The politics of interprofessional working and the struggle for professional autonomy in nursing

This study of interprofessional work relations in a Canadian mental health team examines how nursing deployed different forms of power in order to alter the mental health division of labour, to gain administrative, organizational and content control over its own work, expand its jurisdictional boundaries by expropriating the work of other professionals, and exclude others from encroaching on its old and newly acquired jurisdictions. This is set against the context of nursing's long-standing professional project to consolidate and expand its professional jurisdiction. Using an ethnographic study of a single interprofessional mental health team in a psychiatric hospital in Canada, the paper attempts to understand the politics and paradoxes involved in realizing nursing's professional project and how the politics of professional autonomy and professional dominance are actually conducted through micro-political struggles. The data demonstrates the effects of the political struggles at the organizational and work process levels, particularly in the forms of collaboration that result. Nurses gained substantial autonomy from medical domination and secured practical dominion over the work of non-medical professionals. New forms of interprofessional collaboration were accomplished through both simultaneous and sequential micro-political struggles with psychiatrists and non-medical professionals, and the formation of political alliances and informal agreements. Nursing solidarity at the elite level and substantial effort by the elite nurses and their committed colleagues to mobilize their less enthused members were fundamental to their success. The nurses deployed political (power) strategies and tactics to organize and reorganize themselves and other professionals on multiple levels (politically, organizationally, ideologically, socially and culturally). This study reveals the complexity and robustness of micro-political dynamics in the constitution of professional and collaborative interprofessional work relations.     

Carnitine, valproate, and toxicity

Carnitine is an important nutrient that is present in the diet (particularly in meat and dairy products) and is synthesized from dietary amino acids. It functions to assist long-chain fatty acid metabolism and to regulate the ratio of free coenzyme A to acylcoenzyme A in the mitochondrion. Carnitine deficiency occurs in primary inborn errors of metabolism, in nutritional deficiency, and in various other disorders including antiepileptic drug therapy. Valproate therapy is often associated with decreased carnitine levels and occasionally with true carnitine deficiency. Some experimental and clinical evidence links valproate-induced carnitine deficiency with hepatotoxicity, but this evidence is limited and inconclusive. Carnitine supplementation has been useful in some studies, but these data are also limited. Young children with neurologic disabilities taking multiple antiepileptic drugs may have the greatest risk for carnitine deficiency. Measurement of carnitine levels appears warranted in these patients and in patients with symptoms and signs of possible carnitine deficiency.     

The Mother-Observer Relationship: An Examination of the Participant Role of the Observer in Mother-Infant Observation

SUMMARY. The relationship between mother and observer in mother-infant observation as described by Esther Bick is examined. Specifically, the question as to whether this relationship influences what is being observed is considered.
The author gives an account of her own relationship as an observer with a mother. The mother was an epileptic and fell with her baby (then six weeks old) causing the baby to suffer a broken skull. Exploration of events during the period of observation leads to the conclusion that the relationship between the mother and the observer was one of transference. Within this transference the observer seemed to be the mother of the one observed. This together with the effects on the observed mother's unconscious conflict with her own mother due to epilepsy is described.
Given transference in the mother-observer relationship doubts are raised as to the tenability of the attitude of distance and non-interference prescribed for the observer. The conclusion is drawn that, in any case, the role of the observer is a participant role, which poses the epistemological problem of the interference of the observer with the observed.     

Ventilatory criteria for aeromedical evacuation

Ventilatory requirements during simulated aeromedical transportation were investigated in normal dogs and animals with oleic acid-induced lung injury. Inspired oxygen fractions of 0.21 and 1.0 were used to ventilate the normal and injured dogs, respectively. Both groups were ventilated with a constant-volume piston ventilator. After a control period, animals were exposed to a simulated altitude of 8,000 ft (barometric pressure 564 mm Hg), followed by a second control period at ground level. Both groups of animals had no change in carbon dioxide production, arterial PCO2 or ventilation during exposure to reduced barometric pressure. Systemic blood pressure, heart rate, cardiac output, and lung volume were all lower in oleic acid-injured animals than controls; the alveolar-arterial oxygen difference was larger in the oleic acid group. With altitude exposure, arterial and mixed venous oxygen tensions were decreased in both groups. Adequate gas exchange can be maintained during exposure to altitude even in animals with abnormal function provided that ventilation is constant and the inspired oxygen fraction is increased to compensate for the reduced barometric pressure.     

Quality of life in patients undergoing inguinal hernia repair.

Inguinal hernia repair is one of the most common surgical procedures undertaken in the NHS. Despite this, no previous work has examined quality of life in this patient group. This study examines quality of life preoperatively and at 3 and 6 months postoperatively in 140 patients undergoing inguinal hernia repair in the context of a randomised controlled trial of laparoscopic versus open hernia repair. Surgery was undertaken on a day case basis, and quality of life was assessed using the Short Form 36 (SF36). In the initial phase of the study, 57% of those screened for suitability met the study inclusion criteria and were randomised. No significant differences were found between laparoscopic and open hernia repair in terms of quality of life at 3 and 6 months postoperatively. No difference was found between 3 and 6 month scores, suggesting that patients had already made a good recovery by 3 months. A significant improvement was found between preoperative and postoperative scores, with the greatest change arising on dimensions assessing pain, physical function, and role limitation owing to physical restriction. After standardising for age, sex, and social class, a comparison of the hernia patients to population norms for the SF36 was consistent with improvement from preoperative to postoperative assessment. This study has demonstrated the improvement in quality of life in patients undergoing elective inguinal hernia repair by experienced surgeons on a day case basis. It has also demonstrated the feasibility of assessing quality of life using generic measures in this patient group. Further work in this area is required. Ultimately, the priority given to elective inguinal hernia repair will depend on how the demonstrated benefits compare with those derived from other elective surgical procedures.