Barriers to Goals of Care Discussions With Seriously Ill Hospitalized Patients and Their Families: A Multicenter Survey of Clinicians

Importance: Seriously ill hospitalized patients have identified communication and decision making about goals of care as high priorities for quality improvement in end-of-life care. Interventions to improve care are more likely to succeed if tailored to existing barriers.

Objective: To determine, from the perspective of hospital-based clinicians, (1) barriers impeding communication and decision making about goals of care with seriously ill hospitalized patients and their families and (2) their own willingness and the acceptability for other clinicians to engage in this process.

Design, Setting, and Participants: Multicenter survey of medical teaching units of nurses, internal medicine residents, and staff physicians from participating units at 13 university-based hospitals from 5 Canadian provinces.

Main Outcomes and Measures: Importance of 21 barriers to goals of care discussions rated on a 7-point scale (1 = extremely unimportant; 7 = extremely important).

Results: Between September 2012 and March 2013, questionnaires were returned by 1256 of 1617 eligible clinicians, for an overall response rate of 77.7% (512 of 646 nurses [79.3%], 484 of 634 residents [76.3%], 260 of 337 staff physicians [77.2%]). The following family member-related and patient-related factors were consistently identified by all 3 clinician groups as the most important barriers to goals of care discussions: family members' or patients' difficulty accepting a poor prognosis (mean [SD] score, 5.8 [1.2] and 5.6 [1.3], respectively), family members' or patients' difficulty understanding the limitations and complications of life-sustaining treatments (5.8 [1.2] for both groups), disagreement among family members about goals of care (5.8 [1.2]), and patients' incapacity to make goals of care decisions (5.6 [1.2]). Clinicians perceived their own skills and system factors as less important barriers. Participants viewed it as acceptable for all clinician groups to engage in goals of care discussions-including a role for advance practice nurses, nurses, and social workers to initiate goals of care discussions and be a decision coach.

Conclusions and Relevance: Hospital-based clinicians perceive family member-related and patient-related factors as the most important barriers to goals of care discussions. All health care professionals were viewed as playing important roles in addressing goals of care. These findings can inform the design of future interventions to improve communication and decision making about goals of care.

Building Family Emotional Resilience: Understanding the needs of families with children attending Special Schools in Northern Ireland

This report outlines a small-scale consultation with families of children attending Special Schools, in order to understand their unmet needs in terms of family emotional wellbeing. The research was commissioned by a consortium of organisations that provide emotional wellbeing services:
1. Niamh (Northern Ireland Association for Mental Health);
2. Barnardo’s NI ‘Time 4 Me’ school counselling service; and
3. TakeTen Limited.

Farming, identity and well-being: managing changing gender roles within Western European farm families

This article is concerned with how men and women on farms socially construct their gender and work identities through interaction with each other and public representations of themselves. It is argued that identity is a process, and like gender, it is socially constructed through ‘doing’ identity.
Farming has changed tremendously over the last forty years in Europe. The position of women in the labour market and on the family farm has also undergone significant changes. In Western Europe, women in general and women on family farms are more likely to be active in the labour market than they were forty years ago. While it remains the case that all of their labour on the farm is not properly recorded, they now also have visible, paid employment. Scholars have been surprised that farm women’s gender identity has not changed more significantly with this changed labour market presence. This article argues that in order to understand this limited change we need to understand how men and women in family farms verify and reinforce farming work identities and farming gender identities. It is argued that while off-farm work does not ‘look’ like gender deviant work, it is because it questions the male breadwinner role. An analysis of this helps us understand why the discourse of the family farm remains so dominant and so persistent. In 2012 and 2013, a qualitative study was undertaken in Northern Ireland to examine the gender implications of the EU rural development programme on farms and rural areas. Some of the data gathered as part of this study is interpreted to shed light on how and why particular work and gender identities are constructed within the farm family.

Families and Poverty: Everyday life on a low income

The recent radical cutbacks of the welfare state in the UK have meant that poverty and income management continue to be of great importance for intellectual, public and policy discourse. Written by leading authors in the field, the central interest of this innovative book is the role and significance of family in a context of poverty and low-income. Based on a micro-level study carried out in 2011 and 2012 with 51 families in Northern Ireland, it offers new empirical evidence and a theorisation of the relationship between family life and poverty. Different chapters explore parenting, the management of money, family support and local engagement. By revealing the ordinary and extraordinary practices involved in constructing and managing family and relationships in circumstances of low incomes, the book will appeal to a wide readership, including policy makers.

