Culture, compassion and clinical neglect: probity in the NHS after Mid Staffordshire

Speaking of the public response to the deaths of children at the Bristol Royal Infirmary before 2001, the BMJ commented that the NHS would be 'all changed, changed utterly'. Today, two inquiries into the Mid Staffordshire Foundation Trust suggest nothing changed at all. Many patients died as a result of their care and the stories of indifference and neglect there are harrowing. Yet Bristol and Mid Staffordshire are not isolated reports. In 2011, the Health Services Ombudsman reported on the care of elderly and frail patients in the NHS and found a failure to recognise their humanity and individuality and to respond to them with sensitivity, compassion and professionalism. Likewise, the Care Quality Commission and Healthcare Commission received complaints from patients and relatives about the quality of nursing care. These included patients not being fed, patients left in soiled bedding, poor hygiene practices, and general disregard for privacy and dignity. Why is there such tolerance of poor clinical standards? We need a better understanding of the circumstances that can lead to these outcomes and how best to respond to them. We discuss the findings of these and other reports and consider whether attention should be devoted to managing individual behaviour, or focus on the systemic influences which predispose hospital staff to behave in this way. Lastly, we consider whether we should look further afield to cognitive psychology to better understand how clinicians and managers make decisions?

Managing threatened species – the ecological toolbox, evolutionary theory and the declining-population paradigm

1. The management of threatened species is an important practical way in which conservationists can intervene in the extinction process and reduce the loss of biodiversity. Understanding the causes of population declines (past, present and future) is pivotal to designing effective practical management. This is the declining-population paradigm identified by Caughley. 2. There are three broad classes of ecological tool used by conservationists to guide management decisions for threatened species: statistical models of habitat use, demographic models and behaviour-based models. Each of these is described here, illustrated with a case study and evaluated critically in terms of its practical application. 3. These tools are fundamentally different. Statistical models of habitat use and demographic models both use descriptions of patterns in abundance and demography, in relation to a range of factors, to inform management decisions. In contrast, behaviourbased models describe the evolutionary processes underlying these patterns, and derive such patterns from the strategies employed by individuals when competing for resources under a specific set of environmental conditions. 4. Statistical models of habitat use and demographic models have been used successfully to make management recommendations for declining populations. To do this, assumptions are made about population growth or vital rates that will apply when environmental conditions are restored, based on either past data collected under favourable environmental conditions or estimates of these parameters when the agent of decline is removed. As a result, they can only be used to make reliable quantitative predictions about future environments when a comparable environment has been experienced by the population of interest in the past. 5. Many future changes in the environment driven by management will not have been experienced by a population in the past. Under these circumstances, vital rates and their relationship with population density will change in the future in a way that is not predictable from past patterns. Reliable quantitative predictions about population-level responses then need to be based on an explicit consideration of the evolutionary processes operating at the individual level. 6. Synthesis and applications. It is argued that evolutionary theory underpins Caughley’s declining-population paradigm, and that it needs to become much more widely used within mainstream conservation biology. This will help conservationists examine critically the reliability of the tools they have traditionally used to aid management decision-making. It will also give them access to alternative tools, particularly when predictions are required for changes in the environment that have not been experienced by a population in the past.

Managing threatened species: the ecological toolbox, evolutionary theory and declining-population paradigm

1. The management of threatened species is an important practical way in which conservationists can intervene in the extinction process and reduce the loss of biodiversity. Understanding the causes of population declines (past, present and future) is pivotal to designing effective practical management. This is the declining-population paradigm identified by Caughley. 2. There are three broad classes of ecological tool used by conservationists to guide management decisions for threatened species: statistical models of habitat use, demographic models and behaviour-based models. Each of these is described here, illustrated with a case study and evaluated critically in terms of its practical application. 3. These tools are fundamentally different. Statistical models of habitat use and demographic models both use descriptions of patterns in abundance and demography, in relation to a range of factors, to inform management decisions. In contrast, behaviour-based models describe the evolutionary processes underlying these patterns, and derive such patterns from the strategies employed by individuals when competing for resources under a specific set of environmental conditions. 4. Statistical models of habitat use and demographic models have been used successfully to make management recommendations for declining populations. To do this, assumptions are made about population growth or vital rates that will apply when environmental conditions are restored, based on either past data collected under favourable environmental conditions or estimates of these parameters when the agent of decline is removed. As a result, they can only be used to make reliable quantitative predictions about future environments when a comparable environment has been experienced by the population of interest in the past. 5. Many future changes in the environment driven by management will not have been experienced by a population in the past. Under these circumstances, vital rates and their relationship with population density will change in the future in a way that is not predictable from past patterns. Reliable quantitative predictions about population-level responses then need to be based on an explicit consideration of the evolutionary processes operating at the individual level. 6. Synthesis and applications. It is argued that evolutionary theory underpins Caughley's declining-population paradigm, and that it needs to become much more widely used within mainstream conservation biology. This will help conservationists examine critically the reliability of the tools they have traditionally used to aid management decision-making. It will also give them access to alternative tools, particularly when predictions are required for changes in the environment that have not been experienced by a population in the past.

