Physician burnout: an examination of personal, professional, and organizational relationships

This study presents an empirical assessment of burnout among physicians in two staff model HMOs and examines the critical relationships between physician burnout and personal, professional, and organizational/worklife factors. The authors hypothesize that a substantial proportion (> 40%) of physicians will report high scores on emotional exhaustion, the key burnout dimension, and that high emotional exhaustion will be correlated with low evaluations of organizational/worklife factors. The survey results found 58% of the physicians reported scores in high emotional exhaustion. Regression analyses established that organizational measures, specifically, evaluative ratings of Workload/Scheduling and Input/Influence were the strongest predictors of emotional exhaustion. The substantial proportion of physicians reporting scores high on the burnout dimensions, and the potential for management to intervene and improve the factors that foster burnout, suggests the need for organizations to examine the impact of their structures, policies, and procedures on physician stress and quality of worklife.

Palliative medicine and the medicalization of death

The emergence of the speciality of palliative medicine in the UK has been generally welcomed and can be seen as a continuation of the attempts to improve the care of dying people begun by the modern hospice movement. However, not everyone has welcomed the new speciality unreservedly. In part, this reflects a more general ambivalence and concern about the role of medicine in terminal care. After a brief discussion of the 'medicalization' of death and an overview of the hospital care of dying people, the paper identifies five concerns about the development of the speciality of palliative medicine in Britain. These are: the lack of clarity about its remit; a potential shift of focus away from terminal care; the inappropriate use of medical technology; the role of other health workers; the consequences for hospice care.

Is the increased spatial uncertainty in the normal periphery due to spatial undersampling or uncalibrated disarray?

There are two possible causes for the elevated positional uncertainty of the peripheral field; undersampling by post receptoral arrays or uncalibrated disarray within post receptoral arrays. In order to assess the relative influences of these two factors to peripheral spatial uncertainty, we apply an approach which has enjoyed much success in the field of colour vision to examine the trade-off between position and contrast errors for spatial vision. We show that, if our positional uncertainty in the periphery is due to spatial undersampling, a correlated contrast inaccuracy should be present. We find no evidence for this expected linkage in the peripheral field at any spatial scale. We conclude that uncalibrated neural disarray rather than undersampling is the cause of peripheral positional uncertainty.

Satisfaction and change: a survey of volunteers in a hospice organisation

Volunteers and their voluntary work play an important role within the 'mixed economy' of health and welfare provision in the U.K. A survey of volunteers working in a hospice organisation in Leicestershire (LOROS) found that most of them were satisfied with their work experiences as volunteers, and felt that they were adequately supported and valued by the organisation and its paid staff. They had become volunteers mainly through contact with friends, and a substantial minority were motivated by their own personal experiences of death. Their contact with dying patients did not cause them any serious emotional difficulties. LOROS has grown from a small, tightly focused organisation, dependent on a relatively small group of committed volunteers, to a much larger, busier, more diverse and geographically dispersed organisation, dependent upon a large pool of volunteers. These changes in the organisation had affected the way in which some volunteers experienced their work, and although they were supportive of the expansion of the organisation their sense of intimacy and belonging had lessened. Given the increasing competition for voluntary workers, the sensitive management of change is seen as vital if LOROS is to maintain the commitment of its volunteers and maintain its attractiveness as an organisation which should be supported by voluntary work.

Extracorporeal life support in paediatrics

Extracorporeal membrane oxygenation (ECMO) is a life support technique based on modifications of heart-lung bypass technology. It is used to support severe but potentially reversible pulmonary or cardiopulmonary failure. There is increasing use of the technique for neonates and a return of interest in its use for adults. The number of non-neonatal paediatric patients receiving pulmonary support with ECMO worldwide is, however, small, and survival rates average less than 50%. Initial experience in 15 patients aged 3 months to 5 years with a high survival and low morbidity is reported.