Plain English: Applying Principles to Home School Written Communication Considering Diverse Families

Schools attempting to engage with the families of all learners, including those with culturally and linguistically diverse backgrounds recognize the importance of effective oral and written communication. The aim of this study is to determine if school generated written communication created by an urban school district serving a culturally and linguistically diverse population in the Northeast of the US adhered to the principles of plain English. This exploratory research examined exemplar pieces of written school generated communication, using different forms of linguistic analysis to determine whether the communication contained elements recognized to facilitate or impede the comprehensibility of each piece of communication. Additionally, a text assessment tool which can help schools to analyze the written text communication they send to families was developed and refined.

Looking again at troubled families: parents' perspectives on multiple adversities

The 'Troubled Families' policy and intervention agenda is based on a deficit approach that tends to ignore the role of structural disadvantage in the lives of the families it targets. In an effort to support this rhetoric, both quantitative and qualitative data have been used, and misused, to create a representation of these families, which emphasizes risk and individual blame and minimizes societal factors. This current paper presents findings from an in-depth qualitative study using a biographical narrative approach to explore parents' experiences of multiple adversities at different times over the life-course. Key themes relating to the pattern and nature of adversities experienced by participants provide a more nuanced understanding of the lives of families experiencing multiple and complex problems, highlighting how multiple interpretations are often possible within the context of professional intervention. The findings support the increasing call to move away from procedurally driven, risk averse child protection practice towards more relationally based practice, which addresses not only the needs of all family members but recognizes parents as individuals in their own right.

Homeless young people, families and change.:Family support as a facilitator to exiting homelessness.

The families of homeless young people are most often portrayed as a precipitating factor in their homelessness. However, recent studies, particularly those taking a longitudinal approach, have drawn attention to the enabling role of family members and their positive influence on the housing trajectories of homeless youth. Drawing on selected findings from an ongoing longitudinal qualitative study of homeless young people in Dublin, Ireland, this paper aims to build on this relatively fertile area of research. We demonstrate the supportive role of the families of young people who experience homelessness (often as a consequence of difficult family environments) and specifically examine how family re-engagement is negotiated and achieved. The findings highlight a number of dimensions of transition and change. Prominent among these is the importance of renewed trust and communication. Young people and their parents also had to accept responsibility for areas of life that previously served to undermine their relationships and were implicated in the circumstances surrounding a young person's premature home-leaving. Tensions and resistances on the part of young people are highlighted, demonstrating the adaptive mechanisms at work as they attempt to re-engage with family members. The implications of the findings for social work intervention with homeless youth are discussed.

Quantifying heritable variation in fitness-related traits of wild, farmed and hybrid Atlantic salmon families in a wild river environment

Farmed fish are typically genetically different from wild conspecifics. Escapees from fish farms may contribute one-way gene flow from farm to wild gene pools, which can depress population productivity, dilute local adaptations and disrupt coadapted gene complexes. Here, we reanalyse data from two experiments (McGinnity et al., 1997, 2003) where performance of Atlantic salmon (Salmo salar) progeny originating from experimental crosses between farm and wild parents (in three different cohorts) were measured in a natural stream under common garden conditions. Previous published analyses focussed on group-level differences but did not account for pedigree structure, as we do here using modern mixed-effect models. Offspring with one or two farm parents exhibited poorer survival in their first and second year of life compared with those with two wild parents and these group-level inferences were robust to excluding outlier families. Variation in performance among farm, hybrid and wild families was generally similar in magnitude. Farm offspring were generally larger at all life stages examined than wild offspring, but the differences were moderate (5–20%) and similar in magnitude in the wild versus hatchery environments. Quantitative genetic analyses conducted using a Bayesian framework revealed moderate heritability in juvenile fork length and mass and positive genetic correlations (>0.85) between these morphological traits. Our study confirms (using more rigorous statistical techniques) previous studies showing that offspring of wild fish invariably have higher fitness and contributes fresh insights into family-level variation in performance of farm, wild and hybrid Atlantic salmon families in the wild. It also adds to a small, but growing, number of studies that estimate key evolutionary parameters in wild salmonid populations. Such information is vital in modelling the impacts of introgression by escaped farm salmon.