Process evaluation of appreciative inquiry to translate pain management evidence into pediatric nursing practice

Background

Current healthcare systems have extended the evidence-based medicine (EBM) approach to health policy and delivery decisions, such as access-to-care, healthcare funding and health program continuance, through attempts to integrate valid and reliable evidence into the decision making process. These policy decisions have major impacts on society and have high personal and financial costs associated with those decisions. Decision models such as these function under a shared assumption of rational choice and utility maximization in the decision-making process.

Discussion

We contend that health policy decision makers are generally unable to attain the basic goals of evidence-based decision making (EBDM) and evidence-based policy making (EBPM) because humans make decisions with their naturally limited, faulty, and biased decision-making processes. A cognitive information processing framework is presented to support this argument, and subtle cognitive processing mechanisms are introduced to support the focal thesis: health policy makers' decisions are influenced by the subjective manner in which they individually process decision-relevant information rather than on the objective merits of the evidence alone. As such, subsequent health policy decisions do not necessarily achieve the goals of evidence-based policy making, such as maximizing health outcomes for society based on valid and reliable research evidence.

Summary

In this era of increasing adoption of evidence-based healthcare models, the rational choice, utility maximizing assumptions in EBDM and EBPM, must be critically evaluated to ensure effective and high-quality health policy decisions. The cognitive information processing framework presented here will aid health policy decision makers by identifying how their decisions might be subtly influenced by non-rational factors. In this paper, we identify some of the biases and potential intervention points and provide some initial suggestions about how the EBDM/EBPM process can be improved.     

Policy actors' narrative constructions of migrants' integration in Malmö and Bologna

Governments have policies explicitly directed at the integration of migrants. This article addresses how policymakers and politicians privilege certain constructions of the social relationship between migrants and the majority society (expressed through narratives of ‘integration’), while making it seem as if they were presenting facts in their policies. These constructions provide the justifications for adopting a direction in policy-making over other alternatives. This article sets to analyse comparatively how policy actors in two urban contexts construct migrants' integration through policy narratives and how, within this, they evaluate migrants as ‘integrated’ and ‘non-integrated’. Through narrative analysis, the article sheds light on how migrants are positioned by political institutions within the normative order of the society in which they live. Furthermore, it shows that local policy-making is shaped by national citizenship regimes, models of steering, welfare regimes and stories about the nation and its people.     

Science and policy: valuing framing, language and listening

This paper considers the context for science contributing to policy development and explores some critical issues that should inform science advocacy and influence with policy makers. The paper argues that the key challenges are at least as much in educating conservation scientists and science communicators about society and policy making as they are in educating society and policy makers about science. The importance of developing processes to ensure that scientists and science communicators invest in the development of relationships based on respect and understanding of their audience in both communities and amongst policy makers provides a critical first step. The objectives of the Global Strategy for Plant Conservation acknowledge the importance of developing the capacities and public engagement necessary to implement the Strategy, including knowledge transfer and community capacity building. However, the development of targets to equip institutions and plant conservation professionals to explicitly address the barriers to influencing policy development through knowledge transfer and integration require further consideration.     

A Parametric ROC Model‐Based Approach for Evaluating the Predictiveness of Continuous Markers in Case–Control Studies

Summary The predictiveness curve shows the population distribution of risk endowed by a marker or risk prediction model. It provides a means for assessing the model's capacity for stratifying the population according to risk. Methods for making inference about the predictiveness curve have been developed using cross‐sectional or cohort data. Here we consider inference based on case–control studies, which are far more common in practice. We investigate the relationship between the ROC curve and the predictiveness curve. Insights about their relationship provide alternative ROC interpretations for the predictiveness curve and for a previously proposed summary index of it. Next the relationship motivates ROC based methods for estimating the predictiveness curve. An important advantage of these methods over previously proposed methods is that they are rank invariant. In addition they provide a way of combining information across populations that have similar ROC curves but varying prevalence of the outcome. We apply the methods to prostate‐specific antigen (PSA), a marker for predicting risk of prostate cancer.     