Interoperability for eLearning Service Management and Provision

Learning Objects offer flexibility and adaptability for users to request personalised information for learning. There are standards to guide the development of learning objects. However, individual developers may customise these standards for serving different purposes when defining, describing, managing and providing learning objects, which are normally stored in heterogeneous repositories. Barriers to interoperability hinder sharing of learning services and subsequently affect quality of instructional design as learners expect to be able to receive their personalised learning content. All these impose difficulties to the users in getting the right information from the right sources. This paper investigates the interoperability issues in eLearning services management and provision and presents an approach to resolve interoperability at three levels.

Managing land-use conflict around urban centres: Australian poultry farmer attitudes towards relocation

In analysing the release of agricultural land to urban development, the urban fringe literature has not focused on whether farmers are able to relocate from the urban fringe to remoter rural areas. Through interviews with representatives from the poultry industry in two Australian states, this paper identifies that poultry farm relocation strategies are constrained by off-farm economic relations, the land-use planning system and financial considerations. Closely aligned to these constraints on relocation is the on-going process of poultry farm intensification, which is seen as presenting rising problems for land-use management around expanding metropolitan centres in Australia. Of particular concern is the potential for amenity complaints and associated land-use conflicts, which have not been comprehensively investigated. Recognising that existing environmental and land-use planning controls are ineffective in producing amicable solutions when conflict involving poultry farming is at its most intense, the paper calls for improvements to the regulatory system, including greater consideration for how the process of relocation can be encouraged. (c) 2005 Elsevier Ltd. All rights reserved.

Towards a nutrient export risk matrix approach to managing agricultural pollution at source

A generic Nutrient Export Risk Matrix (NERM) approach is presented. This provides advice to farmers and policy makers on good practice for reducing nutrient loss and is intended to persuade them to implement such measures. Combined with a range of nutrient transport modelling tools and field experiments, NERMs can play an important role in reducing nutrient export from agricultural land. The Phosphorus Export Risk Matrix (PERM) is presented as an example NERM. The PERM integrates hydrological understanding of runoff with a number of agronomic and policy factors into a clear problem-solving framework. This allows farmers and policy makers to visualise strategies for reducing phosphorus loss through proactive land management. The risk Of Pollution is assessed by a series of informed questions relating to farming intensity and practice. This information is combined with the concept of runoff management to point towards simple, practical remedial strategies which do not compromise farmers' ability to obtain sound economic returns from their crop and livestock.

Robust dynamics of Amazon dieback to climate change with perturbed ecosystem model parameters

Climate change science is increasingly concerned with methods for managing and integrating sources of uncertainty from emission storylines, climate model projections, and ecosystem model parameterizations. In tropical ecosystems, regional climate projections and modeled ecosystem responses vary greatly, leading to a significant source of uncertainty in global biogeochemical accounting and possible future climate feedbacks. Here, we combine an ensemble of IPCC-AR4 climate change projections for the Amazon Basin (eight general circulation models) with alternative ecosystem parameter sets for the dynamic global vegetation model, LPJmL. We evaluate LPJmL simulations of carbon stocks and fluxes against flux tower and aboveground biomass datasets for individual sites and the entire basin. Variability in LPJmL model sensitivity to future climate change is primarily related to light and water limitations through biochemical and water-balance-related parameters. Temperature-dependent parameters related to plant respiration and photosynthesis appear to be less important than vegetation dynamics (and their parameters) for determining the magnitude of ecosystem response to climate change. Variance partitioning approaches reveal that relationships between uncertainty from ecosystem dynamics and climate projections are dependent on geographic location and the targeted ecosystem process. Parameter uncertainty from the LPJmL model does not affect the trajectory of ecosystem response for a given climate change scenario and the primary source of uncertainty for Amazon 'dieback' results from the uncertainty among climate projections. Our approach for describing uncertainty is applicable for informing and prioritizing policy options related to mitigation and adaptation where long-term investments are required.

