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.

‘A picture of who we are as a family’: conceptualizing post-adoption contact as practices of family display

Social work has a central role in negotiating and supporting birth family contact following adoption from care. This paper argues that family display (Finch) offers a useful conceptual resource for understanding relationships in the adoptive kinship network as they are enacted through contact. It reports on an interpretative phenomenological analysis of adoptive parents' accounts of open adoption from care that revealed direct and indirect contact to be contexts in which they and birth relatives performed family display practices: communicating the meaning of their respective relationships with the adopted child and seeking recognition that this was a legitimate family relationship. The analysis explores how family display was performed, and the impact of validating or invalidating responses. It aims to illuminate these social and interpretive processes involved in adoptive kinship in order to inform social work support for contact. The findings suggest that successful contact may be promoted by helping adoptive and birth relatives validate the legitimacy of the other's kin connection with the child, and through arrangements that facilitate family-like interactions.

Empowering Human Services Organizations to Embrace Evidence-informed Practice: International Best Practices

Human service organizations are increasingly using knowledge as a mechanism for implementing change. Knowledge emerging from many sources that may include academic publications, grey literature, and service user and practitioner wisdom contributes toward informing best practice. The question is: how do we harness this knowledge to make practice more effective? This paper synthesizes the lessons learned from eight international organizations that have made a commitment to knowledge mobilization as an important priority in their mission and operation. The paper provides a conceptual model, tools and resources to help human services organizations create strategies for building, enhancing or sustaining their knowledge mobilization efforts. The paper describes a flexible blueprint for human service organizations to leverage knowledge mobilization efforts at all levels of service delivery.

National institutions and employers’ age management practices in Britain and Germany:‘Path dependence’and option exploration

We pursue a comparative analysis of employers’ age management practices in Britain and Germany, asking how valid ‘convergence’ and ‘Varieties of Capitalism’ theories are. After rejecting the convergence verdict, we proceed to ask how far ‘path dependence’ helps explain inter-country differences. Through 19 interviews with British and German experts, we find that firms have reacted in different ways to promptings from the EU and the two states. Change has been modest and a rhetoric-reality gap exists in firms as they seek to hedge. We point to continuities in German institutional methods of developing new initiatives, and the emerging role of British NGOs in helping firms and the state develop new options. We argue that ‘path dependence’ offers insight into the national comparison, but also advance the idea of national modes of firm optionexploration as an important way of conceptualizing the processes involved.

The Disorganized Family: Institutions, Practices and Normativity

This paper considers the value of a normative account of the relationship between agents and institutions for contemporary efforts to explain ever more complex and disorganized forms of social life. The character of social institutions, as they relate to practices, agents and norms, is explored through an engagement with the common claim that family life has been deinstitutionalized. The paper argues that a normative rather than empirical definition of institutions avoids a false distinction between institutions and practices. Drawing on ideas of social freedom and creative action from critical theory, the changes in family life are explained not as an effect of deinstitutionalization, but as a shift from an organized to a disorganized institutional type. This is understood as a response to changes in the wider normative structure, as a norm of individual freedom has undermined the legitimacy of the organized patriarchal nuclear family, with gender ascribed roles and associated duties. Contemporary motherhood is drawn on to illustrate the value of analysing the dynamic interactions between institutions, roles and practices for capturing both the complexity and the patterned quality of social experience.

Employee 'words' on high involvement work practices, value congruence and burnout

This article examined the impact of perceived high involvement work practices (HIWPs) on person-organization value congruence (P-O fit) and long term burnout. The study was conducted in a Canadian general hospital. Findings from structural equation modeling (N = 185) revealed that perceived HIWPs were significantly positively associated with P-O fit. While there was no direct effect of HIWPs on burnout, P-O fit fully mediated the relationship between perceptions of HIWPs and burnout. We discuss the implications of these findings for our understanding of HIWPs influence on P-O fit and burnout.