The primary purpose of this study is to identify differences in at­tainment of learning outcomes for ethics courses delivered using two distinct teaching approaches. The first approach uses a case based method in the context of applied moral issues within medical practice. The second approach surveys moral theories in the context of applied moral issues. Significant differences are found in the attainment of learner outcomes between the two groups. In particular, attainment of outcomes related to moral (...) decision-making is higher in those students who take the course with a case based method. In contrast, attainment of outcomes related to personal beliefs about applied moral issues is higher in those students who take an introductory ethics course surveying moral theories in the context of applied issues. Neither of these results is especially surprising. What may be surprising, however, is that students in the case-based course do not appear attain learner outcomes with regard to applied moral issues despite studying those issues in detail. Finally, the assessment tool developed and refined through this study may be of use for assessment in a variety of ethics courses. (shrink)

Motor training to improve walking and balance function is a common aspect of rehabilitation following motor-incomplete spinal cord injury. Evidence suggests that moderate- to high-intensity exercise facilitates neuroplastic mechanisms that support motor skill acquisition and learning. Furthermore, enhancing corticospinal drive via transcranial direct current stimulation may augment the effects of motor training. In this pilot study, we investigated whether a brief moderate-intensity locomotor-related motor skill training circuit, with and without tDCS, improved walking and balance outcomes in persons with MISCI. (...) In addition, we examined potential differences between within-day and between-day effects of MST. Twenty-six adults with chronic MISCI, who had some walking ability, were enrolled in a 5-day double-blind, randomized study with a 3-day intervention period. Participants were assigned to an intensive locomotor MST circuit and concurrent application of either sham tDCS or active tDCS. The primary outcome was overground walking speed measured during the 10-meter walk test. Secondary outcomes included spatiotemporal gait characteristics, peak trailing limb angle, intralimb coordination, the Berg Balance Scale, and the Falls Efficacy Scale-International questionnaire. Analyses revealed a significant effect of the MST circuit, with improvements in walking speed, cadence, bilateral stride length, stronger limb TLA, weaker limb ACC, BBS, and FES-I observed in both the MST+tDCSsham and MST+tDCS groups. No differences in outcomes were observed between groups. Between-day change accounted for a greater percentage of the overall change in walking outcomes. In persons with MISCI, brief intensive MST involving a circuit of ballistic, cyclic locomotor-related skill activities improved walking outcomes, and selected strength and balance outcomes; however, concurrent application of tDCS did not further enhance the effects of MST.Clinical Trial Registration[ClinicalTrials.gov], identifier [NCT03237234]. (shrink)

OBJECTIVE: How outside factors affect physician decision making remains an open question of vital importance. We sought to investigate the importance of various influences on physician decision making when clinical guidelines differ from patient preference. -/- METHODS: An online survey asking 469 primary care providers (PCPs) across four practice sites whether they would order magnetic resonance imaging for a patient with uncomplicated back pain. Participants were randomized to one of four scenarios: a patient's preference for imaging (control), a patient's (...) preference plus a colleague's opinion against imaging (colleague), a patient's preference plus a professional society's recommendation against imaging (profession), or a patient's preference plus an accountable care organization's quality metric that measures physician use of imaging (ACO). Demographic information and the reasoning behind participants' decisions also were obtained. -/- RESULTS: A total of 168 PCPs completed the survey, yielding a 36% completion rate. A majority chose not to pursue imaging: control 68%, colleague 85%, profession 87%, and ACO 78%. Multivariate logistic regression revealed that participants were more likely not to order advanced imaging only when reminded of a professional society recommendation (P = 0.017). Regression also suggested that practice site exerted an effect on the primary outcome. Evidence-based medicine and clinical judgment were the most cited reasons for the decision. -/- CONCLUSIONS: Our results reinforce the potential to leverage professional societies to advance evidence-based medicine and reduce unnecessary testing. At the same time, practice site appeared to exert influence, suggesting that these recommendations must be part of local institutional culture to be effective. (shrink)

A formal, logical, theory of events is developed and used as the basis for a definition of causation and to provide a pragmatics for causal counterfactuals. The theory begins with with a logical formalization of events as represented in the planner strips. The resulting inertial theories include a common sense law of inertia and their pragmatics is based on the principle of chronological minimization. The theory of events is then developed by removing some of the simplifying assumptions of the strips (...) representation. To begin with the assumption that events always succeed, given that their preconditions are true when they occur, is dropped. Instead a common sense law of change is introduced with the effect that events normally succeed but may fail if some qualification (some unusual or unexpected condition) arises. The pragmatics of the resulting causal theories is provided by refining the pragmatics of inertial theories. In particular, where there is a conflict between change and inertia, preference is given to change. The resulting defeasibility of events makes it possible to remove the strips assumption that only one event occurs at any given time; as conflicting events now result in failure rather than inconsistency. However it is desirable to provide a means for adjudicating between conflicting events. Consequently the theory is extended so that qualification preferences can be specified and the pragmatics are refined accordingly. A further strips assumption is that the effects of an event are invariant. In order to remove this assumption a distinction is drawn between primary events, events of the kind described above, and secondary events. Secondary events are invoked by primary events in appropriate contexts, they are causally dependent on primary events and when successful produce the additional, variant, effects of the primary events which invoke them. As a result, both the context-dependent effects of events (their ramifications) and non-deterministic events (events whose outcome is uncertain) can be represented. The theory of primary and secondary events is then used as the basis for a definition of causation which can be seen as providing a formal account of Mackie's definition of a cause as an inus condition. A major theme of this paper is the conflict between the opposite but complementary principles of change and inertia. For much of the paper the emphasis is on restricting the effects of inertia and favouring change. The resulting imbalance becomes unnatural when considering the combined effects of several events. However the definition of causation makes it possible to state a law of change and inertia, which is used to regulate change and inertia and thus ensure a proper balance between them: while caused change is preferred to inertia, inertia is preferred to uncaused change. The theory is then used to provide a pragmatics for causal counterfactuals, thereby extending the representation of actual causal reasoning to counterfactual causal reasoning. This is illustrated by the use of causal counterfactuals in order to obtain explanations. (shrink)

