Implementing a resuscitation policy for patients at the end of life in an acute hospital setting: qualitative study

Objective : To explore attitudes and experiences of doctors and nurses regarding cardiopulmonary resuscitation for patients with end stage illness in an acute hospital. Design : Qualitative study; thematic analysis of two audio-taped focus groups and four semi-structured interviews. Setting : Acute district hospital, Northern Ireland. Participants : Seven nurses and nine doctors; varying nationality, gender and years of professional experience; involved in cardiopulmonary resuscitation decision-making. Results : Participants reported different interpretations of resuscitation policy and of what do not attempt to resuscitate (DNAR) decisions meant in relation to practical care for patients. This confusion in translating policy into practice contributed to communication difficulties in initiating, documenting and implementing cardiopulmonary resuscitation decisions. Participants were aware of how clinical conditions could change and reported uncertainty in determining end stage illness; they expressed fears of potential consequences of DNAR decisions for patients' care. The more disease-centred approach of doctors to patients' management, compared to nurses' more patient-centred approach, contributed to inter-professional conflict within teams. Doctors identified training needs in applying resuscitation policy and ethical principles in `real life' and nurses identified a need for ongoing professional support, which was perceived as being less available to junior doctors. Personal relationships between staff and patients, cultural reluctance to address sensitive issues and local community expectations of relatives being involved in decisions added to policy implementation difficulties. Conclusions : The findings indicate a need for ongoing staff support and training in applying resuscitation policy to decisions for patients with end stage illness in an acute hospital. They support suggestions that reviews of local resuscitation policy and of national guidelines should be undertaken with openness and honesty regarding the goals, opportunities and difficulties involved in trying to deliver good end of life care in local settings. Palliative Medicine 2007; 21 : 305—312 Key Words: do not attempt resuscitation (DNAR) • end stage illness • inter-professional • policy • resuscitation decisions

Boron in copper: A perfect misfit in the bulk and cohesion enhancer at a grain boundary

Using first principles electronic structure methods, we calculate the effects of boron impurities in bulk copper and at surfaces and grain boundaries. We find that boron segregation to the Sigma5(310)[001] grain boundary should strengthen the boundary up to 1.5 ML coverage (15.24 at./nm2). The maximal effect is observed at 0.5 ML and corresponds to boron atoms filling exclusively grain boundary interstices. In copper bulk, B causes significant distortion both in interstitial and regular lattice sites, for which boron atoms are either too big or too small. The distortion is compensated to a large extent when the interstitial and substitutional boron combine together to form a strongly bound dumbbell. Our prediction is that bound boron impurities should appear in a sizable proportion if not dominate in most experimental conditions. A large discrepancy between calculated heats of solution and experimental terminal solubility of B in Cu is found, indicating either a significant failure of the density functional approach or, more likely, strongly overestimated solubility limits in the existing B-Cu phase diagram.

The importance of stakeholder engagement in invasive species management: A cross-jurisdictional perspective in Ireland

The management of invasive non-native species is a frequent cause of conflict in the field of biodiversity conservation because perceptions of their costs and benefits differ among stakeholder groups. A lack of cohesion between scientific researchers, the commercial sector and policy makers lies at the root of a widespread failure to develop and implement sustainable management practices for invasive species. The crisis of this situation is intensified by drivers stemming from international conventions and directives to address invasive species issues. There are further direct conflicts between legislative instruments promoting biodiversity conservation on the one hand while liberalizing trade at the national, European and global level on the other. The island of Ireland provides graphic illustration of the importance of cross-jurisdictional approaches to biological invasions. Using primarily Irish examples in this review, we emphasize the importance of approaching risk assessment, risk reduction and control or eradication policies from a cost-efficient, highly flexible perspective, incorporating linkages between environmental, economic and social objectives. The need for consolidated policies between Northern Ireland and the Republic of Ireland is particularly acute, though few model cross-border mechanisms for such consolidation are available. The importance of engaging affected stakeholders through positive interactions is discussed with regard to reducing the currently fragmented nature of invasive species management between the two jurisdictions.

Child abuse as a complex and wicked problem: Reflecting on policy developments in the United Kingdom in working with children and families with multiple problems

In spite of significant public concern, professional efforts and financial expenditure, there has been a perceived lack of progress in reducing the incidence of child abuse, and in improving the outcomes for children in both the short and longer term. In this article the authors reflect on recent policy developments in the United Kingdom relating to children and families experiencing multiple adversities, and argue that the current conceptualisation of child abuse is flawed. In adopting a rational technical approach to the management of child abuse, there is a tendency to focus on shorter term outcomes for the child, such as immediate safety, that primarily reflect the outputs of the child protection system. However, by viewing child abuse as a wicked problem, that is complex and less amenable to being solved, then child welfare professionals can be supported to focus on achieving longer term outcomes for children that are more likely to meet their needs. The authors argue for an earlier identification of and intervention with children who are experiencing multiple adversity, such as those living with parents misusing substances and exposed to intimate partner violence.

The Diminishing Returns to Trade Policy in the European Union

The notion that the EU is a trade power is central to studies of the Union’s international presence. Credible threats to withhold access to Europe’s markets are said to provide the Union with leverage in respect of other trade partners. This paper queries the continuing ability of the European Union to act effectively this way. The current Doha malaise is a symptom of deeper changes in the international trade system. As emerging markets become more affluent and participate in foreign direct investment, their interest in market access per se become less important relative to other areas of regulation.

Stakeholders and perspectivism in qualitative policy evaluation: A realist reflection

This paper examines the epistemological bases for the inclusion of stakeholders in policy research. While it concedes that the input of stakeholders provides essential expert and experiential knowledge for the understanding of complex policies and programmes, it contends that the approach which assumes that all interpretations of policy including those of stakeholders should be afforded equal validity, which we term relativist perspectivism, undermines the possibility of robust research by allowing power to replace methodological rigour as the primary research dynamic. It is noted that this problem tends to be more acute when the research is qualitative. A study into the gendered effects of Common Agricultural Policy reforms is used as an illustrative example of how research can be compromised by relativist perspectivism. It is argued that realist research methodologies uniquely provide the capacity to maintain epistemological robustness, while also being able to take due account of the perspectives of stakeholders.