Consideraciones bioéticas en el manejo de la esclerosis lateral amiotrófica: Una aproximación al quehacer fonoaudiológico

Introducción: La esclerosis lateral amiotrófica (ELA) es la forma más común de enfermedad degenerativa de motoneurona en la edad adulta y es considerada una enfermedad terminal. Por lo mismo, el accionar del fonoaudiólogo debe considerar el respeto a los principios bioéticos básicos para garantizar una asistencia adecuada. Objetivo: Conocer aquellas consideraciones bioéticas relacionadas al manejo y estudio de personas con ELA para luego brindar una aproximación hacia el quehacer fonoaudiológico. Método: Se efectuó una búsqueda bibliográfica en las bases de datos PubMed, Scopus y SciELO. Se filtraron artículos publicados desde 2000 hasta junio de 2023 y fueron seleccionados aquellos que abordaban algún componente bioético en población con ELA. Resultados: Aspectos relacionados al uso del consentimiento informado y a la toma de decisiones compartidas destacaron como elementos esenciales para apoyar la autonomía de las personas. Conclusión: Una correcta comunicación y una toma de decisiones compartida son claves para respetar la autonomía de las personas. A su vez, la estandarización de procedimientos mediante la investigación clínica permitirá aportar al cumplimiento de los principios bioéticos de beneficencia y no maleficencia, indispensables para la práctica profesional.

Introduction: Amyotrophic lateral sclerosis (ALS) is the most common form of degenerative motor neuron disease in adulthood and is considered a terminal disease. For this reason, the actions of the speech therapist must consider respect for basic bioethical principles to guarantee adequate assistance. Objective: To know those bioethical considerations related to the management and study of people with ALS to then provide an approach to speech therapy. Methodology: A bibliographic search was carried out in the PubMed, Scopus, and SciELO databases. Articles published from 2000 to June 2023 were filtered and those that addressed a bioethical component in the population with ALS were selected. Results: Aspects related to the use of informed consent and shared decision-making stood out as essential elements to support people's autonomy. Conclusion: Proper communication and shared decision-making are key to respecting people's autonomy. In turn, the standardization of procedures through clinical research will contribute to compliance with the bioethical principles of beneficence and non-maleficence, essential for professional practice.

Vaccine Mandates: Weighing the Common Good vs Personal Conscience and Autonomy.

COVID-19 is a serious illness with significant morbidity and mortality. Vaccines to immunize against it were developed in record time. Mandates followed. The question to be considered is when mandates are ethical. Mandates can be used to prevent spread of an infection, prevent overwhelming the healthcare system, or protect public safety, thereby protecting the vulnerable and allowing for full flourishing of the common good. At the same time, one must be careful about respecting autonomy by allowing those who consciences do not allow them to be vaccinated to refuse. Because COVID-19 knowledge is rapidly changing as more information is known and the virus mutates, the conditions under which mandates are ethical change as well. At present, since vaccines prevent severe infection and death in high-risk individuals with added benefit for those who are vaccinated and have a history of infection, mandates can be imposed on those individuals. With an estimated 95% of the US population believed to have been infected and prior history of infection shown to be as effective as vaccination, with immunity lasting at least 500 days, and ability to prevent spread unknown at present but limited at best in the past, the vaccines therefore cannot be ethically mandated for those who are low risk for the versions released September 2023 based on information as of October 2023.

Residents underestimate their robotic performance: evaluating resident robotic console participation time.