The influence of health on family contacts and family feelings in advanced old age: a longitudinal study

This study provides a longitudinal analysis of the influences of health, age, gender, and socioeconomic status on family contacts and family feelings in a sample of 62 members of the Berkeley Older Generation Study. Stability in family contacts and in family feelings was observed over 14 years of advanced old age. Of the four predictor variables, health and socioeconomic status accounted for the largest proportion of observed variance. Contrary to our hypotheses, study participants in better health had greater amounts of contact with family than did those in poorer health. The former also had more feelings of closeness to family members, a finding that may reflect greater possibilities for reciprocity between elders in good health and their family members.

The routinization of hospice: charisma and bureaucratization

In 25 years the number of hospices in Britain has multiplied from under 15 in 1965 to over 430 in 1991. During this period, often working out with the mainstream health system, the hospices actively sought to transform terminal care. More recently a process of diversification and legitimation has meant that hospices have become increasingly subject to mainstream influence. Using Weber's concept of charisma we examine the development of the hospice movement during this period of expansion. We suggest there are a number of factors leading to the routinization of hospice care including the ways in which it was sponsored and developed at the local level, and pressures toward bureaucratization and professionalization. We make links with recent developments in the health services. Finally we consider whether it is possible for the hospice movement to sustain its founding ideals.

Neonatal extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation is an effective life support technique that has had most success in the treatment of neonatal cardiopulmonary failure. We review the technique and its potential indications and present the latest UK and worldwide survival data.

Communication with dying patients in coronary care units

There now seems to be a much greater willingness among hospital staff to disclose a terminal prognosis to a patient. The paper starts with a review of the changing attitudes towards disclosure and then considers communication with dying patients in Coronary Care Units. After considering general factors influencing nurse communication with dying patients sources of difficulty in such communication are considered. Characteristics of patients and relatives, of nurses, and features of the work environment may all contribute to communicational difficulties. The paper closes with a brief overview of basic communicative requirements.

Development of a clinical measure of postural control for assessment of adaptive seating in children with neuromotor disabilities

The primary purposes of this article are to review the literature on seating assessment and to describe the development of a clinical evaluation scale, the Seated Postural Control Measure (SPCM), for use with children requiring adaptive seating systems. The SPCM is an observational scale of 22 seated postural alignment items and 12 functional movement items, each scored on a four-point, criterion-referenced scale. A secondary purpose of this article is to report the reliability of the seven-point Level of Sitting Scale (LSS). Interrater and test-retest reliability of the SPCM items and the one-item LSS were evaluated on a sample of 40 children with developmental disabilities who sat with and without their seating systems. Kappa values of .75 or higher were considered excellent, .40 to .74 as fair to good, and less than .40 as poor. The interrater reliability tests for the two seated conditions and the two test sessions conducted 3 weeks apart yielded overall item Kappa coefficient means of .45 for the alignment section and .85 for the function section. Test-retest results for the SPCM items were less satisfactory, with item Kappa coefficient means for the two seating conditions and raters of .35 and .29 for alignment and function, respectively. Reliability results did not appear to be consistently better among seating conditions, raters, or test sessions. Kappa coefficients for the LSS were fair to good for both interrater and test-retest reliability. Plans for future development of the SPCM and LSS are discussed.

Continuity and change in personality in old age--evidence from five longitudinal studies: introduction to a special issue

This short essay introduces some of the current problems in developmental personality theory and comments on the five articles that follow, all of which arise from longitudinal studies of aging in Israel, Sweden, and the United States. Although the study of personality has always been of central interest in psychology, personality development in advanced old age is a very new topic. We hope that this Special Issue will stimulate a lively discussion and will provoke further studies of personality in old age, which is indeed a "special issue."

Personality in advanced old age: continuity or change?

A longitudinal study of elderly persons found evidence of personality development even in advanced old age. Five traits, similar to traits found in younger persons, were identified. Although considerable continuity was found, change also was apparent. An increase in agreeableness was observed for the old-old, bringing their scores up to the level maintained by the oldest-old. Two traits were stable: satisfaction (65% did not change reliably) and intellect (63% did not change reliably). A decline in extraversion occurred in both age groups. Energetic, in which 40% declined, may be more affected than the other traits by external, environmental circumstances. The study confirms the findings of longitudinal studies of children and younger adults and extends them into the final stages of life.