In 1992, Israel underwent a major constitutional reform, which provided Israel, for the first time in its history, with an effective system of separation of powers between the political branches of government. This reform was not intentional but, rather, a byproduct of the voluntary adoption by the two major political parties of open primaries as the method for choosing candidates on their lists for election to parliament. The adoption of the primaries system produced two major changes in the Israeli constitutional (...) and political order. First, it transformed the Knesset into an independent body and, hence, for the first time in Israel’s history, provided for a functioning system of checks and balances between the legislature and the executive. Second, it shifted power from the Jewish religious minority to the secular majority and even contributed to the increase in the relative power of the Arab parties. On a more general level, the Article demonstrates the impact different modalities of pre-selection of party candidates can have not only on the outcome of the elections and on the relative power relations among the parties, but, more importantly, on the structure and the functioning of the political system. Once proven, this impact requires public attention: legislative regulation of the pre-selection process may be required, indeed even constitutionally mandated, to ensure political checks and balances. (shrink)

I discuss a learning outcome of the Western Carolina University, Department of Philosophy and Religion, which focuses on a student’s development and pursuit of a meaningful, thriving, well-lived life, as a corrective to the poverty of existential reflection in the academy. We achieve this Socratic goal via a targeted series of assignments throughout the student’s education, a required pro-seminar on the topic of human flourishing, and other elective courses. The self-reflective, narrative assignments are designed to help students develop their own (...) tentative position on a flourishing life, consider whether and how they are pursuing that vision, and articulate meaningful ways to integrate potential vocations with a fulfilling existence. Students are introduced to these questions in introductory classes; take a pro-seminar analyzing various positions on ‘the good life’ drawn from numerous philosophical, religious, and literary texts, with a research paper assignment critically evaluating one position of their choice ; and, in their final year, revisit their earlier ‘meaning assignments,’ examining retrospectively their academic career and personal development, and prospectively their postbaccalaureate life and career. I conclude with some suggestions for programs keen to incorporate a similar outcome into their own curriculum. (shrink)

The goal of this paper is to review and describe the characteristics and outcomes of ethics consultations on a gastrointestinal oncology service and to identify areas for systems improvement and staff education. This is a retrospective case series derived from a prospectively-maintained database of the ethics consultation service at Memorial Sloan Kettering Cancer Center. The study analyzed all ethics consultations requested for patients on the gastrointestinal medical oncology service from September 2007 to January 2016. A total of 64 patients (...) were identified. The most common primary ethical issue was the DNR order, followed by medical futility. The most common contextual issues were dispute/conflict between staff and family, dispute/conflict intra-family, and cultural/ethnic/religious issues. The majority of ethical issues leading to consultation were resolved ; i.e., the patient, surrogate, and/or healthcare team followed the recommendation of the ethics consultant. 22% had a DNR order prior to the ethics consult and 69% had a DNR order after the consult. In this population of patients on a gastrointestinal oncology service, ethics consultations are most often called regarding patients with advanced cancers and the most common ethical conflicts arose between families and the health care team over goals of care at the end of life, specifically related to the DNR order and perceived futility of continued/escalation of treatment. Ethics consultations assisted with conflict resolution. Conflicts might be reduced with improved communication about prognosis and earlier end of life care planning. (shrink)

A non-inferiority design accepts the possibility of some efficacy loss, as part of a “successful”, statistically significant result. That loss may be excessive when the non-inferiority threshold is lenient. However, even stringent significance thresholds and safety monitoring may fail to adequately protect study participants when the primary outcome is death. The OPTIMAAL trial, a large randomized clinical trial performed in high-risk patients, is discussed as an example, using the Belmont Report principles as an ethical frame of reference. OPTIMAAL compared (...) losartan, a new drug, to captopril, a drug known to reduce the risk of death in patients with heart failure after a myocardial infarction. Serious ethical challenges occurred in that study. Firstly, subjects had to tolerate captopril to participate, meaning that participation implied the possibility of higher risk of death if randomized to the losartan arm, as compared to the standard of care. Additionally, the stopping rules had to ensure enough powe... (shrink)

Total knee arthroplasty (TKA) is a commonly implemented elective surgical treatment for end-stage osteoarthritis of the knee, demonstrating high success rates when assessed by objective medical outcomes. However, a considerable proportion of TKA patients report significant dissatisfaction postoperatively, related to enduring pain, functional limitations, and diminished quality of life. In this conceptual analysis, we highlight the importance of assessing patient-centred outcomes routinely in clinical practice, as these measures provide important information regarding whether surgery and postoperative rehabilitation interventions have (...) effectively remediated patients’ real-world “quality of life” experiences. We propose a novel precision medicine approach to improving patient-centred TKA outcomes through the development of a multivariate machine-learning model. The primary aim of this model is to predict individual postoperative recovery trajectories. Uniquely, this model will be developed using an interdisciplinary methodology involving non-linear analysis of the unique contributions of a range of preoperative risk and resilience factors to patient-centred TKA outcomes. Of particular importance to the model’s predictive power is the inclusion of a comprehensive assessment of modifiable psychological risk and resilience factors that have demonstrated relationships with TKA and other conditions in some studies. Despite the potential for patient psychological factors to limit recovery, they are typically not routinely assessed preoperatively in this patient group, and thus can be overlooked in rehabilitative referral and intervention decision-making. This represents a research-to-practice gap that may contribute to adverse patient-centred outcomes. Incorporating psychological risk and resilience factors into a multivariate prediction model could improve the detection of patients at risk of sub-optimal outcomes following TKA. This could provide surgeons and rehabilitation providers with a simplified tool to inform postoperative referral and intervention decision-making related to a range of interdisciplinary domains outside their usual purview. The proposed approach could facilitate the development and provision of more targeted rehabilitative interventions on the basis of identified individual needs. The roles of several modifiable psychological risk and resilience factors in recovery are summarised, and intervention options are briefly presented. While focusing on rehabilitation following TKA, we advocate for the broader utilisation of multivariate prediction models to inform individually-tailored interventions targeting a range of health conditions. (shrink)