Individual differences in the effects of perceived controllability on pain perception: critical role of the prefrontal cortex

The degree to which perceived controllability alters the way a stressor is experienced varies greatly among individuals. We used functional magnetic resonance imaging to examine the neural activation associated with individual differences in the impact of perceived controllability on self-reported pain perception. Subjects with greater activation in response to uncontrollable (UC) rather than controllable (C) pain in the pregenual anterior cingulate cortex (pACC), periaqueductal gray (PAG), and posterior insula/SII reported higher levels of pain during the UC versus C conditions. Conversely, subjects with greater activation in the ventral lateral prefrontal cortex (VLPFC) in anticipation of pain in the UC versus C conditions reported less pain in response to UC versus C pain. Activation in the VLPFC was significantly correlated with the acceptance and denial subscales of the COPE inventory [Carver, C. S., Scheier, M. F., & Weintraub, J. K. Assessing coping strategies: A theoretically based approach. Journal of Personality and Social Psychology, 56, 267–283, 1989], supporting the interpretation that this anticipatory activation was associated with an attempt to cope with the emotional impact of uncontrollable pain. A regression model containing the two prefrontal clusters (VLPFC and pACC) predicted 64% of the variance in pain rating difference, with activation in the two additional regions (PAG and insula/SII) predicting almost no additional variance. In addition to supporting the conclusion that the impact of perceived controllability on pain perception varies highly between individuals, these findings suggest that these effects are primarily top-down, driven by processes in regions of the prefrontal cortex previously associated with cognitive modulation of pain and emotion regulation.

Individual Differences in Amygdala and Ventromedial Prefrontal Cortex Activity are Associated with Evaluation Speed and Psychological Well-being

Using functional magnetic resonance imaging, we examined whether individual differences in amygdala activation in response to negative relative to neutral information are related to differences in the speed with which such information is evaluated, the extent to which such differences are associated with medial prefrontal cortex function, and their relationship with measures of trait anxiety and psychological well-being (PWB). Results indicated that faster judgments of negative relative to neutral information were associated with increased left and right amygdala activation. In the prefrontal cortex, faster judgment time was associated with relative decreased activation in a cluster in the ventral anterior cingulate cortex (ACC, BA 24). Furthermore, people who were slower to evaluate negative versus neutral information reported higher PWB. Importantly, higher PWB was strongly associated with increased activation in the ventral ACC for negative relative to neutral information. Individual differences in trait anxiety did not predict variation in judgment time or in amygdala or ventral ACC activity. These findings suggest that people high in PWB effectively recruit the ventral ACC when confronted with potentially aversive stimuli, manifest reduced activity in subcortical regions such as the amygdala, and appraise such information as less salient as reflected in slower evaluative speed.

Individual differences in some (but not all) medial prefrontal regions reflect cognitive demand while regulating unpleasant emotion.

The present study investigated the premise that individual differences in autonomic physiology could be used to specify the nature and consequences of information processing taking place in medial prefrontal regions during cognitive reappraisal of unpleasant pictures. Neural (blood oxygenation level-dependent functional magnetic resonance imaging) and autonomic (electrodermal [EDA], pupil diameter, cardiac acceleration) signals were recorded simultaneously as twenty-six older people (ages 64–66 years) used reappraisal to increase, maintain, or decrease their responses to unpleasant pictures. EDA was higher when increasing and lower when decreasing compared to maintaining. This suggested modulation of emotional arousal by reappraisal. By contrast, pupil diameter and cardiac acceleration were higher when increasing and decreasing compared to maintaining. This suggested modulation of cognitive demand. Importantly, reappraisal-related activation (increase, decrease > maintain) in two medial prefrontal regions (dorsal medial frontal gyrus and dorsal cingulate gyrus) was correlated with greater cardiac acceleration (increase, decrease > maintain) and monotonic changes in EDA (increase > maintain > decrease). These data indicate that these two medial prefrontal regions are involved in the allocation of cognitive resources to regulate unpleasant emotion, and that they modulate emotional arousal in accordance with the regulatory goal. The emotional arousal effects were mediated by the right amygdala. Reappraisal-related activation in a third medial prefrontal region (subgenual anterior cingulate cortex) was not associated with similar patterns of change in any of the autonomic measures, thus highlighting regional specificity in the degree to which cognitive demand is reflected in medial prefrontal activation during reappraisal.

