parents/guardians of these concerns on the use of such medicines in children. In addition, only 56% of respondents believed that unlicensed/off-label medicines should undergo clinical trials in children. Overall, 28.4% of respondents (20.1% of GPs, 41.4% of community pharmacists, 27.7% of paediatric nurses and 94% of consultant paediatricians) indicated their willingness to be actively involved in, and recruit their patients for paediatric clinical research.

Conclusion: The use of unlicensed and off-label medicines remains a major issue in paediatric medicine. Until such times as more licensed medicines are available for children, clear guidance should be developed to allow consistency in practice across the spectrum of healthcare professionals who are involved with such medicines in their routine practice.

Mass media and polarisation processes in the bounded confidence model of opinion dynamics

This paper presents a social simulation in which we add an additional layer of mass media communication to the social network 'bounded confidence' model of Deffuant et al (2000). A population of agents on a lattice with continuous opinions and bounded confidence adjust their opinions on the basis of binary social network interactions between neighbours or communication with a fixed opinion. There are two mechanisms for interaction. 'Social interaction' occurs between neighbours on a lattice and 'mass communication' adjusts opinions based on an agent interacting with a fixed opinion. Two new variables are added, polarisation: the degree to which two mass media opinions differ, and broadcast ratio: the number of social interactions for each mass media communication. Four dynamical regimes are observed, fragmented, double extreme convergence, a state of persistent opinion exchange leading to single extreme convergence and a disordered state. Double extreme convergence is found where agents are less willing to change opinion and mass media communications are common or where there is moderate willingness to change opinion and a high frequency of mass media communications. Single extreme convergence is found where there is moderate willingness to change opinion and a lower frequency of mass media communication. A period of persistent opinion exchange precedes single extreme convergence, it is characterized by the formation of two opposing groups of opinion separated by a gradient of opinion exchange. With even very low frequencies of mass media communications this results in a move to central opinions followed by a global drift to one extreme as one of the opposing groups of opinion dominates. A similar pattern of findings is observed for Neumann and Moore neighbourhoods.

Decisional responsibility for mechanical ventilation and weaning: an international survey

Introduction: Optimal management of mechanical ventilation and weaning requires dynamic and collaborative decision making to minimize complications and avoid delays in the transition to extubation. In the absence of collaboration, ventilation decision making may be fragmented, inconsistent, and delayed. Our objective was to describe the professional group with responsibility for key ventilation and weaning decisions and to examine organizational characteristics associated with nurse involvement.

Methods: A multi-center, cross-sectional, self-administered survey was sent to nurse managers of adult intensive care units (ICUs) in Denmark, Germany, Greece, Italy, Norway, Switzerland, Netherlands and United Kingdom (UK). We summarized data as proportions (95% confidence intervals (CIs)) and calculated odds ratios (OR) to examine ICU organizational variables associated with collaborative decision making.

Results: Response rates ranged from 39% (UK) to 92% (Switzerland), providing surveys from 586 ICUs. Interprofessional collaboration (nurses and physicians) was the most common approach to initial selection of ventilator settings (63% (95% CI 59 to 66)), determination of extubation readiness (71% (67 to 75)), weaning method (73% (69 to 76)), recognition of weaning failure (84% (81 to 87)) and weaning readiness (85% (82 to 87)), and titration of ventilator settings (88% (86 to 91)). A nurse-to-patient ratio other than 1:1 was associated with decreased interprofessional collaboration during titration of ventilator settings (OR 0.2, 95% CI 0.1 to 0.6), weaning method (0.4 (0.2 to 0.9)), determination of extubation readiness (0.5 (0.2 to 0.9)) and weaning failure (0.4 (0.1 to 1.0)). Use of a weaning protocol was associated with increased collaborative decision making for determining weaning (1.8 (1.0 to 3.3)) and extubation readiness (1.9 (1.2 to 3.0)), and weaning method (1.8 (1.1 to 3.0)). Country of ICU location influenced the profile of responsibility for all decisions. Automated weaning modes were used in 55% of ICUs.

Conclusions: Collaborative decision making for ventilation and weaning was employed in most ICUs in all countries although this was influenced by nurse-to-patient ratio, presence of a protocol, and varied across countries. Potential clinical implications of a lack of collaboration include delayed adaptation of ventilation to changing physiological parameters, and delayed recognition of weaning and extubation readiness resulting in unnecessary prolongation of ventilation.

The role of the Professional Engineer in the 21st century

In light of the current world economic and environmental crisis due in part to
unsustainable development and poor financial planning, 21st Century engineers are faced with unprecedented challenges of developing a sustainable world in balance with the forces of nature to combat global environmental, social and economic crises. The European Union, the United States of America and a number of other countries have identified that smart solutions and highly skilled professionals are needed to survive climate change and create long-term prosperity. In this paper the evolution of the changing career of the engineer will be presented. The policy background to the current system of engineering education at bachelor’s and graduate level in Ireland will be introduced and perceptions of engineering as a profession by society in general, and by
school leavers selecting third level courses will be discussed. The role of the engineer as a specialist, expert or generalist will also be studied in terms of the changing demands and needs of society. Finally the responsibility of universities, through broad-based multidisciplinary teaching and training, to prepare the next crop of engineers will be examined.