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

L’Utilisation D’Entretiens Quantitatifs Pour Détecter L’influence des Parents Dans le Développement de Compétences Sportives Chez Les Athlètes

Past research has indicated that parents influence children’s sport performance, but studies using qualitative methodologies and lacking comparison groups have failed to outline specific parent behaviors that constitute support, pressure, involvement, and resource provision at each stage of development. This paper presents a quantitative methodology that assesses specific, observable, verifiable parent behaviors across development, allowing future researchers to highlight differences in parental behaviors of athletes who reach high levels of performance and those who do not. The combined survey and interview methodology examines parents’ demographic information, children’s involvement in sporting activities, and the nature of parents’ involvement in those activities. A case study conducted with the parents of three Canadian junior ice hockey athletes using this methodology found parents’ invested time and specific behaviors changed throughout the development of the athlete.

Re-evaluation of Graneledone setebos (Cephalopoda : Octopodidae) and allocation to the genus Megaleledone

The holotype of the Antarctic octopodid Graneledone setebos was re-examined and found to lack the epidermal warts characteristic of the genus Graneledone. It is similar in its large size to another Southern Ocean species, Megaleledone senoi. A comparative study of G. setebos and specimens attributed to M. senoi led us to conclude that M. senoi is a junior synonym of G. setebos. Although M. senoi is not valid, the genus Megaleledone can be separated from other genera by the structure of the radula (which lacks marginal plates) and we therefore consider the genus to be valid. We propose the new combination of Megaleledone setebos and have refigured the beaks and radula of the holotype herein and expanded the description. A search of museum specimens and the literature shows that Megaleledone setebos is more common in Antarctic waters than previously supposed.

'Trusting the numbers': mineral prospecting, raising finance and the governance of knowledge

Mineral prospecting and raising finance for ‘junior’ mining firms has historically been regarded as a speculative activity. For the regulators of securities markets upon which ‘junior’ mining companies seek to raise capital, a perennial problem has been handling not only the indeterminacy of scientific claims, but also the social basis of epistemic practices. This paper examines the production of a system of public warrant and associated knowledge practices intended to enable investors to differentiate between ‘destructive’ and ‘productive’ varieties of financial speculation. It traces the use of the notion of ‘disclosure’ in constructing and legitimizing the ‘juniors’ market in Canada. It argues that though the work of ‘economics’ may be necessary in the construction of markets, it is by no means sufficient. Attention must also be given to the ways in which legal models of ‘the free-market’ can be translated and constantly re-worked across the sites and spaces of regulatory practice, animating the geographies of markets.

'Mining money': science, legal technologies & working the borderlands of global finance

This paper explores the roles of science and market devices in the commodification of ‘nature’ and the configuration of flows of speculative capital. It focuses on mineral prospecting and the market for shares in ‘junior’ mining companies. In recent years these companies have expanded the reach of their exploration activities overseas, taking advantage of innovations in exploration methodologies and the liberalisation of fiscal and property regimes in ‘emerging’ mineral rich developing countries. Recent literature has explored how the reconfiguration of notions of ‘risk’ has structured the uneven distribution of rents. It is increasingly evident that neoliberal framing of environmental, political, social and economic risks has set in motion overflows that multinational mining capital had not bargained for (e.g. nationalisation, violence and political resistance). However, the role of ‘geological risk’ in animating flows of mining finance is often assumed as a ‘technical’ given. Yet geological knowledge claims, translated locally, designed to travel globally, assemble heterogeneous elements within distanciated regimes of metrology, valuation and commodity production. This paper explores how knowledge of nature is enrolled within systems of property relations, focusing on the genealogy of the knowledge practices that animate contemporary circuits of speculative mining finance. It argues that the financing of mineral prospecting mobilises pragmatic and situated forms of knowledge rather than actuarially driven calculations that promise predictability. A Canadian public enquiry struck in the wake of scandal associated with Bre-X’s prospecting activities in Indonesia is used to glean insights into the ways in which the construction of a system of public warrant to underpin financial speculation is predicated upon particular subjectivities and the outworking of everyday practices and struggles over ‘value’. Reflection on practical investments in processes of standardisation, rituals of verification and systems of accreditation reveal much about how the materiality of things shape the ways in which regional and global financial circuits are integrated, selectively transforming existing social relations and forms of knowledge production.

