Information in dementia care: sense making and a public health direction for the UK?

Providing information is a core focus of policy and practice in dementia care. Information is a vehicle through which people can be enabled or disabled, so it is essential that we ensure that information is available in a way that is accessible and relevant for people with dementia and that it enables personal aspiration and collective identity to be advanced in a way that is to the benefit of those living with dementia. People with dementia need information to support autonomy in making decisions and in acting on those decisions. Information must be provided in a way that is appropriate to the individual and to achieve that requires knowledge of the needs of that individual. However, maintaining autonomy includes, but involves much more than, the provision of information - others need to listen and hear their views and be prepared to act on them. As professionals, we must be aware that the (dementia) information we provide may disrupt the biographical narrative that people with dementia value. Thus, a person-centred approach encourages the sharing of knowledge and information. The (mis)use of information also impacts on the way that society disables, discriminates and applies barriers against people with disability.     

Psychology and nursing: the case for an empirical approach

The arguments presented concern the teaching of psychology to nurses. It is noted that psychology is regarded as an important component of nurse education, though the nature of this relationship can be considered elusive. In pointing out that the effect of learning psychology has yet to be measured in nursing practice, a case is put forward proposing a different approach to its teaching. The emphasis on content-based courses in which nurses are expected simply to learn a body of knowledge and apply that to their nursing is considered. Instead it is argued that a process-based course, that is one which emphasizes the methods and approaches used in gathering psychological information, is more appropriate. This, it is felt, should contribute to the aim of the nursing profession that its members be able to adopt a critical stance and develop research mindedness in the practice of their work.     

Is there a distinctive care ethics?

Is it true that an ethics of care offers something distinct from other approaches to ethical problems in nursing, especially principlism? In this article an attempt is made to clarify an ethics of care and then to argue that there need be no substantial difference between principlism and an ethics of care when the latter is considered in the context of nursing. The article begins by considering the question of how one could in fact differentiate moral theories. As is explained, this cannot be done merely in light of the moral judgements they defend, nor their ontological commitments (e.g. their view of the nature of persons). Following these methodological beginnings, care-based ethics is described and critically discussed. It is shown that ontological commitments embraced within care ethics do not themselves show that care ethics is distinct from other approaches. The idea of 'psychological care' is also discussed, which stems from the work of Margaret Little. Her claim that the 'gestalts' of justice and care cannot be combined is rejected in favour of an approach that does just that and which has been developed by Joan Tronto. It is then claimed that the moral commitments of principlism are certainly not incompatible with those of an ethics of care in the nursing context. A challenge to the idea that principlism and ethics of care might be compatible is anticipated in the work of Eva Feder Kittay. This challenge is responded to and it is concluded that care considered as a moral orientation and the moral values embedded in principlism are best combined in the nursing context. Care provides a moral orientation over which the obligations referred to in principlism can be laid.     

Preserving personhood in dementia research: a literature review

The aim of this literature review was to investigate studies that actively engage older people with dementia in research 'with' rather than 'on' them. The focus of the paper is the methods that researchers have used to ensure that studies are ethical, meaningful and preserve the personhood of individuals. The intention is to present a selection of papers rather than undertake an exhaustive review. It is well recognized that the prevalence of dementia in older adults is increasing, this increase is reflected by a huge rise in the amount of research into this area. The biomedical model continues to dominate dementia research however there is a small, but growing, body of research that actively seeks to engage people with dementia. This increase in research that actively engages people with dementia has developed in parallel with the 'new culture' of dementia care in which Kitwood ( Dementia Reconsidered: The Person Comes First . Open University Press, Buckingham, 1997) exhorts us to respect the personhood of people with dementia. This review identifies 22 studies that sought the views and experiences of older people with dementia. There is evidence in each paper that the researchers had given thought to ensuring that their work was ethical, meaningful and preserved the personhood of individuals. The skill with which this aim was achieved varied considerably from formulaic approaches to those that clearly demonstrate that the researchers have a mindset that is grounded in a powerful belief in, and application of, the concepts of genuine respect for older people with dementia. The examples of good practice that have been drawn from these papers have direct application to both future research and to the provision of clinical care.     

