Enacting Ethics: Bottom-up Involvement in Implementing Moral Case Deliberation

In moral case deliberation (MCD), healthcare professionals meet to reflect upon their moral questions supported by a structured conversation method and non-directive conversation facilitator. An increasing number of Dutch healthcare institutions work with MCD to (1) deal with moral questions, (2) improve reflection skills, interdisciplinary cooperation and decision-making, and (3) develop policy. Despite positive evaluations of MCD, organization and implementation of MCD appears difficult, depending on individuals or external experts. Studies on MCD implementation processes have not yet been published. The aim of this study is to describe MCD implementation processes from the perspective of nurses who co-organize MCD meetings, so called ‘local coordinators’. Various qualitative methods were used within the framework of a responsive evaluation research design. The results demonstrate that local coordinators work hard on the pragmatic implementation of MCD. They do not emphasize the ethical and normative underpinnings of MCD, but create organizational conditions to foster a learning process, engagement and continuity. Local coordinators indicate MCD needs firm back-up from management regulations. These pragmatic action-oriented implementation strategies are as important as ideological reasons for MCD implementation. Advocates of clinical ethics support should pro-actively facilitate these strategies for both practical and ethical reasons

The “ebb and flow” of student learning on placement

There is a rise in interest in work based learning as part of student choice at subject level in the UK (DOE 2017) but there remains an absence of specific guidance on how to best support higher education students learning on placement. An alternative HE experience in England, the degree apprenticeship, underlies the continued focus by policy in securing placement experiences for students without stipulating the type of support that is required at the ‘coal face’ of work based learning. Policy documents (UUK 2016), that urge universities to enter into partnership agreements with both employers and FE colleges to plug skills shortages, are noticeably lacking in their appreciation of the unique qualities of work based learning and how best to support students in this setting (Morley 2017a). Unfortunately, this is not unusual as placements have predominantly been an enriching ‘add on’ to the real business of academic learning in more traditional university programmes. Support initiatives, such as that described in chapter 9, are a rare appreciation of the importance of this role. Undergraduate nursing programmes currently support a 50:50 split between practice learning in clinical placements and the theory delivered at universities. Vocational degrees, such as this, provide an interesting case study as to how students can be supported in the practice environment by an appreciation of how students really learn on placement and how hidden resources can be utilised more explicitly for practice learning. During 2013 – 2015 a professional doctorate research study (Morley 2015) conducted a grounded theory study of 21 first year student nurses on their first placement to discover how they learnt ‘at work’ and the strategies they enlisted to be successful work based learners

Genome-Wide Identification of Susceptibility Alleles for Viral Infections through a Population Genetics Approach

Viruses have exerted a constant and potent selective pressure on human genes throughout evolution. We utilized the marks left by selection on allele frequency to identify viral infection-associated allelic variants. Virus diversity (the number of different viruses in a geographic region) was used to measure virus-driven selective pressure. Results showed an excess of variants correlated with virus diversity in genes involved in immune response and in the biosynthesis of glycan structures functioning as viral receptors; a significantly higher than expected number of variants was also seen in genes encoding proteins that directly interact with viral components. Genome-wide analyses identified 441 variants significantly associated with virus-diversity; these are more frequently located within gene regions than expected, and they map to 139 human genes. Analysis of functional relationships among genes subjected to virus-driven selective pressure identified a complex network enriched in viral products-interacting proteins. The novel approach to the study of infectious disease epidemiology presented herein may represent an alternative to classic genome-wide association studies and provides a large set of candidate susceptibility variants for viral infections

Evidence for predilection of macrophage infiltration patterns in the deeper midline and mesial temporal structures of the brain uniquely in patients with HIV-associated dementia

<p>Abstract</p> <p>Background</p> <p>HIV-1 penetrates the central nervous system, which is vital for HIV-associated dementia (HAD). But the role of cellular infiltration and activation together with HIV in the development of HAD is poorly understood.</p> <p>Methods</p> <p>To study activation and infiltration patterns of macrophages, CD8+ T cells in relation to HIV in diverse CNS areas of patients with and without dementia. 46 brain regions from two rapidly progressing severely demented patients and 53 regions from 4 HIV+ non-dementia patients were analyzed. Macrophage and CD8+ T cell infiltration of the CNS in relation to HIV was assessed using immuno-histochemical analysis with anti-HIV (P24), anti-CD8 and anti-CD68, anti-S-100A8 and granzyme B antibodies (cellular activation). Statistical analysis was performed with SPSS 12.0 with Student's t test and ANOVA.</p> <p>Results</p> <p>Overall, the patterns of infiltration of macrophages and CD8+ T cells were indiscernible between patients with and without dementia, but the co-localization of macrophages and CD8+ T cells along with HIV P24 antigen in the deeper midline and mesial temporal structures of the brain segregated the two groups. This predilection of infected macrophages and CD8+ T cells to the middle part of the brain was unique to both HAD patients, along with unique nature of provirus gag gene sequences derived from macrophages in the midline and mesial temporal structures.</p> <p>Conclusion</p> <p>Strong predilection of infected macrophages and CD8+ T cells was typical of the deeper midline and mesial temporal structures uniquely in HAD patients, which has some influence on neurocognitive impairment during HIV infection.</p

Developing the practice context to enable more effective pain management with older people: an action research approach

Background\ud \ud This paper, which draws upon an Emancipatory Action Research (EAR) approach, unearths how the complexities of context influence the realities of nursing practice. While the intention of the project was to identify and change factors in the practice context that inhibit effective person-centred pain management practices with older people (65 years or older), reflective critical engagement with the findings identified that enhancing pain management practices with older people was dependent on cultural change in the unit as a whole. \ud \ud Methods\ud \ud An EAR approach was utilised. The project was undertaken in a surgical unit that conducted complex abdominal surgery. Eighty-five percent (n = 48) of nursing staff participated in the two-year project (05/NIR02/107). Data were obtained through the use of facilitated critical reflection with nursing staff. \ud \ud Results\ud \ud Three key themes (psychological safety, leadership, oppression) and four subthemes (power, horizontal violence, distorted perceptions, autonomy) were found to influence the way in which effective nursing practice was realised. Within the theme of 'context,' effective leadership and the creation of a psychologically safe environment were key elements in the enhancement of all aspects of nursing practice. \ud \ud Conclusions\ud \ud Whilst other research has identified the importance of 'practice context' and models and frameworks are emerging to address this issue, the theme of 'psychological safety' has been given little attention in the knowledge translation/implementation literature. Within the principles of EAR, facilitated reflective sessions were found to create 'psychologically safe spaces' that supported practitioners to develop effective person-centred nursing practices in complex clinical environments

Nothing left to learn: translation and the Groundhog Day of bureaucracy

Beyond the existing theorizing of translation as a creative disruption in both occupational and semantic terms, the current study explores it critically in the experiential framework of professional translators and as a meaning-making process. Acknowledging the role of translation in creating dialogic and radical climates for learning, the article proposes to explore the other side of this relationship by studying how the limiting of space for translation delimits the possibilities for meaning-creation thus precluding dialogue. In addition to this general point, it ponders the specific aporia of organizationally-embedded adversity of translation in the occupational context (apparently) devoted to semantic labour, namely that of translator’s work. It demonstrates that the rigidity of meaning-making and the inexorableness of partaking in the uncanny déjà vu, are the reflections of specific organizational (bureaucratic) frame, and posits that they may be used as experiential and semantic heuristics for better understanding learning and non-learning in organizations