Lack of formal national robotic curriculum results in a void of knowledge regarding appropriate progression of autonomy in robotic general surgery training. One midwestern academic surgical training program has demonstrated that residents expect to independently operate more on the robotic console than they perceive themselves to do. As such, our study sought to evaluate expectations of residents and faculty regarding resident participation versus actual console participation time (CPT) at a community general surgery training program. We surveyed residents and faculty in two phases. Initially, participants were asked to reflect on their perceptions and expectations from the previous six months. The second phase included surveys (collected over six months) after individual cases with subjective estimation of participation versus CPT calculated by the Intuitive Surgical, Inc. MyIntuitive application. Using Mann-Whitney U-Test, we compared resident perceptions of CPT to actual CPT by case complexity and post-graduate year (PGY). Faculty (n = 7) estimated they allowed residents to complete a median of 26-50% of simple and 0-25% of complex cases in the six months prior to the study. They expected senior residents (PGY-4 and PGY-5) to complete more: 51-75% of simple and 26-50% of complex cases. Residents (n = 13), PGY-2-PGY-5, estimated they completed less than faculty perceived (0-25% of simple and 0-25% of complex cases). Sixty-six post-case (after partial colectomy, abdominoperoneal resection, low anterior resection, cholecystectomy, inguinal/ventral hernia repair, and others) surveys were completed. Residents estimated after any case that they had completed 26-50% of the case. However, once examining their MyIntuitive report, they actually completed 51-75% of the case (median). Residents, especially PGY-4 and 5, completed a higher percentage than estimated of robotic cases. Our study confirms that residents can and should complete more of (and increasingly complex) robotic cases throughout training, like the transition of autonomy in open and laparoscopic surgery.

Low-rank human-like agents are trusted more and blamed less in human-autonomy teaming.

If humans are to team with artificial teammates, factors that influence trust and shared accountability must be considered when designing agents. This study investigates the influence of anthropomorphism, rank, decision cost, and task difficulty on trust in human-autonomous teams (HAT) and how blame is apportioned if shared tasks fail. Participants (N = 31) completed repeated trials with an artificial teammate using a low-fidelity variation of an air-traffic control game. We manipulated anthropomorphism (human-like or machine-like), military rank of artificial teammates using three-star (superiors), two-star (peers), or one-star (subordinate) agents, the perceived payload of vehicles with people or supplies onboard, and task difficulty with easy or hard missions using a within-subject design. A behavioural measure of trust was inferred when participants accepted agent recommendations, and a measure of no trust when recommendations were rejected or ignored. We analysed the data for trust using binomial logistic regression. After each trial, blame was apportioned using a 2-item scale and analysed using a one-way repeated measures ANOVA. A post-experiment questionnaire obtained participants' power distance orientation using a seven-item scale. Possible power-related effects on trust and blame apportioning are discussed. Our findings suggest that artificial agents with higher levels of anthropomorphism and lower levels of rank increased trust and shared accountability, with human team members accepting more blame for team failures.

Designing for student autonomy combining theory and clinical practice - a qualitative study with a faculty perspective.

BACKGROUND: Although extensive research exists about students' clinical learning, there is a lack of translation and integration of this knowledge into clinical educational practice. As a result, improvements may not be implemented and thus contribute to students' learning. The present study aimed to explore the nature of clinical faculty members' learning related to how they apply research about student autonomy. METHODS: A course, "Designing learning for students' development of autonomy in clinical practice" was conducted for faculty responsible for students' clinical education. Within the frame of the course the participants designed a project and planned how they would implement it in their clinical context. Fourteen clinical faculty members participated in the study. The participants' interpretation of the educational intervention, which combines complex theory with the equally complex clinical practice, was explored by studying how the participants' approaches and understanding of the facilitation of autonomy were manifested in their projects. The projects in the form of reports and oral presentations were analyzed using qualitative content analysis together with an abductive approach. FINDINGS: One identified domain was "Characteristics of the design and content of the projects". This domain was signified by two themes with different foci: Preparing the soil for facilitating student autonomy; and Cultivating opportunities for students to actively strive for autonomy. A second identified domain, "Embracing the meaning of facilitating autonomy" was connected to participants understanding of theories underlying how to support the development of autonomy. This domain contained two themes: Connection between activities and autonomy is self-evident and Certain factors can explain and facilitate development of autonomy. CONCLUSION: Education directed to strategic clinical faculty members to develop evidence-based approaches to student learning can be productive. To succeed there is a need to emphasize faculty members individual understanding of actual research as well as learning theories in general. Faculty trying to reinforce changes are dependent on their own mandate, the structure in the clinic, and recognition of their work in the clinical context. To achieve a potential continuity and sustainability of implemented changes the implementation processes must be anchored throughout the actual organization.