Deconstructing child and adolescent mental health: questioning the'taken-for-granted'…

Deconstructing child and adolescent mental health: questioning the 'taken-for-granted'… We present a critical deconstructive reading, seeking to problematise 'taken-for-granted' assumptions in child and adolescent mental health (CAMH). The start point for this critical reading is conventional 'history-telling' within CAMH. The aim is not to take issue with the detail in such histories but to critically examine the texts, so as to highlight constructions that structure the presentation of conventional histories and possible purposes that such constructions may serve. The argument is that such conventional histories leave key questions not just unanswered, but unconsidered - a tendency that can be seen throughout the CAMH literature more generally. Therefore, we then pursue critical discussion of how 'taken-for-granted' constructions of CAMH enabled psychiatry to successfully expand its power and influence to establish hegemony over 'problem children'. We do not claim any closure to this critical reading; that is, we do not claim that our critical deconstructive reading is the only reading possible. Similarly, it is not presented in any sense as 'final word'. Rather our hope for this work is that it might stimulate readers to question the 'taken-for-granteds' that we present, and indeed others that they might identify themselves. In so doing, it is our hope that creative dialogue might ensue.     

Pre-randomization and de-randomization in emergency medical research: new names and rigorous criteria for old methods

Clinical trials are performed to determine if a therapy is effective in the treatment of a disease. The methods of randomization and blinding are used to assure that the only planned difference between the two groups is the therapy itself, and differences in outcome cannot be attributed to bias. Emergency medical conditions, and in particular therapies that must be administered in an emergency, present challenges to inclusion, exclusion, randomization, and blinding that are at times insurmountable in the context of available resources. Pre-randomization (that is, assigning the therapy to be used before the event occurs) and de-randomization (that is, removing randomized cases that do not meet established inclusion criteria) may address some of the challenges resulting from emergency enrollment but have the potential to create bias. We describe these techniques, and provide criteria that should be employed if pre-randomization and/or de-randomization are being considered. It is possible to use these techniques to successfully complete clinical trials that would not have been possible using only standard methodology and still ensure that results are without bias.     

The art of nursing.

It is a common assumption that nursing is an art. Art in this sense is sometimes taken to mean a fine art, and sometimes a skill or craft. This paper reviews some of the arguments for nursing as an art and concludes that nursing is not a fine art, but that it is an art in the more general sense of a craft or skill performed by people. It is further argued that, in most instances, to say that nursing is an art tells us little or nothing that is useful and the word 'art' is redundant in this context.     

The meaning of spirituality: a literature review

This paper presents a literature review in relation to the meaning of spirituality. It is proposed that meeting the spiritual needs of patients is a fundamental part of providing holistic nursing care, but that the assessment and meeting of those needs is impeded by inadequate definitions and conceptual frameworks. It should not be assumed that spirituality is either synonymous, or coterminous, with religion, and it is suggested that to adopt this restrictive view is unhelpful in the provision of individualized care. Reflection on the literature reveals that the self, others and 'God' provide the key elements within a definition of spirituality, and that other emerging themes namely meaning, hope, relatedness/connectedness, beliefs/belief systems and expressions of spirituality, can be articulated in the context of those three key elements. In particular, it is proposed that the nature of 'God' may take many forms and, essentially, is whatever an individual takes to be of highest value in his/her life. It is suggested that the themes emerging from the literature can be utilized as a framework to give practitioners and researchers a direction for future exploration of the concept of spirituality.     