BackgroundClinical ethics consultations can be complex interventions, involving multiple methods, stakeholders, and competing ethical values. Despite longstanding calls for rigorous evaluation in the field, progress has been limited. The Medical Research Council proposed guidelines for evaluating the effectiveness of complex interventions. The evaluation of CEC may benefit from application of the MRC framework to advance the transparency and methodological rigor of this field. A first step is to understand the outcomes measured in evaluations of CEC in healthcare settings. ObjectiveThe (...) primary objective of this review was to identify and map the outcomes reported in primary studies of CEC. The secondary objective was to provide a comprehensive overview of CEC structures, processes, and roles to enhance understanding and to inform standardization.MethodsWe searched electronic databases to identify primary studies of CEC involving patients, substitute decision-makers and/or family members, clinicians, healthcare staff and leaders. Outcomes were mapped across five conceptual domains as identified a priori based on our clinical ethics experience and preliminary literature searches and revised based on our emerging interpretation of the data. These domains included personal factors, process factors, clinical factors, quality, and resource factors. ResultsForty-eight studies were included in the review. Studies were highly heterogeneous and varied considerably regarding format and process of ethical intervention, credentials of interventionist, population of study, outcomes reported, and measures employed. In addition, few studies used validated measurement tools. The top three outcome domains that studies reported on were quality, process factors, and clinical factors. The majority of studies examined multiple outcome domains. All five outcome domains were multidimensional and included a variety of subthemes.ConclusionsThis scoping review represents the initial phase of mapping the outcomes reported in primary studies of CEC and identifying gaps in the evidence. The confirmed lack of standardization represents a hindrance to the provision of high quality intervention and CEC scientific progress. Insights gained can inform the development of a core outcome set to standardize outcome measures in CEC evaluation research and enable scientifically rigorous efficacy trials of CEC. (shrink)

Most studies are inclined to report positive rather than negative or inconclusive results. It is currently unknown how clinicians appraise the results of a randomized clinical trial. For example, how does the study funding source influence the appraisal of an RCT, and do positive findings influence perceived credibility and clinical relevance? This study investigates whether psychiatrists’ appraisal of a scientific abstract is influenced by industry funding disclosures and a positive outcome. Dutch psychiatrists were randomized to evaluate a scientific abstract describing (...) a fictitious RCT for a novel antipsychotic drug. Four different abstracts were created reporting either absence or presence of industry funding disclosure as well as a positive or a negative outcome. Primary outcomes were the perceived credibility and clinical relevance of the study results. Secondary outcomes were the assessment of methodological quality and interest in reading the full article. Three hundred ninety-five psychiatrists completed the survey. Industry funding disclosure was found not to influence perceived credibility nor interpretation of its clinical relevance. A negative outcome was perceived as more credible than a positive outcome 0.43 to 1.18, p?), but did not affect clinical relevance scores. In this study, industry funding disclosure was not associated with the perceived credibility nor judgement of clinical relevance of a fictional RCT by psychiatrists. Positive study outcomes were found to be less credible compared to negative outcomes, but industry funding had no significant effects. Psychiatrists may underestimate the influence of funding sources on research results. The fact that physicians indicated negative outcomes to be more credible may point to more awareness of existing publication bias in the scientific literature. (shrink)

Demands for public participation in technical decision-making are currently high on the agenda of Science & Technology Studies. It is assumed that the democratisation of technical decision-making processes generally leads to more socially desirable and acceptable outcomes. While this may be true in certain cases, this assumption cannot be generalised. I will discuss the case of the so-called ‘South African AZT debate’. The controversy started when President Thabo Mbeki, after reading some scientific papers on the toxicity of AZT, decided (...) to bar the use of the drug in the public health sector as a means to reduce the transmission of HIV from mothers to children. While the scientific mainstream accepts the effectiveness of AZT in reducing the risk of vertical HIV transmission, a few maverick scientists reject the clinical evidence and argue that the risks of using AZT by far outweigh its benefits. Based on various textual sources and using the ‘Periodic Table of Expertises’ developed by Collins and Evans, Mbeki’s expertise at the time of his intervention into the technical question whether AZT is a medicine or a poison can be classified as primary source knowledge. It is shown that this type of expertise is insufficient for technical decision-making. Mbeki’s primary source knowledge legitimated his presentation of the claims of maverick scientists as a serious contribution to the debate—with tragic consequences for tens of thousands of babies.Keywords: Primary source knowledge; Expertise; Technical decision-making; South Africa; AZT; AIDS. (shrink)

SummaryNone of the above should be viewed as a defence of the particular version of OOE currently popular. I have not advanced any proposals concerning what particular ends might be of such importance that they legitimately override her prima facie right to control the contents of her mind. I have suggested that an internal tension exists within CCE as sketched by Forster but even ‘empowerment’ was not assumed by me to successfully meet the onus; my point was merely that it (...) was to be more plausibly construed as an argument for a compulsory, outcome‐driven, rather than for a free, interest‐driven, curriculum. Whether it is right for Janey to be overruled or not is a matter for continuing discussion, a discussion that OOE challenges us to have. It is, however, a prospective dialogue that is pre‐empted by any assumption that, just because CCE is prevalent in primary schools, the task is to protect it from OOE's predatory threat. For all that Forster has provided argument to the contrary, OOE may be a reform; the enemy might not be ‘a narrow vision of the national good’ but a narrow conception of Janey's good; perhaps there are things more important about portions of learning than that Janey finds them to have ‘personal significance’. (shrink)