Diet Management in Congenital Diarrheas and Enteropathies - General Concepts and Disease-Specific Approach, a Narrative Review.

Congenital diarrheas and enteropathies (CODE) are a group of rare, heterogenous, monogenic disorders that lead to chronic diarrhea in infancy. Definitive treatment is rarely available, and supportive treatment is the mainstay. Nutritional management in the form of either specialized formulas, restrictive diet, or parenteral nutrition support in CODE with poor enteral tolerance, is the cornerstone of CODE treatment and long-term growth. The evidence to support the use of specific diet regimens and nutritional approaches in most CODE disorders is limited due to the rarity of those diseases and the scant published clinical experience. The goal of this review is to create a comprehensive guide for nutritional management in CODE, based on the currently available literature, disease mechanism and the PediCODE group experience. Enteral diet management in CODE can be divided into 3 distinct conceptual frameworks - nutrient elimination, nutrient supplementation, and generalized nutrient restriction. Response to nutrient elimination or supplementation can lead to resolution or significant improvement in the chronic diarrhea of CODE and resumption of normal growth. This pattern can be seen in CODE due to carbohydrate malabsorption, defects in fat absorption and occasionally in electrolyte transport defects. In contrast, general diet restriction is mainly supportive. However, occasionally it allows parenteral nutrition weaning or reduction overtime mainly in enteroendocrine defects and rarely in epithelial trafficking and polarity defects. Further research is required to better elucidate the role of diet in the treatment of CODE and the appropriate diet management for each disease.

Evaluation of social inclusion in Brazilian adult women with epilepsy: Perception of stigma and quality of life.

Epilepsy is a chronic disease characterized by recurrent epileptic seizures that can affect the perception of stigma and compromise the quality of life of those living with it. In addition, sociodemographic factors such as employment and maintaining a job, education, and the autonomy to drive vehicles are often impaired. OBJECTIVE: To assess the social inclusion of adult women with epilepsy in relation to the perception of stigma and quality of life, and the clinical aspects of the disease. METHODOLOGY: Data from 70 adult Brazilian women with epilepsy regarding aspects related to their social inclusion were verified. Such data were linked to clinical aspects and scores from the questionnaires: Quality of Life in Epilepsy Inventory 31 (QOLIE-31) and the Epilepsy Stigma Scale (ESS), with a significance level of p < 0.05. RESULTS: Average age of 45.5 years, 40 (57.1 %) women were divorced/single/widowed, 31 (44.3 %) women had less than 10 years of formal education, 32 (45.7 %) women had no income, and 57 (81.4 %) did not have a driver's license. The age at the time of the first seizure was 18 years, the seizures were focal in 46 (65.7 %) cases, and 26 (37.1 %) cases were seizure-free in the last year. A high number of women reported that the diagnosis of epilepsy negatively influenced aspects of autonomy such as the possession of a driver's license and going out alone. Longer duration of epilepsy was associated with lower education, not having children, and lower scores on the QOLIE-31. Higher scores on the QOLIE-31 were correlated with lower frequency of seizures and with the age at the time of the first seizure. Values in the dimension - energy and fatigue of the QOLIE-31 were significantly lower in the group with less independence compared to the other two groups with more independence, in latent class analyses (ANOVA, adjusted for age 42.1 ± 35.6 vs 57.2 ± 28.4 vs 73.9 ± 23.8, p = 0.0295). DISCUSSION: Clinical aspects of epilepsy and having a partner, autonomy, and independence such as driving vehicles are factors that contribute to social inclusion and to the perception of a better quality of life for adult women with epilepsy. CONCLUSION: It was observed that having a partner, autonomy, and independence such as driving vehicles are factors that contribute to social inclusion and to the perception of a better quality of life for adult women with epilepsy.

