Silence as an element of care:A meta-ethnographic review of professional caregivers’ experience in clinical and pastoral settings

Background: In interactions between professional caregivers, patients and family members at the end of life, silence often becomes more prevalent. Silence is acknowledged as integral to interpersonal communication and compassionate care but is also noted as a complex and ambiguous phenomenon. This review seeks interdisciplinary experience to deepen understanding of qualities of silence as an element of care. Aim: To search for published papers which describe professional caregivers’ experience of silence as an element of care, in palliative and other clinical, spiritual and pastoral care settings and to synthesise their findings. Design: Meta-ethnography: employing a systematic search strategy and line-of-argument synthesis. Data sources: PsycINFO and seven other cross-disciplinary databases, supplemented by hand-search, review of reference lists and citation tracking. No date range was imposed. Inclusion criteria focused on reported experience of silence in professional caregiving. Selected papers (n = 18) were appraised; none were rejected on grounds of quality. Results: International, interdisciplinary research and opinion endorses the value of silence in clinical care. As a multi-functional element of interpersonal relationships, silence operates in partnership with speech to support therapeutic communication. As a caregiving practice, silence is perceived as particularly relevant in spiritual and existential dimensions of care when words may fail. Conclusion: Experience of silence as an element of care was found in palliative and spiritual care, psychotherapy and counselling supporting existing recognition of the value of silence as a skill and practice. Because silence can present challenges for caregivers, greater understanding may offer benefits for clinical practice

A Comparison of Bis †"perfluoroalkyl…sulfonyl ‡imide Ionomers and Perfluorosulfonic Acid Ionomers for Applications in PEM Fuel-Cell Technology

Two structurally related perfluorinated ionomer materials, one a conventional sulfonic-acid-based ionomer ͑Nafion͒ and the other an experimental bis͓͑perfluoroalkyl͒sulfonyl͔imide-based ionomer in which the sulfonic acid group has been replaced by a sulfonyl imide acid group, were studied in parallel to evaluate their relative utility as membrane materials for use in polymer electrolyte membrane ͑PEM͒ fuel cells. Studies focused on membrane ionic conductivity and water content under varying conditions of relative humidity, and on device-level fuel-cell tests using membrane-electrode assemblies ͑MEAs͒ fabricated from membranes of the two ionomers. The overall finding is that the two ionomer materials behave similarly with respect to their electrochemical properties and performance in PEM fuel-cell devices. In one instance, a sulfonyl-imide-based MEA exhibited substantially improved performance relative to a comparable Nafion-based MEA in fuel-cell tests. The improvement is probably attributable to a combination of favorable materials properties and membrane thickness effects. Perfluorinated ionomers such as DuPont's Nafion and other closely related perfluorosulfonic acid ͑PFSA͒ ionomers are leading candidates for use as membrane materials in polymer electrolyte membrane ͑PEM͒ fuel cells. They possess many of the desirable qualities required for a successful PEM fuel cell, namely, high protonic conductivity, good mechanical properties, and excellent longterm chemical stability. Despite the desirable qualities of these materials, however, they also possess certain limitations, among which is a tendency toward diminished protonic conductivity under conditions of low water availability. 1 Several members of a related class of ionomers based on the bis͓͑perfluoroalkyl͒sulfonyl͔imide acid group have been synthesized and characterized by DesMarteau and co-workers. 2-4 The perfluorosulfonyl imide group is known to possess stronger gas-phase acidity 5 and improved thermal stability relative to the perfluorosulfonic acid moiety. Additionally, enhanced oxygen reduction kinetics have been reported in phosphoric acid fuel cells ͑PAFCs͒ when a small amount of a monomeric bis͓͑perfluoroalkyl͒sulfo-nyl͔imide species was used as an electrolyte additive. 6 Recent work by Sumner and co-workers has established that sulfonyl imide-based ionomers ͑Fig. 1b͒ exhibit ionic conductivities that are at least as high as that of Nafion ͑Fig. 1a͒ ionomers of similar structure and equivalent weight. 4,7 Thus, there is reasonable expectation that ionomer materials based on the perfluorosulfonyl imide moiety are good candidates for use as membranes in PEM fuel cells. Work presented in this paper explores the similarities and differences between perfluorosulfonylimide ionomers and perfluorosulfonic acid ionomers as membrane materials for use in PEM fuel cells. Membrane-electrode assemblies ͑MEAs͒ were fabricated from Nafion and the experimental sulfonylimide ionomer membranes using the thin-film decal transfer method. Experimental Ionomer synthesis and membrane preparation.-Nafion 117 and 1135 membranes were obtained commercially ͑Solution Technology, Inc., Mendenhall, PA͒ and were cleaned using a multistep procedure involving boiling in a 3% aqueous hydrogen peroxide solution followed by boiling in deionized water for 1 h. The sulfonyl imide ionomer materials were prepared by copolymerization of tetrafluoroethylene and a perfluorinated vinyl ether monomer ͑as the sodium salt͒ using a continuous addition semibatch redox-initiated aqueous emulsion polymerization technique. 2 Membranes were prepared by solution casting of the ionomer in the tetraalkylammonium salt form from a water/methanol/N,N-dimethylformamide solvent mixture. The solvents were removed at 80°C under 75 kPa vacuum followed by annealing at 220-250°C for 4 h. The membranes were cleaned and converted to the proton form via sequential treatment with hot concentrated nitric acid, deionized ͑DI͒ water, 3% hydrogen peroxide, hydrochloric acid, and again DI water. Ionic conductivity and water uptake measurements.-Ionomer conductivities were measured at ambient temperature (25 Ϯ 1°C) as a function of the relative humidity of the environment using a two-electrode cell similar to that described by Zawodzinski and co-workers. The water content of ionomer samples exposed to different relative humidity environments was measured gravimetrically with a conventional analytical balance at room temperature. Ionomer samples were first soaked in DI water for 2 h and weighed. The samples were then suspended in a specific relative humidity environment in a closed vessel for 90 min after which they were re-* Electrochemical Society Student Member

Defining professionalism in medical education: a systematic review

Introduction: We undertook a systematic review and narrative synthesis of the literature to identify how professionalism is defined in the medical education literature. Methods: Eligible studies included any articles published between 1999 and 2009 inclusive presenting viewpoints, opinions, or empirical research on defining medical professionalism. Results: We identified 195 papers on the topic of definition of professionalism in medicine. Of these, we rated 26 as high quality and included these in the narrative synthesis. Conclusion: As yet there is no overarching conceptual context of medical professionalism that is universally agreed upon. The continually shifting nature of the organizational and social milieu in which medicine operates creates a dynamic situation where no definition has yet taken hold as definitive