Psychopathy is typically seen as a trait that is undesirable in any context, including the workplace. But several authors have suggested that people high in psychopathy might possess resources that preserve their ability to perform well in stressful contexts. We consider the possibility that primary psychopathy is adaptive—for the employee, if not for the organization—under conditions of abusive supervision. In particular, we draw from the multimotive model of interpersonal threat and the theory of purposeful work behavior to argue that (...) high primary psychopathy individuals possess characteristics that enable them to experience higher levels of well-being and lower levels of anger than their peers under abusive supervisors. Based on a scenario study and a time-lagged field study, we found support for a model in which abusive supervision moderates the relationships between primary psychopathy and positive work-related outcomes, such that these relationships are positive under conditions of abusive supervision and either diminished or negative under conditions of low abusive supervision. Abusive supervision also affected the relationship between primary psychopathy and anger in the field study such that high primary psychopathy individuals were less angry under more abusive supervisors. Thus, there appears to be some credence to the notion of a “psychopathic advantage” in that primary psychopaths do have access to greater psychological resources than their peers under abusive supervision. However, these findings also suggest that abusive supervisors may empower employees with characteristics that hold strong potential to damage the organization and its stakeholders. (shrink)

BackgroundPublication and outcome reporting bias is often caused by researchers selectively choosing which scientific results and outcomes to publish. This behaviour is ethically significant as it distorts the literature used for future scientific or clinical decision-making. This study investigates the practicalities of using ethics applications submitted to a UK National Health Service research ethics committee to monitor both types of reporting bias.MethodsAs part of an internal audit we accessed research ethics database records for studies submitting an end of study (...) declaration to the Hampshire A research ethics committee between 1st January 2010 and 31st December 2011. A literature search was used to establish the publication status of studies. Primary and secondary outcomes stated in application forms were compared with outcomes reported in publications.ResultsOut of 116 studies the literature search identified 57 publications for 37 studies giving a publication rate of 32 %. Original Research Ethics Committee applications could be obtained for 28 of the published studies. Outcome inconsistencies were found in 16 of the published studies.ConclusionsThis study showed that the problem of publication and outcome reporting bias is still significant in the UK. The method described here demonstrates that UK NHS research ethics committees are in a good position to detect such bias due to their unique access to original research protocols. Data gathered in this way could be used by the Health Research Authority to encourage higher levels of transparency in UK research. (shrink)

Acts of civil disobedience and conscientious objection provide valuable indications of the congruence of political outcomes with citizens’ conceptions of justice and the good. As their primary concern is substantive, their logic seems extraneous to procedural approaches to justice. Accordingly, it has often been argued that these latter condemn citizens to a ‘deaf-and-blind’ acceptance of the outcomes of agreed procedures. A closer analysis of such acts of contestation shall reveal that although, for proceduralism, the outcomes of (...) just procedures cannot be contested as unjust, they may be contested on the ground of values other than justice, such as someone’s religious/ethical allegiances. Proceduralism about justice will be thus shown to be consistent with the commitment to realising certain outcome-oriented values. (shrink)

With agriculture the primary driver of biodiversity loss, farmers are increasingly expected to produce environmental outcomes and protect biodiversity. However, lack of attention to the way farmers perceive native vegetation has resulted in conservation targets not being met. The Yorke Peninsula (YP), South Australia, is an agricultural landscape where 50% farmers perceived that long-term planning was for ≤ 30 years, not enough time to promote ecosystem conservation; (5) a lack of natural resource management information for farmers—as a result, (...) farmers relied on their own experience to manage vegetation. Furthermore, most farmers depended on agronomists, who generally had no stake in biodiversity conservation. We recommend that (1) the Local Council restore social capital by liaising with farmers to promote roadside vegetation (2) long-term farmer-led conservation action be established and supported by Government and industry acting as facilitators rather than project managers; (3) a change in policy and training promote the involvement of agronomists in conservation and its management on private properties; (4) all levels of Government develop schemes to demonstrate the tangible benefits of native vegetation as habitat for wildlife; (5) on-farm conservation be celebrated as successful farming. (shrink)

Primary healthcare plays a fundamental role in advancing public health, and the evaluation of its effectiveness is crucial part for ongoing enhancement and evolution. The escalating prevalence of non-communicable diseases is placing significant burden on the healthcare resources of both developed and developing countries. The aim of this study is to evaluate the financial efficiency and quality of care provided through telemedicine in virtual clinics compared to traditional clinical visits for chronic patients attending Primary Healthcare Centers (PHCs) in (...) Makkah, Saudi Arabia. This research is using an analytical cross-sectional study design, and it included all adults registered in the HIS for 2023 with DM or HTN. The researcher compared in-person and virtual visit costs and some of the health outcomes. The study included 106,828 participants, with 392,441 visits to Primary Health Centers. The distribution was 52.12% male and 47.88% female, with 53.89% having DM and 46.11% HTN. Education level significantly influences visit preferences (p = 0.003), with higher educated participans evenly splitting between in-person and virtual visits, while those with no literacy favored in-person visits. Significant cost differences were observed between in-person and virtual visits (p <.001), with in-person visits incurring higher lab test counts and costs. In conclusion, our findings show that virtual visits and telehealth services have lower costs compared to the in-person consultations, with almost identical health outcomes for both groups. Which indicates that the virtual and in-person consultations have comparable quality. (shrink)

PurposeAlthough an increasing body of literature suggests a relationship between brain irradiation and deterioration of neurocognitive function, it remains as the standard therapeutic and prophylactic modality in patients with brain tumors. This review was aimed to abstract and evaluate the prediction models for radiation-induced neurocognitive decline in patients with primary or secondary brain tumors.MethodsMEDLINE was searched on October 31, 2021 for publications containing relevant truncation and MeSH terms related to “radiotherapy,” “brain,” “prediction model,” and “neurocognitive impairments.” Risk of bias (...) was assessed using the Prediction model Risk Of Bias ASsessment Tool.ResultsOf 3,580 studies reviewed, 23 prediction models were identified. Age, tumor location, education level, baseline neurocognitive score, and radiation dose to the hippocampus were the most common predictors in the models. The Hopkins verbal learning and the trail making tests were the most frequent outcome assessment tools. All studies used regression as machine learning method. All models were judged to have a high risk of bias mainly due to issues in the analysis.ConclusionExisting models have limited quality and are at high risk of bias. Following recommendations are outlined in this review to improve future models: developing cognitive assessment instruments taking into account the peculiar traits of the different brain tumors and radiation modalities; adherence to model development and validation guidelines; careful choice of candidate predictors according to the literature and domain expert consensus; and considering radiation dose to brain substructures as they can provide important information on specific neurocognitive impairments. (shrink)