The Ethics of Full Body Skin Exams (FBSE).

Full body skin examinations (FBSEs) are part of the purview of a dermatologic exam. Because this involves examination of sensitive or "intimate" areas, there are many ethical issues involved. Herein we discuss whether screening patients with a FBSE is ethical and consistent with the ethical tenet of distributive justice, how to ethically deal with our disabled patients, how to ethically navigate patients who have been emotionally or physically traumatized in the past, and the ethical ramifications of the use of a chaperone.

Advance directives need full legal status in persons with dementia.

Currently, in the United States, there is no legal obligation for medical professionals or civil courts to uphold patients' Advance Directives (ADs) regarding end-of-life care. The applicability and standing of ADs prepared by Alzheimer's patients is a persistent issue in bioethics. Those who argue against giving ADs full status take two main approaches: (1) appealing to beneficence on behalf of the Alzheimer's patient and (2) claiming that there is no longer any personal equivalence between the AD's creator and the subject of the AD. In this paper, I present profound arguments against both approaches. Firstly, I argue that the principle of beneficence cannot apply in the case of Alzheimer's patients, and, secondly, that the moral and legal authority of the AD need not depend on strict equivalence of personal identity. I conclude by arguing that valid ADs protect the dignity and autonomy of Alzheimer's patients and that, therefore, there are moral obligations to uphold ADs which should be reflected in public policy and legislation.

Creating a safer and better functioning system: Lessons to be learned from the Netherlands for an ethical defence of an autonomy-only approach to assisted dying.

The proposal to allow assisted dying for people who are not severely ill reignited the Dutch end-of-life debate when it was submitted in 2016. A key criticism of this proposal is that it is too radical a departure from the safe and well-functioning system the Netherlands already has. The goal of this article is to respond to this criticism and question whether the Dutch system really can be described as safe and well functioning. I will reconsider the usefulness of the suffering criterion, and I will ultimately argue this criterion should be rejected altogether. Instead, we should consider moving towards an autonomy-only approach to assisted dying. This would resolve some significant issues occurring under the current system of assisted dying in the Netherlands and ultimately make the process safer and better functioning. I will then consider some possible objections to adopting an autonomy-only approach and provide some preliminary responses to these also. I will finally highlight some potential areas where further research may be necessary, namely, how to mitigate the effect of external factors such as poverty or other life aspects that may have the potential to distort the individual's ability to make autonomous decisions. I will also consider some possible international lessons that can be taken from both current as well as the proposed practice in the Netherlands.

Patient perspectives on informed consent for medical AI: A web-based experiment.

Objective: Despite the increasing use of AI applications as a clinical decision support tool in healthcare, patients are often unaware of their use in the physician's decision-making process. This study aims to determine whether doctors should disclose the use of AI tools in diagnosis and what kind of information should be provided. Methods: A survey experiment with 1000 respondents in South Korea was conducted to estimate the patients' perceived importance of information regarding the use of an AI tool in diagnosis in deciding whether to receive the treatment. Results: The study found that the use of an AI tool increases the perceived importance of information related to its use, compared with when a physician consults with a human radiologist. Information regarding the AI tool when AI is used was perceived by participants either as more important than or similar to the regularly disclosed information regarding short-term effects when AI is not used. Further analysis revealed that gender, age, and income have a statistically significant effect on the perceived importance of every piece of AI information. Conclusions: This study supports the disclosure of AI use in diagnosis during the informed consent process. However, the disclosure should be tailored to the individual patient's needs, as patient preferences for information regarding AI use vary across gender, age and income levels. It is recommended that ethical guidelines be developed for informed consent when using AI in diagnoses that go beyond mere legal requirements.

Unlocking future learning: Exploring higher education students' intention to adopt meta-education.

