Preparing for the future: challenges and opportunities for management and leadership skills.

OBJECTIVE: The aim of the study was to explore dental leaders' perceptions of the current position of leadership in the dental profession. DESIGN: A qualitative, key informant, exploratory research study was used with semi-structured interviews as the means of data collection. MATERIALS AND METHODS: Participants were invited based on their role in dental services in the UK and their ability to act as a key informant. Thirteen participants were secured and interviewed either at their workplace or in a University setting. Each interview lasted between 45 and 60 minutes. RESULTS: The findings show that while recognising that a lack of focus on leadership skills has caused problems in the past, current dental leaders are prepared to lead the profession forward. The participants viewed education at all levels as vital to this process and education for leadership at undergraduate level was perceived as an important way forward. CONCLUSIONS: The development of effective leaders is essential for all healthcare professions and increasingly is becoming a key focus for the UK dental profession. There is comparatively little research about dental leadership in a UK context and this paper should begin to help to redress the balance and to highlight areas for future consideration. Three broad emergent themes are described and discussed - characteristics and behaviours of dental leaders; challenges for dental leaders; education and training for dental leadership.

Educating the dental team: exploring perceptions of roles and identities.

Interprofessional education (IPE) should help to promote a team-based approach to professional practice but there are barriers to its implementation including professional identity. The aim of this study was to use a qualitative research methodology to explore dental and dental care professional (DCP) students' perceptions of professional roles and identities in the dental team. Data were collected by means of focus groups from a purposive sample of dental and DCP students and were audio recorded, transcribed and analysed using an explanatory framework. Five common themes emerged around the issue of professional roles and identity in the dental team. The results indicate that professional identity was an important factor in team development and was determined by direct responsibility for patient care and by the amount of clinical experience acquired. Professional identity within a team context was perceived as different from professional identity per se. Dental students were found to lack confidence in their role as team leaders which was related to their lack of knowledge of team roles, responsibilities and experience. The role of the dental technician was perceived as 'outside' the dental team due to lack of patient interaction.

Salivary cortisol levels in children adopted from romanian orphanages.

Six and a half years after adoption. 6- to 12-year-old children reared in Romanian orphanages for more than 8 months in their first years of life (RO. n = 18) had higher cortisol levels over the daytime hours than did early adopted (EA, < or = 4 months of age, n = 15) and Canadian born (CB, n = 27) children. The effect was marked, with 22% of the RO children exhibiting cortisol levels averaged over the day that exceeded the mean plus 2 SD of the EA and CB levels. Furthermore, the longer beyond 8 months that the RO children remained institutionalized the higher their cortisol levels. Cortisol levels for EA children did not differ in any respect from those of CB comparison children. This latter finding reduces but does not eliminate concerns that the results could be due to prenatal effects or birth family characteristics associated with orphanage placement. Neither age at cortisol sampling nor low IQ measured earlier appeared to explain the findings. Because the conditions in Romanian orphanages at the time these children were adopted were characterized by multiple risk factors, including gross privation of basic needs and exposure to infectious agents, the factor(s) that produced the increase in cortisol production cannot be determined. Nor could we determine whether these results reflected effects on the limbic-hypothalamic-pituitary-adrenal axis directly or were mediated by differences in parent-child interactions or family stress occasion by behavioral problems associated with prolonged orphanage care in this sample.

Relations between behavioral and cardiac autonomic reactivity to acute pain in preterm neonates.