The publication of Circular 14/93 'Initial Training of Primary School Teachers' sees yet another attempt to redefine and control the objectives, methods, outcomes and location of initial teacher education. It implies changes in the role of subject studies in initial teacher education, although its prescriptions in this regard are elusive. The interpretation and implications of these changes for subject studies are the focus of this paper. It reviews the current role of subject studies in primary initial teacher (...) education and outlines those elements of the Circular which will impact upon those roles. Inconsistencies in the Circular are identified. Critiques of the current role of subject studies are used to suggest how the generalised statements about levels of competence in the Circular can be expanded to redefine subject studies. The paper sets out the criteria subject studies will have to adopt to enact the expanded and more clearly defined roles required if they are to meet the objectives of the Circular. The paper specifically addresses the implications for subject studies courses of differentiated subject training for specialist and generalist primary school teachers. (shrink)

IntroductionThere is a paucity of clinical guidelines for the routine assessment of maladaptive reproductive grief reactions in outpatient primary care and OB-GYN settings in the United States. Because of the disenfranchised nature of perinatal grief reactions, many clinicians may be apt to miss or dismiss a grief reaction that was not identified in the perinatal period. A significant number of those experiencing a reproductive loss exhibit signs of anxiety, depression, or post-traumatic stress disorder. Reproductive losses are typically screened for (...) and recorded numerically as part of a woman’s well-visit intake, yet this process often fails to identify patients emotionally troubled by a prior pregnancy loss.Materials and MethodsA summative content analysis of 164 recent website blogs from female participants who self-reported having experienced a miscarriage or abortion in their lifetime was conducted. The narratives were reviewed for details regarding the time span between the pregnancy loss and the composition of the blog post. The stories were analyzed for subsequent relationship problems and detrimental mental health conditions. Maladaptive reactions were contrasted for those that indicated a greater than 12 months’ time-lapse and those who had not.ResultsMore than a third of the women reported in the narrative that at least one year or more had passed since experiencing the miscarriage or abortion. For those women, the median time span between the loss and composing the blog was 4 years with a range of 47 years. Mental health conditions attributed to the reproductive loss by those who reported longer bereavement times included subsequent relationship problems, substance misuse, depression, suicidal ideation, and PTSD. The percent of reported maladaptive issues was more than double for those who reported that a year or more had passed since the loss of the pregnancy.DiscussionGrief reactions following the loss of a pregnancy may be prolonged or delayed for several months which can contribute to adverse biopsychosocial outcomes. Recognition and treatment of maladaptive grief reactions following a pregnancy loss are critical. Screening methods should be enhanced for clinicians in medical office settings to help identify and expedite the appropriate mental health assistance. (shrink)

A growing body of research emphasises the role of ‘social determinants of health’ in generating inequalities in health outcomes. How, if at all, should primary care providers respond? In this paper, I want to shed light on this issue by focusing on the role that ‘big data’ might play in allowing primary care providers to respond to the social determinants that affect individual patients’ health. The general idea has been proposed and endorsed by the Institute of Medicine, (...) and the idea has been developed in more detail by Bazemore et al.. In Bazemore et al.’s proposal, patients’ addresses are used to generate information about the patients’ neighbourhood; this information is then included in patients’ health care records and made available to providers. This allows primary care providers to take this information into account when interacting with, and providing care to, patients. I explore three issues arising from this proposal. First, while questions of privacy have been central to discussions about big data, Bazemore et al.’s proposal also allows us to see that there might be costs to not making certain information available. Second, I consider some of the questions arising for primary care from the influence of social factors on health outcomes: given that we know these factors to be significant contributors to social inequalities in health, what precisely should be done about this in the primary care context? Finally, I address problems arising from the use of population level data when dealing with individuals. (shrink)

Following Shelly Kagan’s useful terminology, foundational consequentialists are those who hold that the ranking of outcomes is at the foundation of all moral assessment. That is, they hold that moral assessments of right and wrong, virtuous and vicious, morally good and morally bad, etc. are all ultimately a function of how outcomes rank. But foundational consequentialists disagree on what is to be directly evaluated in terms of the ranking of outcomes, which is to say that they disagree (...) on what the primary evaluative focal point is. Act-consequentialists take acts to be the primary evaluative focal point. They evaluate acts in terms of how their outcomes rank (the higher ranked the outcome, the morally better the act), but evaluate everything else in terms of the morally best acts. Thus, the morally best rules are those that would, if internalized, most reliably lead us to perform the morally best acts. Rule-consequentialists, by contrast, take rules to be the primary evaluative focal point. They evaluate rules according to how their outcomes rank and then assess everything else in terms of the morally best rules. Thus, the morally best acts are those that conform to the morally best rules. In this paper, I argue that foundational consequentialists should not take the primary evaluative focal point (or points) to be acts, rules, virtues, or even everything. In so doing, I argue against act-consequentialism, rule-consequentialism, and global consequentialism. But my project is not entirely negative, for I argue that the primary evaluative focal point should be a complex of acts and attitudes. In the end, then, I claim that foundational consequentialists should accept a new kind of consequentialism, which I call attitude-consequentialism. (shrink)

For the first time in 20 years, the prefectural level 2001 LDP primaries offer a chance to reevaluate the relationship between Diet members and the LDP rank and file. Since 1982, scholars have agreed that Diet members use their support organizations to control how rank and file vote in LDP leadership contests; and the absence of any suitable data from the 1980s and 1990s has prevented a reassessment of this hypothesis in Japan's evolving political environment. This study uses regression analysis (...) on prefectural-level primary ballot totals in order to measure Diet member influence over the rank-and-file primaries. The results suggest while national politicians did influence voters, their impact was too small to affect the outcome of the election. This implies that the relationship between LDP Diet members and the rank and file is changing and suggests directions for further study. (shrink)