'To save the honour of thinking': a slightly petulant response to Griffiths

This is a response (a reply? a riposte?) to Peter Griffiths (Int. J. Nurs. Stud., in press, ) that attempts to answer some of the charges, which he levels at our book 'Deconstructing Evidence-based Practice' (Routledge, London, 2004). It begins by countering Griffiths' mistaken assertion that, in deconstruction, 'anything goes'. It argues that Griffiths is wrong because he has literally mistaken the meanings of certain words; that is, he has taken them wrongly. His biggest mistake, on which all of his others rests, is to mistake the word 'deconstruction' to imply a form of extreme relativism in which there are no right or wrong readings. In this, he is simply wrong. He is wrong in his assumption that there are no wrong readings, and the fact (yes, fact) that he is wrong demonstrates that some readings can be wrong. In particular, he mistakes the word 'challenge' to mean 'deny', and the word 'authority' to mean 'legitimacy'. This is not simply our reading of what we took him to mean (which could, by our own argument, be mistaken). It is his reading and his writing, there on the page in black and white. And this misreading, this mistake, inevitably leads him to a wrong conclusion. Having clarified the small matter that, in deconstruction, anything does not go, and that deconstructionists are not constrained to accept everything that is written about them, we then attempt to point out some other mistakes in Griffiths' non-review. Most importantly, we reject Griffiths' accusation that postmodernism is a strategy to 'save us from thinking' and instead, with Lyotard, advocate it as an attempt 'to save the honour of thinking'.     

Dysferlin-mediated membrane repair protects the heart from stress-induced left ventricular injury

Dilated cardiomyopathy is a life-threatening syndrome that can arise from a myriad of causes, but predisposition toward this malady is inherited in many cases. A number of inherited forms of dilated cardiomyopathy arise from mutations in genes that encode proteins involved in linking the cytoskeleton to the extracellular matrix, and disruption of this link renders the cell membrane more susceptible to injury. Membrane repair is an important cellular mechanism that animal cells have developed to survive membrane disruption. We have previously shown that dysferlin deficiency leads to defective membrane resealing in skeletal muscle and muscle necrosis; however, the function of dysferlin in the heart remains to be determined. Here, we demonstrate that dysferlin is also involved in cardiomyocyte membrane repair and that dysferlin deficiency leads to cardiomyopathy. In particular, stress exercise disturbs left ventricular function in dysferlin-null mice and increases Evans blue dye uptake in dysferlin-deficient cardiomyocytes. Furthermore, a combined deficiency of dystrophin and dysferlin leads to early onset cardiomyopathy. Our results suggest that dysferlin-mediated membrane repair is important for maintaining membrane integrity of cardiomyocytes, particularly under conditions of mechanical stress. Thus, our study establishes what we believe is a novel mechanism underlying the cardiomyopathy that results from a defective membrane repair in the absence of dysferlin.     

In whose interests? The best interests principle under ethical scrutiny

This paper critically examines the best interests principle and its role in making decisions about intensive care treatment. In current practice the best interests principle is sometimes relied upon to guide decision making in circumstances when the patient is incompetent, although it is intrinsically linked to inconsistent assumptions about what is meant by quality of life. This situation means that there is potential that moral errors will be made that may result in an unwanted extension of life for some individuals or the premature death of others.

It is difficult to justify such decision making on ethical grounds. A greater understanding of the best interests principle, and consequently the concept of quality of life, is needed in order to ensure that decision making about intensive care is ethically defensible. It is argued that an ideal theory of quality of life provides an appropriate framework for best interests decisions, and that the decision making process ought to, whenever possible, involve the patient's close family.     

Adaptive designs, informed consent, and the ethics of research

The ethical tension in research design is often characterized as that between individual and collective ethics. While adaptive clinical trials (ACTs) are generally considered to be more sensitive to individual ethics, the concomitant loss of statistical power associated with them is often used to justify randomized clinical trials (RCTs). This paper challenges this characterization of the central ethical problem in research design. It argues that the key consideration in clinical research hinges on the process of informed consent. When the research context is such that the subject is able to provide informed consent, RCTs can be justified and may be required. However, in desperate medical situations the process of informed consent is often undermined. It is argued that in such situations ACTs are ethically required. We introduce "the principle of interchangeability" and argue that it must be satisfied if research in desperate medical situations is to be justified.     