Early social experience and individual differences in infants' joint attention

Fifty-nine healthy infants were filmed with their mothers and with a researcher at two, four, six and nine months in face-to-face play, and in toy-play at six and nine months. During toy-play at both ages, two indices of joint attention (JA)—infant bids for attention, and percent of time in shared attention—were assessed, along with other behavioural measures. Global ratings were made at all four ages of infants’ and mothers’ interactive style. The mothers varied in psychiatric history (e.g., half had experienced postpartum depression) and socioeconomic status, so their interactive styles were diverse. Variation in nine-month infant JA — with mother and with researcher — was predicted by variation in maternal behaviour and global ratings at six months, but not at two or four months. Concurrent adult behaviour also influenced nine-month JA, independent of infant ratings. Six-month maternal behaviours that positively predicted later JA (some of which remained important at nine months) included teaching, conjoint action on a toy, and global sensitivity. Other behaviours (e.g., entertaining) negatively predicted later JA. Findings are discussed in terms of social-learning and neurobiological accounts of JA emergence.

‘We are managing our own lives...’: life transitions and care in sibling-headed households affected by AIDS in Tanzania and Uganda

This paper explores the ways that young people express their agency and negotiate complex lifecourse transitions according to gender, age and inter- and intra-generational norms in sibling-headed households affected by AIDS in East Africa. Based on findings from a qualitative and participatory pilot study in Tanzania and Uganda, I examine young people's socio-spatial and temporal experiences of heading the household and caring for their siblings following their parent's/relative's death. Key dimensions of young people's caring pathways and life transitions are discussed: transitions into sibling care; the ways young people manage changing roles within the family; and the ways that young people are positioned and seek to position themselves within the community. The research reveals the relational and embodied nature of young people's life transitions over time and space. By living together independently, young people constantly reproduce and reconfigure gendered, inter- and intra-generational norms of ‘the family’, transgressing the boundaries of ‘childhood’, ‘youth’ and ‘adulthood’. Although young people take on ‘adult’ responsibilities and demonstrate their competencies in ‘managing their own lives’, this does not necessarily translate into more equal power relations with adults in the community. The research reveals the marginal ‘in-between’ place that young people occupy between local and global discourses of ‘childhood’ and ‘youth’ that construct them as ‘deviant’. Although young people adopt a range of strategies to resist marginalisation and harassment, I argue that constraints of poverty, unequal gender and generational power relations and the emotional impacts of sibling care, stigmatisation and exclusion can undermine their ability to exert agency and control over their sexual relationships, schooling, livelihood strategies and future lifecourse transitions.

Treatment of written verb and written sentence production in an individual with aphasia: A clinical study

Background: Although the efficacy of treatments for spoken verb and sentence production deficits in aphasia has been documented widely, less is known about interventions for written verb and written sentence production deficits. Aims: This study documents a treatment aiming to improve production of (a) written subject-verb sentences (involving intransitive verbs) and (b) written subject-verb-object sentences (involving transitive verbs). Methods & Procedures: The participant, a 63-year-old female aphasic speaker, had a marked language comprehension deficit, apraxia of speech, relatively good spelling abilities, and no hemiplegia. The treatment involved intransitive verbs producing subject-verb active sentences and transitive verbs producing subject-verb-object active non-reversible sentences. The treatment was undertaken in the context of current UK clinical practice. Outcomes & Results: Statistical improvements were noted for the trained sets of verbs and sentences. Other improvements were also noted in LW's ability to retrieve some non-treated verbs and construct written sentences. Treatment did not generalise to sentence comprehension and letter spelling to dictation. Conclusions: Our participant's ability to write verbs and sentences improved as a result of the treatment.