Despite the potential of meta-education to transform higher education, there remains a scarcity of research investigating students' adoption intentions. This study aimed to identify factors influencing students' intentions to adopt meta-education using an extended Decomposed Theory of Planned Behavior model (DTPB). Data was collected via an online survey of 596 higher education students from Jordan who were purposefully selected. Structural equation modeling using partial least squares analysis revealed attitude, social influence, and perceived behavioral control as key antecedents of adoption intention. Furthermore, newly added variables including perceived enjoyment, herd behavior, student autonomy, and student innovativeness showed efficiency in explaining variance in attitude, social influence, and perceived behavioral control. Overall, the extended model provided meaningful insights on factors driving students' willingness to adopt meta-education. The study contributes to theory by extending the decomposed TPB model in the context of emerging educational technologies. It also provides practical implications for policymakers and educators aiming to encourage meta-education adoption.

Ankle fracture surgery performed by orthopaedic residents without supervision has comparable outcomes to surgery performed by fellowship trained orthopaedic surgeons.

BACKGROUND: Unstable fractures often necessitate open reduction and internal fixation (ORIF), which generally yield favourable outcomes. However, the impact of surgical trainee autonomy on healthcare quality in these procedures remains uncertain. We hypothesized that surgery performed solely by residents, without supervision or participation of an attending surgeon, can provide similar outcomes to surgery performed by trauma or foot and ankle fellowship-trained orthopaedic surgeons. METHODS: A single-center cohort of an academic level-1 trauma center was retrospectively reviewed for all ankle ORIF between 2015 and 2019. Data were compared between surgery performed solely by post-graduate-year 4 to 6 residents, and surgery performed by trauma or foot and ankle fellowship-trained surgeons. Demographics, surgical parameters, preoperative and postoperative radiographs, and primary (mortality, complications, and revision surgery) and secondary outcome variables were collected and analyzed. Univariate analysis was performed to evaluate outcomes. RESULTS: A total of 460 ankle fractures were included in the study. Nonoperative cases and cases operated by senior orthopaedic surgeons who are not trauma or foot and ankle fellowship-trained orthopaedic surgeons were excluded. The average follow-up time was 58.4 months (SD ± 12.5). Univariate analysis of outcomes demonstrated no significant difference between residents and attendings in complications and reoperations rate (p = 0.690, p = 0.388). Sub-analysis by fracture pattern (Lauge-Hansen classification) and the number of malleoli involved and fixated demonstrated similar outcomes. surgery time was significantly longer in the resident group (p < 0.001). CONCLUSION: The current study demonstrates that ankle fracture surgery can be performed by trained orthopaedic surgery residents, with similar results and complication rates as surgery performed by fellowship-trained attendings. These findings provide valuable insights into surgical autonomy in residency and its role in modern clinical training and surgical education. LEVEL OF EVIDENCE: Level III - retrospective cohort study.

Seize the Data: An Analysis of Guardianship Annual Reports.

Courts have a legal and ethical duty to monitor adult guardianship cases to protect the rights of individuals with guardians. Aging and disability advocates have been recommending improvements to adult guardianship monitoring for decades. The aim of this study is to examine annual guardianship reporting procedures in each state. Using the National Guardianship Association's (NGA) Standards of Practice as a guide, we summarize what is missing from adult guardianship annual report forms in each state. Since 2000, the NGA Standards have been the benchmark for guiding guardianship best practices, making it a valuable tool for guardianship reporting and monitoring. Results show that most states are not collecting thorough data on adults with guardians, their guardians, or the guardian-client relationship. Additionally, many existing annual report forms may be difficult to complete due to confusing question structure and reading levels that are above the national average, especially since most adult guardians are nonprofessional guardians. Improved reporting procedures would help courts monitor guardianships more effectively, ensure that the rights of individuals with guardians are being protected, and provide meaningful data on the overall state of guardianship. Limitations and plans for future research are also discussed.

Laparoscopic vs robotic inguinal hernia repair: a comparison of learning curves and skill transference in general surgery residents.