Improving the politics of biotechnological innovations in food security and other sustainable development goals

The unwarranted interference of some environmental non-governmental organisations (ENGOs) in decision-making over genetically modified (GM) crops has prompted calls for politics to be removed from the regulatory governance of these products. However, regulatory systems are inevitably political because their purpose is to decide whether the use of particular products will help or hinder the delivery of public policy objectives. ENGOs are most able to interfere in regulatory decision-making when policy objectives and decision-making criteria are vague, making the process vulnerable to disruption by organisations that have a distinct agenda. Making regulatory decision-making about GM crops and other green biotechnology more resistant to interference therefore requires better politics not the removal of politics. Better politics begins with political leadership making a case for green biotechnology in achieving food security and other sustainable development goals. Such a policy must involve making political choices and cannot be outsourced to science. Other aspects of better politics include regulatory reform to set policy aims and decision-making criteria that encourage innovation as well as control risk, and engagement with civil society that discusses the values behind attitudes to the application of green biotechnology. In short, green biotechnology for sustainable development needs better politics to counter well-organised opposition, to encourage innovation, and to build the trust of civil society for these policies. Removing politics from regulatory governance would be a gift to ENGOs that are opposed to the use of biotechnology.

     

Sorcerers,saints and charlatans: Black folk healers in urban America

Case histories of black Americans who believe their illness has been caused by sorcery have been reported with increasing frequency in the clinical literature. Such individuals often believe that their problems are not amenable to orthodox medical regimens and they may leave treatment to seek out a folk healer. Healers believed to be able to cure sorcery are viewed ambivalently as they are thought able to magically cause illness as well as cure it. There is little information available on such individuals or their modes of treatment, making it difficult to assess their abilities. This article reviews what is known about such individuals, including an attempt to learn more about those who have advertised in a large city newspaper. It is concluded that some of these individuals provide a useful service to their clients but that many others use their reputations as manipulators of occult powers to extract money from the poor and gullible.     

Making predictive ecology more relevant to policy makers and practitioners

One of the aims of ecology is to aid policy makers and practitioners through the development of testable predictions of relevance to society. Here, we argue that this capacity can be improved in three ways. Firstly, by thinking more clearly about the priority issues using a range of methods including horizon scanning, identifying policy gaps, identifying priority questions and using evidence-based conservation to identify knowledge gaps. Secondly, by linking ecological models with models of other systems, such as economic and social models. Thirdly, by considering alternative approaches to generate and model data that use, for example, discrete or categorical states to model ecological systems. We particularly highlight that models are essential for making predictions. However, a key to the limitation in their use is the degree to which ecologists are able to communicate results to policy makers in a clear, useful and timely fashion.     

Are life cycle assessments a threat to sound public policy making?

This paper deals with the question of whether Life Cycle Assessments (LCAs), with their focus on objective and quantitative results, are the best way to support public policy processes. The public policy making process is characterized as a continuous discoursive struggle. Criteria are defined to distinguish between good and bad public policy discourses to judge the effects of LCA on the public policy process. Many policy scientists argue that methodologies that emphasize quantification and the use of formal methods are not beneficial for sound public policy making. An empirical report of the role LCAs played in public policy making processes on PVC and chlorine in the Netherlands is made to evaluate the contribution of LCAs to public policy making processes and to identify the main limitations of the current LCA methodologies and practices. It appears that political actors tend to use LCAs in a polarizing way. LCAs are easily misused due to their apparent objectivity, and the quantitative and black box nature of their results. LCAs contain an implicit, normative frame that does not match the environmentalists’ perception on the kind of evidence needed on toxic effects of organochlorines, which reduced the open nature of the Dutch PVC debate. It is recommended to develop a methodology for product evaluation that approaches the issue in a more open and emergent way to prevent “premature closure” of the analysis. It is expected that a focus on the development of balanced, rich arguments on facts and values in the study process will be more fruitful than the calculation of integral, quantitative indicators.     