The accuracy of accredited glaucoma optometrists in the diagnosis and treatment recommendation for glaucoma

Aim: To compare the diagnostic performance of accredited glaucoma optometrists (AGO) for both the diagnosis of glaucoma and the decision to treat with that of routine hospital eye care, against a reference standard of expert opinion (a consultant ophthalmologist with a special interest in glaucoma). Methods: A directly comparative, masked, performance study was undertaken in Grampian, Scotland. Of 165 people invited to participate, 100 (61%) were examined. People suspected of having glaucoma underwent, within one month, a full ophthalmic assessment in both a newly established community optometry led glaucoma management scheme and a consultant led hospital eye service. Results: Agreement between the AGO and the consultant ophthalmologist in diagnosing glaucoma was substantial (89%; ? = 0.703, SE = 0.083). Agreement over the need for treatment was also substantial (88%; ? = 0.716, SE = 0.076). The agreement between the trainee ophthalmologists and the consultant ophthalmologist in the diagnosis of glaucoma and treatment recommendation was moderate (83%, ? = 0.541, SE = 0.098, SE = 0.98; and 81%, ? = 0.553, SE = 0.90, respectively). The diagnostic accuracy of the optometrists in detecting glaucoma in this population was high for specificity (0.93 (95% confidence interval, 0.85 to 0.97)) but lower for sensitivity (0.76 (0.57 to 0.89)). Performance was similar when accuracy was assessed for treatment recommendation (sensitivity 0.73 (0.57 to 0.85); specificity 0.96 (0.88 to 0.99)). The differences in sensitivity and specificity between AGO and junior ophthalmologist were not statistically significant. Conclusions: Community optometrists trained in glaucoma provided satisfactory decisions regarding diagnosis and initiation of treatment for glaucoma. With such additional training in glaucoma, optometrists are at least as accurate as junior ophthalmologists but some cases of glaucoma are missed.

How well do midwives use skills and knowledge in examining newborns?

Physical examination of the newborn (PEN) was established as part of postnatal care in the late 1960s. The role of discharging babies within the first 72 hours of birth was traditionally undertaken by junior doctors. Currently midwives, nurses, advanced nurse practitioners, and health visitors are being trained to undertake the PEN (NHS Screening Programmes, 2010). However, only a fraction of midwives utilize their acquired skills in clinical practice. A survey by Townsend et al (2004) showed that 2% of babies in England were examined by midwives while 83% were examined by junior doctors.This study aimed to evaluate how well midwives who undertook the PEN course between 2002 and 2005 (n = 40) at a large London University utilized the skills acquired on the course. Questionnaires with a series of open and closed questions were sent out by post followed by phone and email reminders. The eight that responded were midwives. All respondents said they were appropriately trained and felt well prepared for their role to examine babies. However, they felt they were not provided with opportunities to use the skills. Guidelines based on this extended role are available in the workplace but only a few midwives seemed to have negotiated time to implement these and may need greater managerial support for the role.

'Trusting the numbers': mineral prospecting, raising finance and the governance of knowledge

Mineral prospecting and raising finance for ‘junior’ mining firms has historically been regarded as a speculative activity. For the regulators of securities markets upon which ‘junior’ mining companies seek to raise capital, a perennial problem has been handling not only the indeterminacy of scientific claims, but also the social basis of epistemic practices. This paper examines the production of a system of public warrant and associated knowledge practices intended to enable investors to differentiate between ‘destructive’ and ‘productive’ varieties of financial speculation. It traces the use of the notion of ‘disclosure’ in constructing and legitimizing the ‘juniors’ market in Canada. It argues that though the work of ‘economics’ may be necessary in the construction of markets, it is by no means sufficient. Attention must also be given to the ways in which legal models of ‘the free-market’ can be translated and constantly re-worked across the sites and spaces of regulatory practice, animating the geographies of markets.

Evaluation of a Final Year Work-shadowing Attachment

The transition from medical student to junior doctor is well recognised to be a difficult and stressful period. To ease this transition, most UK universities have a work-shadowing period (WSP), during which students can learn practical skills needed for forthcoming employment. The aim of this study was to evaluate the WSP at Queen's University Belfast, and gain the views of both students and Foundation Programme Supervisors and Directors (FPSDs). The study utilised both qualitative (focus groups) and quantitative (questionnaires) approaches. The FPSDs completed a specific questionnaire designed for this study, while the students completed the university's internal quality assurance questionnaire. Twenty-eight of the 37 (76%) FPSDs and 106 / 196 (54%) students completed the questionnaires. Focus groups were conducted with up to 10 students in each group in both a regional centre and a district general hospital at the start and the end of the WSP as well as 8 weeks into working life. The transcripts of the focus groups were analysed and themes identified. A number of deficiencies with the current WSP were identified, including concerns about the use of log books, the timing of the attachment and relatively low levels of supervision provided by senior hospital staff members. As a result, students felt unprepared for commencing work, with particular mention given to medical emergencies, prescribing, and the emotional aspects of the job. A number of recommendations are made, including the need for more senior input to ensure better student attendance, participation and clinical interaction. Furthermore, students should be offered additional supervised responsibility for delivery of patient care and more experiential learning with respect to drug prescribing and administration. The study also suggests that more needs to be done to help ease the emotional and psychological stresses of the early FY1 period. These issues have been resolved to a large extent with the introduction of the new final year Student Assistantship module in the academic year 2010-2011. © The Ulster Medical Society, 2012.

