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Moral reasoning in social context.

Scholarly thinking about morality has been deeply affected by the confrontation with practical moral problems epitomized by bioethics. Attention to social context is increasingly seen as vital to sound moral reasoning. The dominant model in bioethics assumes that moral reasoning proceeds downward, from fundamental principles to specific cases. This top-down model, deductivism, is flawed both as a description of moral reasoning, and as a prescription for how moral reasoning should be done. In recent years, another model known as casuistry and based on case-centered moral reasoning has emerged to challenge deductivism. Casuistry suggests new lines of empirical and conceptual research into the history of moral disputes and the practice of moral reasoning and debate.

Advisory Committees↗

Development and psychometric evaluation of the Professional Practice Environment (PPE) scale.

PURPOSE: To describe the Professional Practice Environment (PPE) scale, its conceptual development and psychometric evaluation, and its uses in measuring eight characteristics of the professional practice environment in an acute care setting. DESIGN AND METHODS: The 38-item PPE Scale was validated on a sample of 849 professional practice staff at the Massachusetts General Hospital in Boston. Psychometric analysis included: item analysis, principal components analysis (PCA) with varimax rotation and Kaiser normalization, and internal consistency reliability using Cronbach's alpha coefficient. FINDINGS: Eight components were shown, confirming the original conceptually derived model's structure and accounting for 61% of explained variance. Cronbach's alpha coefficients for the eight PPE subscales ranged from .78 to .88. CONCLUSIONS: Findings showed the 38-item PPE Scale was reliable and valid for use in health outcomes research to examine the professional practice environment of staff working in acute care settings.

Acute Disease↗

Psychiatric endophenotypes and the development of valid animal models.

Endophenotypes are quantifiable components in the genes-to-behaviors pathways, distinct from psychiatric symptoms, which make genetic and biological studies of etiologies for disease categories more manageable. The endophenotype concept has emerged as a strategic tool in neuropsychiatric research. This emergence is due to many factors, including the modest reproducibility of results from studies directed toward etiologies and appreciation for the complex relationships between genes and behavior. Disease heterogeneity is often guaranteed, rather than simplified, through the current diagnostic system; inherent benefits of endophenotypes include more specific disease concepts and process definitions. Endophenotypes can be neurophysiological, biochemical, endocrine, neuroanatomical, cognitive or neuropsychological. Heritability and stability (state independence) represent key components of any useful endophenotype. Importantly, they characterize an approach that reduces the complexity of symptoms and multifaceted behaviors, resulting in units of analysis that are more amenable to being modeled in animals. We discuss the benefits of more direct interpretation of clinical endophenotypes by basic behavioral scientists. With the advent of important findings regarding the genes that predispose to psychiatric illness, we are at an important crossroads where, without anthropomorphizing, animal models may provide homologous components of psychiatric illness, rather than simply equating to similar (loosely analogized) behaviors, validators of the efficacy of current medications or models of symptoms. We conclude that there exists a need for increased collaboration between clinicians and basic scientists, the result of which should be to improve diagnosis, classification and treatment on one end and to increase the construct relevance of model organisms on the other.

Animals↗

An evaluation of the breastfeeding support skills of midwives and voluntary breastfeeding supporters using the Breastfeeding Support Skills Tool (BeSST).

The promotion of breastfeeding has been established as a global public health issue. Despite this global agenda, breastfeeding initiation and duration rates remain low in many countries. The lack of provision of adequate support to the breastfeeding mother is an important contributory factor to shorter duration of breastfeeding. Health professionals and voluntary breastfeeding supporters are in a prime position to work collaboratively to provide comprehensive support to the breastfeeding mother. However, a comparative evaluation of the breastfeeding support skills of voluntary breastfeeding supporters and health professionals has never been conducted. This study aimed to assess the breastfeeding support skills of midwives and Breastfeeding Network (BfN) supporters. Breastfeeding support skills were assessed using a between-subjects design conducted with 15 midwives and 15 BfN supporters in the north-west of England. Support skills were measured using the prevalidated Breastfeeding Support Skills Tool (BeSST), a questionnaire and video tool. Total scores on the BeSST were significantly higher in the BfN group (mean = 42.5 +/- 6.4 SD) than in the midwife group (mean = 30.7 +/- 8.2 SD) [t (26.5) = 4.4, P < 0.0001]. The BfN group has the breastfeeding support skills necessary to provide adequate assistance for breastfeeding mothers. An interagency and interdisciplinary collaborative model is crucial to developing a coherent and cohesive approach to the support infrastructure for breastfeeding women.