Insulin resistance, hyperinsulinemia, hypertriglyceridemia, and hypertension. Parallels between human disease and rodent models

There is considerable evidence that abnormalities of glucose, insulin, and lipoprotein metabolism occur more frequently in untreated hypertensive patients than in normotensive control subjects. More recently, it has also become apparent that similar metabolic abnormalities occur in rodent models of hypertension. One purpose of this article is to review the experimental data that have led to the above generalizations. The second goal is to address the significance of these findings, which is certainly not clear. For example, it could be argued that the relationship between high blood pressure and the associated metabolic defects is incidental. On the other hand, there is evidence that the changes in glucose, insulin, and lipoprotein metabolism may play a role in the etiology and/or clinical course of patients with high blood pressure. Although it is impossible at this point to definitively choose between these possibilities, an effort is made to marshal the evidence in support of the latter alternative.     

Alcoholism and other drug dependencies

The disease of addiction is upon us and it is obvious that the elderly are not immune. There is every reason to believe from early reports that the elderly respond favorably to treatment, perhaps more so than their younger counterparts. It is believed that treating chemical dependency as a primary disease rather than as a symptom of something else has been a great boon in terms of improving recovery rates. Furthermore, group therapy is the main component of treatment in rehabilitation, as it affords the greatest opportunity to shift the dependence on chemical to a dependence on human beings. The physician is in a key position to help the elderly, because so many elderly need and use medical care. Intervention is highly recommended if the doctor is knowledgeable and skilled in this area and is willing to kindly confront the patient with a somewhat undesirable diagnosis. Rehabilitation regimens are becoming more plentiful throughout the country. If services are unavailable, however, there is always AA to fall back on or to recommend initially. Remember, fully one third of all AA members are older than 50 and that it is a source of acceptance, support, and an opportunity to depend on human beings instead of psychoactive chemicals. Remember too that few patients with addiction recover by themselves. It is worth remembering that this is an incurable disease in that once addicted, it is unlikely that anyone can ever use socially psychoactive chemical substances again. Use of psychoactive chemicals is fraught with danger for the physician and the patient and indeed may place the physician at risk for malpractice. There is great satisfaction to be gained from helping those afflicted with alcoholism and other drug dependencies. The gratitude displayed by those receiving help for this affliction is truly remarkable and one that will leave the clinician with a sense of "a job well done."     

Interprofessional education for the quality use of medicines: Designing authentic multimedia learning resources

It is claimed that health care students who learn together will be better prepared for contemporary practice and more able to work collaboratively and communicate effectively. In Australia, although recognised as important for preparing nursing, pharmacy and medical students for their roles in the medication team, interprofessional education is seldom used for teaching medication safety. This is despite evidence indicating that inadequate communication between health care professionals is the primary issue in the majority of medication errors. It is suggested that the pragmatic constraints inherent in university timetables, curricula and contexts limit opportunities for health professional students to learn collaboratively. Thus, there is a need for innovative approaches that will allow nursing, medical and pharmacy students to learn about and from other disciplines even when they do not have the opportunity to learn with them. This paper describes the development of authentic multimedia resources that allow for participative, interactive and engaging learning experiences based upon sound pedagogical principles. These resources provide opportunities for students to critically examine clinical scenarios where medication safety is, or has the potential to be compromised and to develop skills in interprofessional communication that will prepare them to manage these types of situations in clinical practice.     

A pain neuromatrix approach to patients with chronic pain

This paper presents an approach to rehabilitation of pain patients. The fundamental principles of the approach are (i) pain is an output of the brain that is produced whenever the brain concludes that body tissue is in danger and action is required, and (ii) pain is a multisystem output that is produced when an individual-specific cortical pain neuromatrix is activated. When pain becomes chronic, the efficacy of the pain neuromatrix is strengthened via nociceptive and non-nociceptive mechanisms, which means that less input, both nociceptive and non-nociceptive, is required to produce pain. The clinical approach focuses on decreasing all inputs that imply that body tissue is in danger and then on activating components of the pain neuromatrix without activating its output. Rehabilitation progresses to increase exposure to threatening input across sensory and non-sensory domains.     