OBJECTIVE: The purpose of this study was to assess relations and concordance between behavioral and physiologic reactivity to pain in preterm neonates at 32 weeks postconceptional age as a function of gestational age at birth. SETTING: Level III neonatal intensive care unit. DESIGN/PATIENTS: The study group comprised 136 preterm neonates (mean [range] birthweight, 1,020 g [445-1,500 g]: gestational age at birth, 28 weeks [23-32 weeks]) separated into three groups according to gestational age at birth as follows: 23 to 26 weeks (n = 48), 27 to 29 weeks (n = 52), and 30 to 32 weeks (n = 36). OUTCOME MEASURES: Reactivity to routine blood collection at 32 weeks postconceptional age was assessed using bedside-recorded behavioral and autonomic measures. Coders who were blinded to the study design scored behavioral responses (facial activity using the Neonatal Facial Coding System, sleep/waking state, and finger splay). Autonomic reactivity was assessed by change in heart rate and spectral analysis of heart rate variability (change in low-frequency and high-frequency power, and the ratio of low-frequency to high-frequency power during blood collection). RESULTS: Facial activity and state correlated moderately with change in heart rate across gestational age groups (r = 0.41-0.62). Facial activity and state did not correlate significantly with change in low-frequency and high-frequency power, or the ratio of low-frequency to high-frequency power (r = 0.00-0.31). Finger splay did not correlate with any autonomic recording (r = 0.03-0.41). Concordance between established biobehavioral measures of pain revealed individual differences. Although some neonates showed high behavioral but low physiologic reactivity, other neonates displayed the opposite reaction; however, the majority displayed concordant reactions. CONCLUSIONS: The study findings confirm the value of measuring domains independently, especially in neonates born at a very young gestational age.

Birthing at home: the resolution of expectations.

OBJECTIVE: To describe the experience of ten couples who have had a home birth in Western Australia. DESIGN, SETTING AND PARTICIPANTS: Using a phenomenological approach, ten parent couples were interviewed and three home-birth videos observed. Of the ten couples, four discussed their first child's home birth. The remaining six couples had three or four children who had been born at home. FINDINGS: The essence of these parents' experiences of home birth was gained through identifying significant statements from transcripts and field notes and clustering these into the four themes of 'constructing the environment'; 'assuming control'; 'birthing'; and 'resolving expectations'. The first two themes were presented in a previous paper (Morison et al 1998). The latter two themes are now presented. The theme 'birthing' was where parents elaborated on their birth beliefs, discussed the actual birth and shared aspects of the relationship between the couple and the midwife. 'Resolving expectations' concerned the process of parents forming expectations, experiencing the reality of birth and then evaluating whether expectations were met. KEY CONCLUSIONS: The development of a supportive relationship between couples and their midwife was essential during this transition to parenthood. Resolving expectations was an essential process that the parents undertook to clarify the meaning of their birth experience, and thereby acknowledge its uniqueness. IMPLICATIONS FOR PRACTICE: The findings are important to midwives' practice as they reveal the value clients place on a shared philosophy about birth. Midwives, in any setting, can reflect on their own birthing beliefs and determine their compatibility with their clients' beliefs.

Survival estimates for adults with cystic fibrosis born in the United Kingdom between 1947 and 1967. The UK Cystic Fibrosis Survey Management Committee.

BACKGROUND: The UK has published observed cohort survival figures for subjects with cystic fibrosis born since 1968. Prior to 1968 cohorts cannot be established directly from routine data as cystic fibrosis was classified with a number of unrelated conditions in ICD7. Reported here are interrupted survival curves from 1978 for patients with cystic fibrosis born before 1968. METHODS: Life tables for the three year cohorts born between 1947 and 1967 were constructed by firstly estimating the numbers of patients with cystic fibrosis born in each cohort from live birth data and the disease incidence. The number of the estimated cohort that had survived to 1978 is known, which enables the proportion surviving to 1978 to be calculated. The survival of these cohorts after 1978 can be calculated in the usual way. RESULTS: The survival for each successive cohort was better than that of the previous one, but most of the improvements appear to have taken place up to the age of about 20 years. Only 3% of the 1947-49 cohort survived to 30 years of age compared with 21% for the 1965-67 cohort, and 3% of the 1953-55 cohort survived to 40 years of age. For the later cohorts the mortality rate for those aged between 26 and 30 years appears to be about 50 per 1000 per year. CONCLUSIONS: While the trend in the numbers surviving into later adulthood is upwards, the mortality rates for these ages does not appear to be improving. It is not possible to tell from these data whether the high mortality rates in adulthood will improve with better resourced adult clinics or with improved treatment during childhood.

Constructing a home birth environment through assuming control.

