Out-of-hours decision-making in deteriorating patients by foundation year doctors: Relationship to moral distress.

BACKGROUND: Moral distress (MD) refers to psychological unease when healthcare professionals identify morally correct actions to take but are constrained in their ability to take those actions. METHODS: This study evaluated the relationship between out-of-hours decisions and MD among 40 Foundation Year 2 (FY2) doctors. They were asked to choose the 'expected' and the 'right' management options for five out-of-hours scenarios and complete an adapted Measure of Moral Distress for Health Professionals (MMD-HP) questionnaire. RESULTS: 28/40 (70%) reported discordance between 'expected' and 'right' options more frequently than concordance. The mean total MMD-HP score was low: 64.9 (SD = 26.9), range 13-143, maximum 288. The association between decision-making discordance and MMD-HP score was weak. CONCLUSION: Out-of-hours decisions by FY2 doctors were characterised by doing what is 'expected' rather than what is perceived to be 'right'. Providing guidance regarding decision-making in deteriorating patients is needed for patient safety and staff well-being.

Contemporary pedagogy? The use of theory in practice: An evidence-informed perspective.

Utilizing cognitive psychology as a foundation, this paper offers a deeper consideration of contemporary theoretical influences on coaching pedagogy. Countering recent dichotomies suggested between pedagogic approaches, we reintroduce key findings from the cognitive tradition and their implications for practice which coaches may find useful. Using cognitive load, novice and expert differences, desirable difficulty, and fidelity, we suggest that the lines drawn between different "pedagogies" may not be as sharp as suggested. Instead, we suggest that coaches avoid defining themselves as being aligned to a specific pedagogical or paradigmatic stance. We conclude by advocating for research informed practice, absent of strict theoretical boundaries and instead, considering contemporary pedagogy as drawing on the needs of the context, the experience of the coach and the best available evidence.

Strategy in talent systems: Top-down and bottom-up approaches.

Building on a large volume of recent research in talent identification and development, this paper future directions for research and practice. We suggest that strategic coherence become a greater point of emphasis in both, with the Performance, Outcome and Process framework holding the potential to signal various markers of effectiveness. Secondly, greater recognition of the need to deploy limited resources where they promote movement toward these markers of effectiveness. Finally, we make recommendations for the operationalising of strategy in talent and performance systems by considering the integration of top down and bottom-up strategic processes.

The Role of Siblings in Talent Development: Implications for Sport Psychologists and Coaches.

Developing talent requires consideration of social networks that can facilitate or inhibit progression. Of fundamental influence in this regard is the family, with recent investigation extending its focus from parents to the role of siblings. As such, the purpose of this Conceptual Analysis article is to, firstly, review the characteristics of the sibling relationship that may support or inhibit talent development. Secondly, the analysis then provides empirically derived practical examples to emphasize the holistic and complex role that siblings can play in talent development. Thirdly, strategies are proposed to support practitioners identify specific sibling characteristics, alongside recommendations for how the relationship can be utilized within both the formal and informal environments by coaches and psychologists. Finally, and crucially, important implications of these characteristics are considered to support effective coach and sport psychologist decision making.

Early morning impairment in cerebral autoregulation and cerebrovascular CO2 reactivity in healthy humans: relation to endothelial function.

The reduction in cerebrovascular reactivity to CO(2) and/or endothelial function that occurs in the early hours after waking are potential causes for the increased risk for cardiovascular events at this time point. It is unknown whether cerebral autoregulation is reduced in the morning. We tested the hypothesis that early morning reduction in endothelium-dependent vascular reactivity would be linked to changes in cerebrovascular reactivity to CO(2) and cerebral autoregulation (CA). Overnight changes in a dynamic cerebral autoregulation index (ARI) were determined from continuous recordings of blood flow velocity in the middle cerebral artery (MCAv) and arterial blood pressure (BP) during transiently induced hypotension in 20 individuals. Frontal cortical oxygenation (near infrared spectroscopy) and cerebral haemodynamics were also monitored during hypercapnia and before and during 3 min of active standing. Brachial artery flow-mediated endothelium-dependent vasodilatation (FMD) and endothelium-independent dilatation (NFMD) were also monitored. From evening to morning, there was a significant lowering in ARI (5.3 +/- 0.5 versus 4.7 +/- 0.6 a.u.; P < 0.05), cerebrovascular reactivity to CO(2) (5.3 +/- 0.6 versus 4.6 +/- 1.1% mmHg(-1); P < 0.05) and FMD (7.6 +/- 0.9 versus 6.0 +/- 1.4%; P < 0.05). The lowered FMD was related to the decrease in cerebrovascular reactivity to CO(2) (r = 0.76; P < 0.05). Transient reductions in morning MCAv and cortical oxyhaemoglobin concentrations were observed upon resuming a supine-to-upright position (P < 0.05 versus evening). The early morning reduction in cerebral autoregulation may facilitate the onset of cerebrovascular accidents; this may be of particular relevance to at-risk groups, especially upon resuming the upright position.

The use of medications with known or potential anticholinergic activity in patients with dementia receiving cholinesterase inhibitors.

OBJECTIVES: To assess the prevalence of prescribed medications with anticholinergic activity given concurrently with acetylcholinesterase-inhibitor therapy in long-term care residents with dementia and to recommend dose adjustment or discontinuation of these medications with anticholinergic activity. DESIGN: Prospective case series. SETTING: Long-term care facilities in Indiana. PATIENTS: Geriatric residents in long-term care facilities were included if they were receiving both an agent with anticholinergic activity as determined by radioreceptor assay and an acetylcholinesterase inhibitor. INTERVENTIONS: Recommendations were made to the resident's physician suggesting substitution, dose reduction, or discontinuation of the agent with anticholinergic activity. MAIN OUTCOME MEASURES: The number of residents with a recommended change in their anticholinergic medication regimen as a result of the consultant pharmacist's recommendation. RESULTS: Of the 2,021 long-term care residents evaluated, 498 (25%) were receiving an acetylcholinesterase inhibitor. Of the 498 residents receiving acetylcholinesterase inhibitor therapy, 103 (20.7%) were receiving concurrent medications with anticholinergic activity. The most commonly prescribed medication with anticholinergic activity was furosemide, an agent with "possible" or low anticholinergic effects. One hundred forty-six medications with anticholinergic activity were used in these 103 residents. Overall, adjustments to the agents with anticholinergic activity were completed in 24 (16.4%) cases. The majority of medications prescribed had "possible" anticholinergic activity (62.3%) compared with those prescribed with "definite" anticholinergic activity (37.7%). No medication dose adjustments or discontinuations were frequent, regardless of whether the medication was deemed to have "definite" (29.1%) or "possible" (31.9%) anticholinergic activity. Medication changes or discontinuations occurred in 13 (23.6%) agents with "definite" and 11 (12.1%) agents with "possible" anticholinergic activity. CONCLUSIONS: Medications with anticholinergic activity may interfere with the beneficial effects of acetylcholinesterase inhibitors. Attention should be placed, however, on agents with moderate or strong anticholinergic activity or the use of multiple medications with anticholinergic activity. Health care providers should consider the risk versus benefit of using agents with anticholinergic activity in someone with cognitive impairment receiving an acetylcholinesterase inhibitor.