BACKGROUND: There is no consensus on whether laparoscopic experience should be a prerequisite for robotic training. Further, there is limited information on skill transference between laparoscopic and robotic techniques. This study focused on the general surgery residents' learning curve and skill transference within the two minimally invasive platforms. METHODS: General surgery residents were observed during the performance of laparoscopic and robotic inguinal hernia repairs. The recorded data included objective measures (operative time, resident participation indicated by percent active time on console or laparoscopy relative to total case time, number of handoffs between the resident and attending), and subjective evaluations (preceptor and trainee assessments of operative performance) while controlling for case complexity, patient comorbidities, and residents' prior operative experience. Wilcoxon two-sample tests and Pearson Correlation coefficients were used for analysis. RESULTS: Twenty laparoscopic and forty-four robotic cases were observed. Mean operative times were 90 min for robotic and 95 min for laparoscopic cases (P = 0.4590). Residents' active participation time was 66% on the robotic platform and 37% for laparoscopic (P = < 0.0001). On average, hand-offs occurred 9.7 times during robotic cases and 6.3 times during laparoscopic cases (P = 0.0131). The mean number of cases per resident was 5.86 robotic and 1.67 laparoscopic (P = 0.0312). For robotic cases, there was a strong correlation between percent active resident participation and their prior robotic experience (r = 0.78) while there was a weaker correlation with prior laparoscopic experience (r = 0.47). On the other hand, prior robotic experience had minimal correlation with the percent active resident participation in laparoscopic cases (r = 0.12) and a weak correlation with prior laparoscopic experience (r = 0.37). CONCLUSION: The robotic platform may be a more effective teaching tool with a higher degree of entrustability indicated by the higher mean resident participation. We observed a greater degree of skill transference from laparoscopy to the robot, indicated by a higher degree of correlation between the resident's prior laparoscopic experience and the percent console time in robotic cases. There was minimal correlation between residents' prior robotic experience and their participation in laparoscopic cases. Our findings suggest that the learning curve for the robot may be shorter as prior robotic experience had a much stronger association with future robotic performance compared to the association observed in laparoscopy.

A multicenter randomized controlled feasibility trial of a digital self-management intervention for adults with epilepsy.

OBJECTIVE: Self-management interventions may enhance health-related quality of life (HRQoL) in epilepsy. However, several barriers often impair their implementation in the real world. Digital interventions may help to overcome some of these barriers. Considering this, the Helpilepsy Plus Prototype was developed as a prototype smartphone-delivered self-care treatment program for adults with epilepsy. METHODS: The 12-week Helpilepsy Plus Prototype was evaluated through a randomized controlled feasibility trial with a waiting-list control (WLC) group. Outcome measurement at baseline and at 12 weeks assessed adherence to the prototype intervention and changes in epilepsy-related outcomes. The primary endpoint was patient autonomy measured with EASE, and secondary endpoints included HRQoL measured with QOLIE-31, health literacy measured with HLQ, anxiety, and depression symptoms measured with HADS. Semi-structured interviews were conducted with a heterogeneous sample of participants to assess user-friendliness and usefulness. The prototype program was delivered through the Neuroventis Platform (Neuroventis, BV, Overijse, Belgium), a certified medical device (under EU/MDD Class I, and EU/MDR grace period). RESULTS: Ninety-two patients were included (46 in the intervention group, 46 in WLC). Most participants (63%, 58/92 women, median age 30 years) had pharmacoresistant epilepsy (61%, 56/92). Only 22% of participants (10/46) in the intervention group completed at least half of all intervention sessions. No significant differences between the intervention group and WLC were observed. Although there was a larger proportion of patients in the intervention group with meaningful improvements in HRQoL compared to WLC (19/46 versus 11/46), the difference was not significant (p = 0.119). Qualitative feedback showed that participants would appreciate more personalization, such as adaptation of the content to their current epilepsy knowledge level, a more interactive interface, shorter text sections, and interaction through reminders and notifications. SIGNIFICANCE: Digital interventions should allow sufficient scope for personalization and interaction to increase patient engagement and enable benefits from self-care apps. Feedback loops allow the participatory development of tailored interventions. PLAIN LANGUAGE SUMMARY: In this study, we investigated the effectiveness of an app-based self-help intervention. Study participants were either randomly assigned to a group that had access to the app or a group that received access to the app after the end of the study. Although a larger proportion of participants in the intervention group showed a relevant improvement in quality of life, the difference between the two groups was not statistically significant. Less than one-fifth of participants in the intervention group attended at least half of all intervention sessions; patient feedback showed that patients required more personalization and interactive options.