Adult↗

Addressing the learning deficit in breastfeeding: strategies for change.

This paper summarizes the findings of the learning needs assessment described in this issue. Limitations and strengths are discussed. The paper describes a national, multi-sectoral, multidisciplinary picture. Our respondents may over-represent those with an interest in breastfeeding; if so, the true picture may be even more problematic than described here. Major deficits were identified in the knowledge and skills of practitioners from all backgrounds and all sectors. Many professionals report poor knowledge about breastfeeding and have low levels of confidence and clinical competence. Organizational constraints and barriers to effective education and practice include fragmentation of care and education, lack of facilities, and a low priority being given to breastfeeding. There is a range of current educational provision, although not all is fit for purpose. Voluntary organizations seem to have higher standards than do some current professional learning opportunities. Preferred methods of training include practical observation and mentorship, volunteer counsellor involvement in training programmes, as well as self-study and online opportunities. Recommendations include: a funded, mandatory, interagency and multidisciplinary approach; appropriate content; support at local and national levels; breastfeeding education to be included in clinical governance and audit mechanisms; and further research and evaluation to examine optimum ways of providing education and training. Organizational barriers could be addressed through a public health policy and evidence-based approach.

Breast Feeding↗

A proposal for a code of ethics for nurse practitioners.

PURPOSE: To review established codes for health care professionals and standards of practice for the nurse practitioner (NP) and to utilize these codes and standards, general ethical themes, and a new ethical triangle to propose an ethical code for NPs. DATA SOURCES: Reviews of three generally accepted ethical themes (deontological, teleological, and areteological), the ethical triangle by Potter, the American Academy of Nurse Practitioners (AANP) standards of practice for NPs, and codes of ethics from the American Nurses Association (ANA) and the American Medical Association (AMA). CONCLUSIONS: A proposal for a code of ethics for NPs is presented. This code was determined by basic ethical themes and established codes for nursing, formulated by the ANA, and for physicians, formulated by the AMA. The proposal was also developed in consideration of the AANP standards of practice for NPs. IMPLICATIONS FOR PRACTICE: The role of the NP is unique in its ethical demands. The authors believe that the expanded practice of NPs presents ethical concerns that are not addressed by the ANA code and yet are relevant to nursing and therefore different than the ethical concerns of physicians. This proposal attempts to broaden NPs' perspective of the role that ethics should hold in their professional lives.

American Nurses' Association↗

A multidisciplinary health care team's efforts to improve educational attainment in children with sickle-cell anemia and cerebral infarcts.

The primary objective of this study was to improve the educational success of children with sickle-cell disease (SCD) and cerebral infarcts. A prospective intervention trial was conducted; a multidisciplinary team was created to maximize educational resources for children with SCD and cerebral infarcts. Students were evaluated systematically before and after the intervention. A baseline evaluation was completed assessing the presence of an Individualized Education Plan (IEP), grade retention in school, and days absent from school in the year preceding the intervention. A postintervention assessment occurred 2 years later for these same measurements. At baseline, 74% (17 of 23) of the students were receiving IEPs. Two years later, 87% (20 of 23) students received IEPs (p = .34). Despite the intervention, the rate of children retained in their school grade increased from 0.6 per 100 years in school at baseline to 1.7 per 100 years, 95% CI (-3.86, 1.49). The school absenteeism rate did not significantly change after the intervention; the average days absent per student rose from 15.5 to 22.5, (p = .05). The multidisciplinary team effort alone was insufficient to decrease grade retention and absenteeism rate. Further support, from either the parents or school administration, is needed to increase education attainment of students with cerebral infarcts.

Adolescent↗