Prevalence and Causes of Prescribing ErrorsL The PRescribing Outcomes for Trainee Doctors Engaged in Clinical Training (PROTECT) Study

Objectives: Study objectives were to investigate the prevalence and causes of prescribing errors amongst foundation doctors (i.e. junior doctors in their first (F1) or second (F2) year of post-graduate training), describe their knowledge and experience of prescribing errors, and explore their self-efficacy (i.e. confidence) in prescribing.

Method: A three-part mixed-methods design was used, comprising: prospective observational study; semi-structured interviews and cross-sectional survey. All doctors prescribing in eight purposively selected hospitals in Scotland participated. All foundation doctors throughout Scotland participated in the survey. The number of prescribing errors per patient, doctor, ward and hospital, perceived causes of errors and a measure of doctors’ self-efficacy were established.

Results: 4710 patient charts and 44,726 prescribed medicines were reviewed. There were 3364 errors, affecting 1700 (36.1%) charts (overall error rate: 7.5%; F1:7.4%; F2:8.6%; consultants:6.3%). Higher error rates were associated with : teaching hospitals (p,0.001), surgical (p = ,0.001) or mixed wards (0.008) rather thanmedical ward, higher patient turnover wards (p,0.001), a greater number of prescribed medicines (p,0.001) and the months December and June (p,0.001). One hundred errors were discussed in 40 interviews. Error causation was multi-factorial; work environment and team factors were particularly noted. Of 548 completed questionnaires (national response rate of 35.4%), 508 (92.7% of respondents) reported errors, most of which (328 (64.6%) did not reach the patient. Pressure from other staff, workload and interruptions were cited as the main causes of errors. Foundation year 2 doctors reported greater confidence than year 1 doctors in deciding the most appropriate medication regimen.

Conclusions: Prescribing errors are frequent and of complex causation. Foundation doctors made more errors than other doctors, but undertook the majority of prescribing, making them a key target for intervention. Contributing causes included work environment, team, task, individual and patient factors. Further work is needed to develop and assess interventions that address these.

Learning fluid prescription skills: why is it so challenging?

IIt is well recognised that medical students and junior doctors find fluid prescription a challenging topic. This study was designed to gain a greater understanding of the experiences that medical students face related to learning about fluid prescribing. Methods: A qualitative approach, using focus groups, was employed in this research. Final-year medical students in academic year 2011-12 at Queen's University Belfast were invited to participate during their 'Assistantship' placement in March 2012. Discussions in focus groups, consisting of between six and eight students, were recorded and transcribed verbatim. The research team, consisting of three separate investigators, conducted thematic analysis independently. A final consensus regarding emerging themes was reached by discussion within the whole research team. Medical students and junior doctors find fluid prescription a challenging topic Results: Five prominent themes emerged: 'Teaching experience: a disruptive variation'; 'Curricular disconnections'; 'The driving test: Theory-practice transformation'; 'Role modelling: which standard to aspire to?'; and finally 'Reconciling the perceived risk'. Discussion: This re search provided insights into medical students' opinions of the teaching practices and learning experiences related to fluid prescribing. The learning of prescribing skills is complex andcontextual. In the development of such skills, medical students are often exposed to conflicting educational experiences that challenge the novicelearner in making judgements on best prescribing practice. This study adds to the body of evidence that fluid prescription is a difficult topic, and has generated a number of multifaceted and strategic recommendations to potentially improve fluid prescription teaching.