OBJECTIVE: The purpose of this qualitative study was to describe the experience of couples who have had a home birth. DESIGN, SETTING AND PARTICIPANTS: A phenomenological approach was used to provide an understanding of the human experience of home birth in Western Australia. The research design consisted of a field study, in which 10 parent couples were interviewed and three videos of home births observed. Of the ten couples, four couples spoke of their first baby's home birth and the remaining six couples had three or four children who had been born at home. FINDINGS: The couples' experiences of home birth were gained through identifying significant statements from transcripts and field notes, and clustering these into the following four themes: 'constructing the environment'; 'assuming control'; 'birthing'; and 'resolving expectations'. The themes of 'constructing the environment' and 'assuming control' are described in detail in this paper. 'Constructing the environment' describes how couples adapted the physical environment, and established support to create a positive birth environment. 'Assuming control' discusses exerting control and taking responsibility for the birth. The remaining themes of 'birthing' and 'resolving expectations' are described in a subsequent paper (Morison et al, in press). KEY CONCLUSIONS: The research furnishes an insight into the couples' experience of home birth. The lived experience of birthing at home involved a process where a couple actively created an environment that enabled them to assume control and responsibility for the birth. IMPLICATIONS FOR PRACTICE: The findings are important for midwives in any setting, as they reveal the extent to which some parents value the right to assume control and responsibility for the birth of their baby. Although the physical environment of a home birth cannot be replicated in every setting, issues specific to the birth environment are relevant to all midwives.

Incidence, population, and survival of cystic fibrosis in the UK, 1968-95. UK Cystic Fibrosis Survey Management Committee.

The UK Cystic Fibrosis Survey holds data on all people resident in the UK who were diagnosed as having cystic fibrosis and born either since 1968 or before 1968 and alive in 1977. Thus, incidence may be reported from 1968 and prevalence from 1977. The previous estimates are updated to the end of 1995 from data held in the database on 23 August 1996. The incidence is now calculated as one in 2415 live births. The 1992 mid-year population was 6500 people with 65% aged under 16 years. Births outnumber deaths by 160 per year, which suggests a population of 7750 by the year 2000, with all the increase being in the adult age range. The survival of successive cohorts continues to be better than earlier cohorts, the linear descent of the curves is still evident. The infant mortality rate for cystic fibrosis is now under 20 per thousand per year and early childhood mortality is under five per thousand per year. The crude mortality rate for 1995 was 21 per thousand per year, but the standardised mortality ratio was about 3300.

Height and weight in cystic fibrosis: a cross sectional study. UK Cystic Fibrosis Survey Management Committee.

Cross sectional data reporting the height, weight, and body mass index of UK patients with cystic fibrosis are presented. During the first decade of life height and weight in patients with cystic fibrosis are maintained at about 0.5 SD below those of the general population, which reflects an improvement over earlier published observations. Postpubertal stature and weight maintenance in the cystic fibrosis population still show substantial deficits which may be related to treatment.

Cystic fibrosis in the United Kingdom, 1968-1988: incidence, population and survival.

A thorough survey was conducted of patients with cystic fibrosis living in the UK from 1977 onwards. This was supplemented with death certificate data back to 1968. There was one case identified for each 2475 births. The total number of cases in the UK rose linearly from 4086 in 1977 to 5426 in 1988 and is estimated to be 6000 in 1992. The probability of survival improved in the period under study for all age groups and in both sexes. It was worst in the first year of life, dropped sharply thereafter but then increased steadily with age. There has been a very marked improvement over the years in survival in the first year of life, but a lesser one in older age groups. Male mortality was greater than that in females in the first year of life, but less in subsequent years giving, overall, worse survival for females. A set of cohort and 'current' survival graphs for the two sexes are given.

Juror and expert knowledge of child sexual abuse.

Mental health professionals with expertise in child sexual abuse (CSA) often testify as expert witnesses in court. There is significant controversy over the admissibility of this type of evidence. To be admissible, the testimony of an expert must be beyond the common knowledge of the jury and based on information generally considered to be reliable within the professional community in which it is used. To date, no empirical data have existed to allow courts to make an informed judgement as to the extent of either juror knowledge or professional acceptance of CSA data. The present study addresses this issue. Jurors and experts completed a questionnaire designed to reveal their understanding of CSA. Results indicate that experts demonstrated strong consensus on 29 of 40 items included in the questionnaire, and that relative to experts, jurors have limited knowledge of these issues. These results suggest that many of the scientific findings concerning CSA are reliable and that the information is often beyond the common knowledge of the jury. These findings argue for the use of expert testimony in select cases of child sexual abuse.