Why treat doctors like pushers?

Harsher laws and enforcement procedures are making Canadian physicians more vulnerable to conviction as drug traffickers. The authors question this development on the grounds that it extends a drug prohibition policy that has failed in the past and has incurred intolerable social costs. To help envision an alternative, the authors discuss conflicting claims about the British tradition of permitting doctors to prescribe narcotics to addicts. They conclude that, with some restrictions, allowing Canadian doctors to prescribe narcotics according to their judgements of patient needs would be more efficacious than increasing the penalties they face for violating nonmedical norms.     

Dynamic models and large scale field experiments in environmental impact assessment and management

Abstract Dynamic numerical models and field experiments play important roles in impact assessment and management. Unfortunately, extreme and simplistic views have developed about whether and how to use these tools, so their complementary values to the manager are often not recognized. We often hear the outrageous claim (or hope) that numerical models can synthesize ‘all’ relevant information for predicting the impact of policy choice, hence making experimental experience unnecessary. From experimentalists, we hear the equally naive criticism that ecological systems are so complex that nothing is predictable without experimental experience. What we usually get from the proponents of these extremes are either models that are dangerously unreliable, or experiments that provide nice scientific answers to the wrong questions. Wise use of modelling begins with the following points: (i) explicit modelling is an excellent way to clarify policy concerns and identify processes that are most likely to be important in making predictions about policy effects; (ii) we can do a very good job of modelling some processes and relationships, particularly those having to do with basic spatial and temporal scales of impact as related to physical transport, chemical transformations, and life history characteristics of indicator populations (longevity, delays and response times due to age structured rates of reproduction and mortality); and (iii) there are some important dynamic processes, such as long-term accumulation of toxic materials in the environment, that unfold over such large space and time scales as to preclude direct experimental study (leaving only the issue of which models to use in making predictions, not whether to model - unless the processes are simply ignored). But points (i) and (ii) represent steps that a good experimentalist will take anyway: be clear about what practical results an experiment is intended to produce, and do not waste effort on experiments to measure things that can be predicted reliably from existing knowledge. The key to successful use of modelling and experimentation in management is in making good judgements about the interface between points (ii) and (iii); that is, in making good judgements about both what variables cannot be reliably predicted, and of these, which to treat experimentally and which to gamble on predicting from models.     

Mensch and Mesh

This article discusses several relationships between technologies, industries, and socioeconomic institutions that are central to the emerging field of industrial ecology but as of yet have found little recognition. Special attention is given to the history of changes in the complexity of technologies and socioeconomic institutions, methods for dealing with this complexity conceptually and in the context of decision making, and interrelationships between technology and policy choice at various levels of system organization. On the basis of that discussion, new roles for systems thinking and modeling, systems engineering, and technology and industrial policy are identified to promote the development of industrial ecosystems that minimize their environmental impacts.     

The development, regulation and use of biopesticides for integrated pest management

Over the past 50 years, crop protection has relied heavily on synthetic chemical pesticides, but their availability is now declining as a result of new legislation and the evolution of resistance in pest populations. Therefore, alternative pest management tactics are needed. Biopesticides are pest management agents based on living micro-organisms or natural products. They have proven potential for pest management and they are being used across the world. However, they are regulated by systems designed originally for chemical pesticides that have created market entry barriers by imposing burdensome costs on the biopesticide industry. There are also significant technical barriers to making biopesticides more effective. In the European Union, a greater emphasis on Integrated Pest Management (IPM) as part of agricultural policy may lead to innovations in the way that biopesticides are regulated. There are also new opportunities for developing biopesticides in IPM by combining ecological science with post-genomics technologies. The new biopesticide products that will result from this research will bring with them new regulatory and economic challenges that must be addressed through joint working between social and natural scientists, policy makers and industry.     