The recruitment crisis in nursing: placing Irish psychiatric nursing in context--a review

There is a decline in recruitment to pre-registration programmes in psychiatric nursing in Ireland. This article discusses factors that may relate to the Irish situation in the context of relevant international literature on nurse recruitment. It is noted that disciplines and courses in Ireland, such as social care, that engage in similar work to that of psychiatric nurses do not suffer from such a shortage of applicants. Whilst it is difficult to account for this difference, a number of factors identified from the literature are discussed. The need to highlight differences with general nursing and the importance of career guidance are seen as important in overcoming prejudices and stereotypes. From a review of the literature it appears that studies dedicated to recruitment to psychiatric nursing alone are notable by their paucity, and absent in the case of Ireland. Therefore, the available literature fails to fully explain the fall in psychiatric nurse recruitment compared to the robust recruitment position of social care. It is argued that dedicated research on recruitment to psychiatric nursing within an Irish setting is needed if a sustainable recruitment policy is to be implemented to reverse the long-term decline in recruitment.     

THE EFFECT OF DIGESTIVE JUICES ON THE POTENCY OF BOTULINUS TOXIN

Botulinus toxin resists a degree of acidity equivalent to that of the stomach even when exposed thereto for 24 hours at 37°C. It is less resistant to alkali, however, as shown by the fact that in a medium of weakly alkaline reaction its potency is reduced to less than one-tenth in 24 hours. It is unaffected by peptic and tryptic digestion. Because of its instability in mildly alkaline solutions and resistance to acid, there is reason to believe that the toxin is in the main absorbed from the upper portion of the digestive tract; that is to say, from the stomach and upper duodenum.     

Nephrotoxic serum nephritis in rats. I. Distribution and specificity of the antigen responsible for the production of nephrotoxic antibodies

Studies have been carried out to determine the distribution of antigen capable of inducing the formation in rabbits of antibodies nephrotoxic for the rat. The results indicate that the antigen is present both in cortex and medulla of rat kidney. It can be extracted to a limited extent with saline. It is non-dialyzable and destroyed by boiling. The nephrotoxic serum antigen is also present in rat lung and placenta, in amounts roughly comparable to that in kidney, and in a number of other rat organs in smaller amounts. These various tissues not only are capable of stimulating the production of nephrotoxic antibodies, but each tissue is also able to absorb the nephrotoxic antibodies induced by injections of other rat tissues. These studies indicate that the nephrotoxic serum antigen in various rat tissues is the same or closely related. The nephrotoxic serum antigen of the rat is distinct from that of the dog and the rabbit, but there appears to be a cross-reaction between the nephrotoxic serum antigens of the rat and mouse. It is concluded that the nephrotoxic serum antigen is not a specific component of kidney; it is neither limited to kidney in its distribution within the rat, nor is the rat antigen present in kidney tissue of 2 other species examined. Rather, it is probable that the antigen is to a large extent specific for tissue of a given species. The preponderance of renal injury following injections of the anti-organ sera presumably is due to the occurrence in the kidney of large amounts of the antigen in positions of physiological importance in which it is exposed directly to the circulating antibodies.     

Lactate and shock state: the metabolic view

PURPOSE OF REVIEW: The conventional view in severe sepsis or septic shock is that most of the lactate that accumulates in the circulation is due to cellular hypoxia and the onset of anaerobic glycolysis. A number of papers have suggested that lactate formation during sepsis is not due to hypoxia. I discuss this hypothesis and outline the recent advances in the understanding of lactate metabolism in shock. RECENT FINDINGS: Numerous experimental data have demonstrated that stimulation of aerobic glycolysis - that is, glycolysis not attributable to oxygen deficiency - and glycogenolysis occurs not only in resting, well-oxygenated skeletal muscles but also during experimental haemorrhagic shock and experimental sepsis, and is closely linked to stimulation of sarcolemmal Na+/K+ -ATPase under epinephrine stimulation. A human study of hyperkinetic septic shock demonstrated that skeletal muscle is a leading source of lactate production by exaggerated aerobic glycolysis through Na+/K+ -ATPase stimulation. SUMMARY: There is increasing evidence that sepsis is accompanied by a hypermetabolic state, with enhanced glycolysis and hyperlactataemia. This should not be rigorously interpreted as an indication of hypoxia. It now appears, at least in the hyperkinetic state, that increased lactate production and concentration as a result of hypoxia are often the exception rather than the rule.