Intensive Care Unit Nurses' Professional Autonomy: A Scoping Review.

Intensive care unit (ICU) nurses' professional autonomy is a critical factor affecting their ability to sustainably provide high-quality care to patients who are critically ill and to their families. However, in the absence of a systematic or scoping review of ICU nurses' professional autonomy, limited information and evidence are available on this topic. The aim of this scoping review was to clarify the extent and type of evidence on ICU nurses' professional autonomy. This scoping review was conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews. The following research questions were addressed: (1) Which areas of interest and trends regarding ICU nurses' professional autonomy have been explored in studies published in scientific journals? And (2) What is known about ICU nurses' professional autonomy? The data sources included MEDLINE, CINAHL Ultimate, PsycINFO, Cochrane Library, and Ichushi-Web of the Japan Medical Abstracts Society databases. Identified studies were mapped based on their aim, design, methodology, and key findings and categorized according to their focus areas. Of the 734 identified studies, 16 were analyzed. The identified categories were as follows: "relationship between professional autonomy and mental issues," "experiences and processes of exercising professional autonomy," "relationship between professional autonomy and nurse-physician collaboration," "relationship between professional autonomy and demographic characteristics," "concept of professional autonomy," "barriers to professional autonomy," and "team approach to improve professional autonomy." Most studies have focused on the relationship between professional autonomy and mental health issues and nurse-physician collaboration and few included interventions to enable or promote the exercise of professional autonomy, highlighting a research gap. Future research should identify factors that inhibit the professional autonomy of ICU nurses and that can be changed through interventions and should develop educational and organizational change-based interventions to modify the factors.

The pedagogical foundations of student voice practices: The role of relationships, differentiation, and choice in supporting student voice practices in high school classrooms.

Although teachers and administrators increasingly support the idea of student voice, questions remain about what "student voice" looks like in practice. This mixed methods study in two urban U.S. high schools explores what student voice practices in the classroom entail and how these practices relate to other pedagogical strategies. Findings reveal that student-teacher relationships, differentiated instruction, and choice serve as core building blocks for the use of student voice practices in the classroom. Findings also underscore the rarity of the student voice practices of seeking student feedback and input and engaging in collaborative decision-making with students.

Autonomy, Resilience and Life Satisfaction among Badminton Paralympians.

Background: People with disabilities are marginalised in mainstream culture and they also experience increased restrictions in a variety of areas, such as sport. The barriers they encounter may adversely affect their life satisfaction, especially if they have a low perceived sense of autonomy and resilience. The purpose of this study was to investigate the relationship between autonomy, resilience and life satisfaction in para-badminton athletes and the mediating role of resilience in the relationship between autonomy and life satisfaction. Methods: Data were collected from 137 para-badminton athletes (male: 65.0% and female: 35.0%). Self-reported measures were used to assess the participants' autonomy, resilience and life satisfaction levels. Results: A structural equation model analysis was performed; the model had sufficient fit indices (comparative fit index [CFI] = 0.94, root mean square error of approximation [RMSEA] = 0.06, standardised root mean square residual [SRMR] = 0.07). The findings showed that autonomy had a significant effect on resilience (ß = 0.32, P = 0.001). Further, resilience had a significant effect on life satisfaction (ß = 0.19, P = 0.011) and significantly mediated the effect of autonomy on life satisfaction (ß = 021, P = 0.033). Conclusion: This study revealed that autonomy fosters resilience among athletes, in turn allowing them to achieve greater life satisfaction. Therefore, society and sport communities should actively seek ways to improve the autonomy and resilience levels of athletes with disabilities.