Background: No studies have examined the underlying structure or predictive validity of the Cognitive Therapy Adherence and Competence Scale. Examining the structure of the CTACS is of great relevance because it could provide information on what constitutes competence in CBT, and whether some underlying factors are more important for predicting treatment outcomes than others. This study investigates the psychometric properties of the Norwegian version of CTACS and its associations with treatment outcomes in a sample of primary care (...) clients who received CBT for anxiety and/or depression.Method: Independent assessors rated audiotaped therapy sessions in a sample of 132 primary care clients, participating in the Prompt Mental Health Care trial. Outcomes were symptoms of anxiety and depression assessed by patient self-report questionnaires. Structural validity was examined by means of confirmatory and exploratory factor analyses, whereas longitudinal associations with treatment outcome were explored by adopting multilevel modeling.Results: No evidence was found for the divergent validity of the constructs competence and adherence as indicated by a very high correlation between these two subscales in CTACS. Regarding reliability, ICCs for the mean score of the full competence scale and its associated subscales were generally good to excellent, although the subscale measuring the quality of the therapeutic relationship was relatively low. Internal consistency was overall acceptable, but our CFA models did not provide an acceptable fit for the pre-specified one-factor and four-factor solutions. EFA results were difficult to interpret, with a sub-optimal three-factor solution providing best model fit and only two meaningful factors [CBT specific skills and session structure ]. Overall, the results indicated no evidence for the scales' predictive validity.Conclusion: Our findings point to several psychometric problems of the CTACS that may limit both its research and clinical utility. The importance of providing empirical evidence for both reliability and validity aspects of scales are discussed and suggestions for future research are provided. (shrink)

Scholars and leaders have assumed that prosocial motivation is the primary driver for social enterprises (SEs) to do good. Despite the significance of prosocial motivation, we argue that it may not be the single driver for SE motivation. A dual-motivations approach based on insights from motivation research is proposed to examine how different types of SE motivation can act together to influence the outcomes of SEs. Empirical findings based on survey data from Hong Kong demonstrate that dual motivations—prosocial-intrinsic (...) and prosocial-extrinsic motivations—explain the outcomes of SEs beyond what the direct effects of prosocial motivation can explain separately. Based on moderation analyses, intrinsic motivation enhances the positive relationships between prosocial motivation and business and social outcomes, whereas extrinsic motivation undermines the relationship related to business outcomes. Implications for research on social entrepreneurship and business ethics are discussed. (shrink)

Background: Nurse-patient communication is a unique clinical skill in the healthcare professions that promotes good quality care and patient outcomes. This communication can be disrupted by many barriers that impact the therapeutic relationship and deliver of care. Purpose: The study aims to identify the barriers affecting nurse-patient communication at primary health centers in Almadina Munawara City, Saudi Arabia. Methods: A cross-sectional study was performed among 212 nurses and 214 patients utilizing a self-reporting questionnaire. A version of the same (...) file was then uploaded into NVivo, and data that were coded under all communication barriers including language discordance among patients and healthcare providers (e. g., subtheme: patient prefers a mother tongue speaking doctor), cultural-religious difference and environmental cues between the involved parties to determine their importance in this context as well (see Table 2). Results: The results showed that language, cultural and environmental differences had an extensive influence on how nurses communicated with patients. Key barriers included nurse shortages, limited communication time and low income. Our results suggest that these barriers differ in their effect with language barrier and habitat disturbance being the most important ones. Conclusions: This study concludes that nurse-patient communication is a complex multi-sectional process, constrained by numerous barriers. Strategic intervention aimed at addressing these barriers can strengthen nurse-patient interaction and accelerate patient care. Communication remains a cornerstone in all the best practices of delivering healthcare effectively and keeping patients happy. (shrink)

This study examined the effect of self-support on loneliness, the mediation effect of school belonging, and the moderation effect of self-esteem using a sample comprising 1,126 Chinese mainland primary school students, 621 are boys and 505 are girls, and their mean age was 10.51 years. Participants completed questionnaires regarding self-support, loneliness, school belonging and self-esteem. In the model hypothesis, self-support is an independent variable, loneliness is an outcome variable, school belonging is a mediating variable, and self-esteem is a regulatory (...) variable. After controlling the demographic variables, the data were analyzed, and the results showed that: self-support had a significantly negative predictive effect on loneliness; the relation between self-support and loneliness was mediated by school belonging; and the relation between school belonging and loneliness was moderated by self-esteem, supporting the moderated mediation model. Moderated mediation analysis further indicated that the mediated path make loneliness weaker for pupils with higher levels of self-esteem. These results revealed the formation mechanism of loneliness in primary school students and have certain enlightenment significance for the intervention of loneliness in primary school students. These results revealed the formation mechanism of loneliness among primary school students and have significant implications for interventions against loneliness in the primary school context. (shrink)

This paper explores ethical concerns arising in healthcare integration. We argue that integration is necessary imperative for meeting contemporary and future healthcare challenges, a far stronger evidence base for the conditions of its effectiveness is required. In particular, given the increasing emphasis at the policy level for the entire healthcare infrastructure to become better integrated, our analysis of the ethical challenges that follow from the logic of integration itself is timely and important and has hitherto received insufficient attention. We evaluated (...) an educational intervention which aims to improve child health outcomes by making transitions between primary to secondary care more efficient, ensuring children and parents are better supported throughout. The programme provided skills for trainee paediatricians and general practitioners (GPs) in co-designing integrated clinical services. The key ethical challenges of integrated care that arose from a clinical perspective are: professional identity and autonomy in an integrated working environment; the concomitant extent of professional responsibility in such an environment; and the urgent need for more evidence to be produced on which strategies for integrating at scale can be based. From our analysis we suggest a tentative way forward, viewed from a normative position broadly situated at the intersection of deontology and care ethics. We adopt this position because the primary clinical ethical issues in the context of integrated care concern: how to ensure that all duties of care to individual patients are met in a newly orientated working environment where clinical responsibility may be ambiguous; and the need to orientate care around the patient by foregrounding their autonomous preferences and ensuring good patient clinician relationships in clinical decision-making. (shrink)