Devolving authority for health care in Canada's provinces: 4. Emerging issues and prospects

Devolution or authority for health care is evaluated in the context of 3 objectives of provincial governments--community empowerment to garner new allies for health care restructuring, service integration to create a true "system" and conflict containment as spending is cut. Devolved authorities cannot pursue each of these objectives with equal vigour because they must balance the competing pressures from their provincial government, their providers and their local citizens. Each devolved authority accommodates these pressures in its own way, through different trade-offs. Appointed board members are generally well intentioned in representing the interests of their entire community but are unlikely to overcome formidable barriers to community empowerment in health care. Unless future board elections attract large and representative voter turnouts, they may fragment board members'' accountability (by making them more accountable to multiple interest groups) rather than solidify it (by making them more accountable to the community). Although boards have integrated and rationalized parts of the institutional sector, integration of the community sector is hampered by structural constraints such as the lack of budgetary authority for a broader scope of services, including physicians'' fees and drugs. Devolved authorities will deflect blame from provincial governments and contain conflict only while they believe that there is still slack in the system and that efficiency can be improved. When boards no longer perceive this, they are likely to add their voices to local discontent with fiscal retrenchment. Continuing evaluation and periodic meetings of authorities to share experiences and encourage cross-jurisdictional policy learning are needed.     

Evidence for social role in a dolphin social network

Social animals have to take into consideration the behaviour of conspecifics when making decisions to go by their daily lives. These decisions affect their fitness and there is therefore an evolutionary pressure to try making the right choices. In many instances individuals will make their own choices and the behaviour of the group will be a democratic integration of everyone’s decision. However, in some instances it can be advantageous to follow the choice of a few individuals in the group if they have more information regarding the situation that has arisen. Here I provide early evidence that decisions about shifts in activity states in a population of bottlenose dolphin follow such a decision-making process. This unshared consensus is mediated by a non-vocal signal, which can be communicated globally within the dolphin school. These signals are emitted by individuals that tend to have more information about the behaviour of potential competitors because of their position in the social network. I hypothesise that this decision-making process emerged from the social structure of the population and the need to maintain mixed-sex schools.     

Precaution,threshold risk and public deliberation

It has been argued that the precautionary principle is incoherent and thus useless as a guide for regulatory policy. In a recent paper in Bioethics, Wareham and Nardini propose a response to the ‘precautionary paradox’ according to which the precautionary principle's usefulness for decision making in policy and regulation contexts can be justified by appeal to a probability threshold discriminating between negligible and non‐negligible risks. It would be of great significance to debates about risk and precaution if there were a sound method for determining a minimum probability threshold of negligible risk. This is what Wareham and Nardini aim to do. The novelty of their approach is that they suggest that such a threshold should be determined by a method of public deliberation. In this article I discuss the merits of Wareham and Nardini’s public deliberation method for determining thresholds. I raise an epistemic worry about the public deliberation method they suggest, and argue that their proposal is inadequate due to a hidden assumption that the acceptability of a risk can be completely analysed in terms of its probability.     

Vaccine mandates,value pluralism,and policy diversity

Political communities across the world have recently sought to tackle rising rates of vaccine hesitancy and refusal, by implementing coercive immunization programs, or by making existing immunization programs more coercive. Many academics and advocates of public health have applauded these policy developments, and they have invoked ethical reasons for implementing or strengthening vaccine mandates. Others have criticized these policies on ethical grounds, for undermining liberty, and as symptoms of broader government overreach. But such arguments often obscure or abstract away from the diverse values that are relevant to the ethical justifications of particular political communities’ vaccine‐mandate policies. We argue for an expansive conception of the normative issues relevant to deciding whether and how to establish or reform vaccine mandates, and we propose a schema by which to organize our thoughts about the ways in which different kinds of vaccine‐mandate policies implicate various values.     

Combinatorial approaches to protein stability and structure.