Educational interventions in neurology:A comprehensive systematic review

A fear of neurology and neural sciences (neurophobia) may have clinical consequences. There is therefore a need to formulate an evidence-based approach to neurology education. A comprehensive systematic review of educational interventions in neurology was performed. BEI, Cochrane Library, Dialog Datastar, EBSCO Biomedical, EBSCO Psychology & Behavioral Sciences, EMBASE, ERIC, First Search, MDConsult, Medline, Proquest Medical Library and Web of Knowledge databases were searched for all published studies assessing interventions in neurology education among undergraduate students, junior medical doctors and residents up to and including July 2012. Two independent literature searches were performed for relevant studies, which were then classified for level of evidence using the Centre of Evidence-based Medicine criteria and four levels of Kirkpatrick educational outcomes. One systematic review, 16 randomized controlled trials (RCTs), nine non-randomized cohort/follow-up studies, 33 case series or historically controlled studies and three mechanism-based reasoning studies were identified. Educational interventions showed favourable evaluation or assessment outcomes in 15 of 16 (94%) RCTs. Very few studies measured subsequent clinical behaviour (two studies) and patient outcomes (one study). There is very little high quality evidence of demonstrably effective neurology education. However, RCTs are emerging, albeit without meeting comprehensive educational criteria. An improving evidence base in the quality of neurology education will be important to reduce neurophobia. © 2013 EFNS.

Foreskin surgery under local anaesthetic – OK? Or oh no!

Aim: Foreskin surgical procedures such as circumcision, prepuceplasty, frenuloplasty, dorsal slit, reduction of paraphimosis etc. in the adult male is usually performed by both general surgeons and urologists. Our aim was to evaluate the acceptance of performing these procedures in the day procedure unit or in the emergency unit under penile block. 
Method: Fifty patients who underwent foreskin surgeries under local anaesthetic (LA) were evaluated with their experience. Twenty patients who underwent circumcision, 20 patients who underwent foreskin preserving operations such as frenuloplasty or prepuceplasty and 10 patients who underwent other procedures such as reduction of paraphimosis (five) and dorsal slit (five) were included inthe study. The patients were asked about their symptoms such as pain or discomfort during local infiltration of lignocaine, any discomfort during the actual procedure, post-operative discomfort and general acceptance. All the patients were given penile block using smaller size needle (25 gauge, 5/8th inch orange sterile luer slip hypodermic needle) and 1% plain lignocaine. Thirty doctors from general surgery (10), urology (10) and emergency medicine (10) participated in the survey. They were asked about their opinion, confidence and preference about performing foreskin surgical procedures under LA. This included both junior trainees, middle grade doctors and consultants. The majority of middle grade doctors and consultants were fairly confident in performing procedures under LA, whereas the junior trainees in surgery, urology and emergency were lacking confidence. 
Conclusion: Penile block is a safe and effective way ofproviding sufficient anaesthesia for foreskin surgeries. Thetechnique is easy to learn. It reduces post-operative pain aswell. It can reduce the risk and cost of administering generalanaesthesia. doctors who are in training surgical specialityand emergency medicine should be encouraged to learnthe principles and technique in administering penile block.

Report on the 2014 UKONS Annual Conference Belfast, 14–15 November 2014: focus on living with and beyond cancer, patient information and support, and innovations in treatment and care

The UK Oncology Nursing Society’s (UKONS) annual conference focused on three major themes. These were ‘Living With and Beyond Cancer’, ‘Patient Information and Support’, and ‘Innovations in Treatment and Care’. It featured a wide range of presentations, industry satellites, exhibitions, poster discussions. and workshops. Presenters ranged from those eminent in their particular field to those gracing the speaker’s podium for the first time. The rich variety of presentations covered policy, cancer trends, clinical developments, care initiatives, personal development, and advances in practice. There was a strong emphasis on skills, knowledge, values, and attitudes, with the most junior and novice nurses mixing with experienced and highly esteemed practitioners.

Mining Money: the generative capacities of scientific and legal knowledge practices in the making of resource economies

In 1997 a scandal associated with Bre-X, a junior mining firm, and its prospecting activities in Indonesia, exposed to public scrutiny the ways in which mineral exploration firms acquire, assess and report on scientific claims about the natural environment. At stake here was not just how investors understood the provisional nature of scientific knowledge, but also evidence of fraud. Contemporaneous mining scandals not only included the salting of cores, but also unreliable proprietary sample preparation and assay methods, mis-representations of visual field estimates as drilling results and ‘overly optimistic’ geological reports. This paper reports on initiatives taken in the wake of these scandals and prompted by the Mining Standards Task Force (TSE/OSC 1999). For regulators, mandated to increase investor confidence in Canada’s leading role within the global mining industry, efforts focused first and foremost upon identifying and removing sources of error and wilfulness within the production and circulation of scientific knowledge claims. A common goal cross-cutting these initiatives was ‘a faithful representation of nature’ (Daston and Galison 2010), however, as the paper argues, this was manifest in an assemblage of practices governed by distinct and rival regulative visions of science and the making of markets in claims about ‘nature’. These ‘practices of fidelity’, it is argued, can be consequential in shaping the spatial and temporal dynamics of the marketization of nature.