The lantern exhibition at the Lantern Festival is an important traditional festival in Taiwan. Visitors play an important role in the promotion and sustainable development of intangible cultural heritage. In recent years, the involvement of digital technology in traditional lantern design and shows has contributed to the protection, inheritance, and promotion of ICH, there remains less research on using augmented reality with ICH tourism. In this study, AR is used for ICH lantern exhibition to discuss the learning experience in lantern (...) tourism and the relationship between technology acceptance and satisfaction from the perspective of visitors, as well as evaluate what AR has on improving visitors’ awareness and learning experience. Then, primary variables of the technology acceptance model are combined with generic learning outcomes to integrate ICH, education, and technology to expand TAM, building a new model to study the ICH learning experience. A questionnaire and observation are used. Respondents are visitors participating in the AR lantern exhibition in Taiwan, which is designed by the author. There is a total of 200 questionnaires collected in the end. The result shows that knowledge and understanding, attitudes and values, activity, behavior, and progression, and enjoyment, inspiration, and creativity from GLOs have a positive effect on technology acceptance and actual use. Therefore, visitors are satisfied with innovative and interesting technology learning experiences, enhancing learning interest and results. Besides, the interaction of the AR system improves visitors’ learning motivation, which shows the combination of AR technology with ICH tourism helps improve cultural awareness. (shrink)

Experiences of discrimination such as everyday racism can negatively affect the mental and physical health of children and adolescents with an immigrant background and impair their integration process in the host societies. Although experiences of racism are part of the everyday life of many minors affected by the process of “Othering” (e.g., those with an immigrant background), an overview of empirical findings is missing for this age group worldwide. A systematic review was conducted to identify and analyze international research on (...) the impact of discrimination on the developmental outcomes and integration of immigrant children and adolescents. Three scientific databases were systematically searched up to June 11, 2021. A total ofk= 4,769 identified publications were reviewed based on inclusion and exclusion criteria in terms of the PICOS format by independent reviewers. Thirty-four primary studies published between 1998 and 2021 met all inclusion criteria. The samples examined were mainly migrant youth (k= 30), with onlyk= 2 studies assessing refugee youth andk= 1 study assessing both migrant and refugee youth. The majority of included studies assessed perceived discrimination, with onlyk= 1 study directly assessing experiences of racism. The association between discrimination or racism and developmental outcomes was assessed by the included studies within the three main topics of (a) mental and physical health-related outcomes (k= 30, e.g., self-esteem, depressive symptoms), (b) school-related outcomes (k= 6, e.g., academic achievement), and (c) other developmental outcomes (k= 13, e.g., misconduct or delinquency). Data collection procedures were implemented, and findings on minors’ developmental outcomes and integration process who experience discrimination and racism were summarized and discussed. The current review suggests experienced (racial) discrimination as a negative predictor of children and adolescents’ (mental) health-related outcomes, while no clear results could be found for the association between discrimination and school-related outcomes. A need for more empirical research focusing on the path and (possibly) indirect link between discrimination and children and adolescents’ school-related outcomes as well as resulting school recommendations and the chosen career path was derived.Systematic Review Registration[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=260291], identifier [CRD42021260291]. (shrink)

Despite the growth of philosophy for/with children over the last five decades, its legitimacy remains contested. Key themes within the P4C literature are the potential learning outcomes for children as well as possible personal and professional development benefits for those that teach it. The literature on the former, while extensive, presents a mixed picture and highlights the challenges inherent in determining the impact of P4C on learning outcomes. The literature on the latter, while little explored, may provide valuable (...) insights for teacher professional development. Unlike much of the literature, this paper examines the impact of P4C from the P4C educators’ perspective. The paper presents the findings from a pilot study of volunteer teachers with the Primary Ethics program in Sydney, Australia. Two key findings emerged. First, ethics teachers felt they were making a material and positive difference to the children they taught, which included: the development of critical thinking and reasoning skills; increased confidence to express themselves; and enjoyment derived from class discussions. Second, teachers that use a philosophical and a community of inquiry approach with their students may themselves become more reflective and engage in critical thinking and ethical reasoning. (shrink)

By incorporating the conservation of resource theory, this study examines how high-performance work practices (HPWPs) affect the employee's in-role performance (EIRP) and employee's task performance (ETP) during the coronavirus disease 2019 (COVID-19) pandemic. Furthermore, this study investigates how organization-based self-esteem (OBSE) and positive psychological capital (PPC) affect the relationship between HPWPs and outcomes of employees such as EIRP and ETP. A quantitative technique based on the survey method was used to gather the primary data of the investigation. Two (...) hundred and eleven bank employees working in different banks of Punjab and Pakistan participated in the survey process. The PROCESS-macro was used to test the relationship among the study constructs. Our results supported all the study hypotheses, however positive psychological capital did not moderate the indirect effect of high performance work practices on employee's task performance via organization based self-esteem. This study is the earliest of its kind that focuses on HPWPs and outcomes of employees amid the COVID-19 pandemic in a developing country like Pakistan. The findings of this study provide practical implications in the post and continuing pandemic situation for organizations to human resource management to redesign workforce strategies to increase their contribution and responses to realize organizational priorities. Although researchers have explored the topic in different sectors, scant studies have investigated the potential impact, barriers, and enabling mechanisms that function as a catalyst in HPWPs during the pandemic situation. (shrink)

One of the core goals of Digital Health Technologies (DHT) is to transform healthcare services and delivery by shifting primary care from hospitals into the community. However, achieving this goal will rely on the collection, use and storage of large datasets. Some of these datasets will be linked to multiple sources, and may include highly sensitive health information that needs to be transferred across institutional and jurisdictional boundaries. The growth of DHT has outpaced the establishment of clear legal pathways (...) to facilitate the collection, use and transfer of potentially sensitive health data. Our study aimed to address this gap with an ethical code to guide researchers developing DHT with international collaborative partners in Singapore. We generated this code using a modified Policy Delphi process designed to engage stakeholders in the deliberation of health data ethics and governance. This paper reports the outcomes of this process along with the key components of the code and identifies areas for future research. (shrink)