Why do proteins adopt the conformations that they do, and what determines their stabilities? While we have come to some understanding of the forces that underlie protein architecture, a precise, predictive, physicochemical explanation is still elusive. Two obstacles to addressing these questions are the unfathomable vastness of protein sequence space, and the difficulty in making direct physical measurements on large numbers of protein variants. Here, we review combinatorial methods that have been applied to problems in protein biophysics over the last 15 years. The effects of hydrophobic core composition, the most important determinant of structure and stability, are still poorly understood. Particular attention is given to core composition as addressed by library methods. Increasingly useful screens and selections, in combination with modern high-throughput approaches borrowed from genomics and proteomics efforts, are making the empirical, statistical correlation between sequence and structure a tractable problem for the coming years.     

Assessing the state of the art in national ocean policy studies

Abstract

For over a decade the nation‐states of the world have been redefining the legal and political status of the world's oceans, both unilaterally and in multilateral negotiations. Despite the growing importance of ocean policy, we know too little concerning what are current nation‐state marine interests, how they make their marine related decisions, or how they organize themselves for marine policy. This paper was written as an organizing paper for a workshop to assess the state of the art in national ocean policy studies. It was sponsored by the Marine Science Affairs Program, International Decade of Ocean Exploration Office, National Science Foundation. The paper states the goal of the workshop, it defines the terms of reference, such as public policy, public policy analysis, comparative public policy analysis and national ocean policy; it offers a “systems”; influenced model for the evaluation of national ocean policy, and it identifies the state of our knowledge of the various components of national ocean policy by performing a computer‐based survey of the literature. Some 5,000 studies were examined and reduced to 1,000 relevant items. Highlights of the findings show that: 1) we know most about the output stage of ocean policy, less about input, little about process; 2) we know most about bureaucratic ocean decisions, less about legislative, little about judicial ocean decisions; 3) output studies rose and declined, input studies have increased steadily, and process studies may show a sharp rise; 4) we know most about the United States, Japan, and the USSR, less about Western Europe, little about the Third World; and 5) most of the studies were conducted by those using “traditional”; research tools.     

Marketplace conversations in Cameroon: How and why popular medical knowledge comes into being

The author argues that buyers and sellers of Western pharmaceuticals at a local marketplace in Cameroon construct their ideas about illness and medicines in reaction to two kinds of situations in which they find themselves. The market situation induces people to adjust their medical beliefs to the economic transaction. Sellers are likely to inflate the efficacy of medicines and customers adjust their medical concepts to fit their limited financial means. In that way they rationalise their inability to buy all the drugs they would have liked to buy. The interview situation leads informants to produce rather specific and assured answers on topics about which they may know very little. Reasons include the inequality between interviewer and informant and the latter's wish to avoid making an ignorant impression on the interviewer. Three conversations held during fieldwork in 1983 are discussed.     

Distinguishing structural and functional restraints in evolution in order to identify interaction sites

Structural genomics projects are producing many three-dimensional structures of proteins that have been identified only from their gene sequences. It is therefore important to develop computational methods that will predict sites involved in productive intermolecular interactions that might give clues about functions. Techniques based on evolutionary conservation of amino acids have the advantage over physiochemical methods in that they are more general. However, the majority of techniques neither use all available structural and sequence information, nor are able to distinguish between evolutionary restraints that arise from the need to maintain structure and those that arise from function. Three methods to identify evolutionary restraints on protein sequence and structure are described here. The first identifies those residues that have a higher degree of conservation than expected: this is achieved by comparing for each amino acid position the sequence conservation observed in the homologous family of proteins with the degree of conservation predicted on the basis of amino acid type and local environment. The second uses information theory to identify those positions where environment-specific substitution tables make poor predictions of the overall amino acid substitution pattern. The third method identifies those residues that have highly conserved positions when three-dimensional structures of proteins in a homologous family are superposed. The scores derived from these methods are mapped onto the protein three-dimensional structures and contoured, allowing identification clusters of residues with strong evolutionary restraints that are sites of interaction in proteins involved in a variety of functions. Our method differs from other published techniques by making use of structural information to identify restraints that arise from the structure of the protein and differentiating these restraints from others that derive from intermolecular interactions that mediate functions in the whole organism.