There are tensions within formal education between imparting knowledge and the development of skills for handling that knowledge. In the primary school sector, the latter can also be squeezed out of the curriculum by a focus on basic skills such as literacy and numeracy. What happens when an explicit attempt is made to develop young children's reasoning—both in terms of their apparent cognitive abilities and their basic skills? This paper reports an independent evaluation of an in-class intervention called ‘Philosophy (...) for Children’, after just over one year of schooling. The intervention aims to help children become more willing and able to question, reason, construct arguments and collaborate with others. A group of 48 volunteer schools were randomised to receive P4C or act as a control for one year. This paper reports the CAT results for all pupils in years 4 and 5 initially, and the Key Stage 2 attainment in English and Maths for those starting in year 5. There was no school dropout. Individual attrition from a total of 3,159 pupils was around 11 percent—roughly equal between groups. There were small positive ‘effect’ sizes in favour of the P4C group in progress in reading and maths, and even smaller perhaps negligible improvements in CAT scores and writing. The results for the most disadvantaged pupils were larger for attainment, but not for CATs. Observations and interviews suggest that the intervention was generally enjoyable and thought to be beneficial for pupil confidence. Our conclusion is that, for those wishing to improve attainment outcomes in the short term, an emphasis on developing reasoning is promising, especially for the poorest students, but perhaps not the most effective way forward. However, for those who value reasoning for its own sake, this evaluation demonstrates that using curriculum time in this way does not damage attainment, and so suggests that something like P4C is an appropriate educational approach. (shrink)

There are tensions within formal education between imparting knowledge and the development of skills for handling that knowledge. In the primary school sector, the latter can also be squeezed out of the curriculum by a focus on basic skills such as literacy and numeracy. What happens when an explicit attempt is made to develop young children's reasoning—both in terms of their apparent cognitive abilities and their basic skills? This paper reports an independent evaluation of an in-class intervention called ‘Philosophy (...) for Children’, after just over one year of schooling. The intervention aims to help children become more willing and able to question, reason, construct arguments and collaborate with others. A group of 48 volunteer schools were randomised to receive P4C or act as a control for one year. This paper reports the CAT results for all pupils in years 4 and 5 initially, and the Key Stage 2 attainment in English and Maths for those starting in year 5. There was no school dropout. Individual attrition from a total of 3,159 pupils was around 11 percent—roughly equal between groups. There were small positive ‘effect’ sizes in favour of the P4C group in progress in reading and maths, and even smaller perhaps negligible improvements in CAT scores and writing. The results for the most disadvantaged pupils were larger for attainment, but not for CATs. Observations and interviews suggest that the intervention was generally enjoyable and thought to be beneficial for pupil confidence. Our conclusion is that, for those wishing to improve attainment outcomes in the short term, an emphasis on developing reasoning is promising, especially for the poorest students, but perhaps not the most effective way forward. However, for those who value reasoning for its own sake, this evaluation demonstrates that using curriculum time in this way does not damage attainment, and so suggests that something like P4C is an appropriate educational approach. (shrink)

When is it appropriate to harm a single person to help multiple others? Psychologists have investigated this question through the study of hypothetical “trolley” dilemmas involving extreme physical harm life-or-death situations that contrast outcome-focussed, consequentialist moral reasoning with principle-focussed, deontological moral reasoning. The present studies investigate whether participants’ preference for consequentialism generalises across domains. We administered traditional physical harm dilemmas as well as a trolley-type dilemma involving monetary harm. Across four studies (N = 809), an internal meta-analysis demonstrated that participants’ (...) responses to the traditional dilemmas predicted their responses to the monetary dilemma. Additionally, previous research has uncovered that primary psychopathy predicts consequentialist responses on physical harm dilemmas. The current work uncovers that this association does not generalise to monetary harm dilemmas, suggesting that the association between primary psychopathy and consequentialist reasoning is not related to consequentialist reasoning per se, but to the idiosyncrasies of traditional harm-centric trolley dilemmas instead. (shrink)

A surprisingly large number of scholars believe that (a) we are blameworthy, and therefore punishable, only for what we have control over; (b) we have control only over our actions and intentions, not the consequences of our actions; and therefore (c) if two agents perform the very same action (e.g., attempting to kill) with the very same intentions, then they are equally blameworthy and deserving of equal punishment – even if only one of them succeeds in killing. This paper argues (...) against these “equivalence theorists” that harmful consequences do make a moral difference, that the harm produced by the killer’s attempt retroactively makes her action more blameworthy, and therefore deserving of more punishment, than the failed attempter’s attempt. The primary argument for this “non-equivalence theory” is an analogy with gambling. Just as a gambler makes a deal with the casino to allow metaphysical luck to retroactively determine the “profit status” of her bet, so too the attempted killer makes a deal with “the casino of morality” to allow metaphysical luck to retroactively determine the moral status of her attempt. She makes the “moral deal” that if her attempt succeeds, her attempt was more blameworthy than if her attempt does not succeed. And it is the greater blameworthiness of the killer’s attempt that justifies our intuition that the killer should be punished more harshly than the failed attempter. (shrink)

E.R. Dodds’ 1959 edition of Plato’s Gorgias is a conventional treatment of this dialogue, aimed at audiences interested in close study of the text. Dodds himself regretted this outcome. He felt he had lost sight of an earlier goal, formulated at a time of political turmoil on the eve of WorldWar II, of using the Gorgias to bring out ‘both the resemblance and the difference between Plato’s situation and that of the intellectual today’. The present paper attempts to reconstruct that (...) goal, as it survives residually in his edition, surfaces in his The Greeks and the Irrational, and appears in some writings from the 1930s, particularly in unpublished lectures. Dodds did frequently juxtapose ancient and modern conceptions of the intellectual, and in a way that cast Plato in a positive light, as someone politically engaged and self-critical, and acutely sensitive, as Dodds himself was, to the political implications of social psychology. (shrink)