Fear of death and strategies for coping with patient death among medical trainees

This paper describes a longitudinal study of fear of death following up fourth-year medical students in their junior house officer year. It confirms previous findings that the fear of death is and remains multidimensional, with fear of being dead having the lowest score on both occasions and fear of someone close dying being consistently the highest. Fear of death reduces on each dimension over time, though not significantly. An analysis of descriptions of strategies used by students to cope with patient death showed that passive acceptance through rationalizing was the most commonly used, especially by men, followed by supporting the patient emotionally or clinically, which was used especially by women. The highest fear and stress scores were associated with avoidance, dismissal and seeking advice, while the lowest were shown by those who rationalized the event. The paper goes on to describe the relationship of fear of death to various individual differences including empathy, gender, parental death, parental anxiety, and stress.

Survival and place of treatment after premature delivery

In a one year prospective study in the Trent region we examined the short term outcome (survival to discharge) of all infants who required admission to a baby care unit. Infants of less than or equal to 28 weeks' gestation who received all their perinatal care in one of five large centres (each providing more than 600 ventilator days/year) showed significantly better survival rates than infants electively treated throughout their entire course at one of the 12 smaller units (34 survivors from 65 infants (52%) compared with eight survivors from 37 infants (22%). These differences occurred despite the elective transfer of many of the sickest infants from the smaller units to the larger. Differences in survival between more mature infants were not significant. These results support the policy that there should be a more centralised neonatal service for those infants at or below 28 weeks' gestation.

Nurse's accounts of nursing the terminally ill on a coronary care unit

This paper is based on nurses' reported experiences about nursing people dying in a coronary care unit, and their attitudes towards such work. Two patterns of dying associated with cardiac arrest and cardiac failure were typical in the unit, each with its difficulties and problems. However, the nurses did not report any severe coping difficulties associated with their nursing care of dying patients. Their most severe difficulties were those relating to telling relatives about a patient's death. Elements within the unit's ethos and organisation associated with this positive coping were the high staff-patient ratio, low staff turnover, good and supportive relationships among staff, and the policy of open and honest communication about prognosis. Of particular importance was the feeling that everything that it was possible to have done for the patient had been done.

Cerebral haemodynamic effects of changes in positive end expiratory pressure in preterm infants

The effects of changes in positive end expiratory pressure (PEEP) on cerebral blood flow velocity, arterial blood gases, and mean arterial pressure were studied in newborn infants. In mechanically ventilated premature infants with severe respiratory disease, an increase in PEEP from 2 to 6 cm H2O was associated with an increase in cerebral blood flow velocity. There was no significant change in mean arterial blood pressure. There was a significant increase in PaO2 and PaCO2 for every stepwise rise in PEEP. Multivariate regression analysis showed that 72% of the effect on cerebral blood flow velocity was attributable to PaCO2 alone and that any change in blood pressure was not likely to contribute to these changes. There was no evidence that changes in PEEP within the commonly used range adversely affected the neonatal cardiovascular or cerebral circulations.

Emotional involvement with the dying in a coronary care unit

The conflict between professional distance and emotional involvement has been identified as a central problem for nurses in their care of dying patients. While some nurses may attempt to maintain their professional distance, individualised methods of patient care encourage the development of emotional involvement between nurses and their patients. Where such nursing methods are used it is essential that appropriate ways exist of handling the problems which such involvement may cause nurses. In the coronary care unit studied, the organisation of nursing work facilitated close and continuing contact between nurses and their patients, thereby increasing the chance that emotional involvement would develop. The death of a patient was not viewed by the nurses as a 'failure', but there were sometimes difficulties for them arising from their involvement with the patient. This paper describes the handling of death and dying in the unit, and some of the issues surrounding emotional involvement and communication with dying patients.

Inspiratory-to-expiratory ratio during ventilation for idiopathic respiratory distress syndrome

We have studied the effects of changes in inspiratory-to-expiratory ratios (I/E ratios) on transcutaneous blood gases in a group of 30 infants receiving respiratory support for the idiopathic respiratory distress syndrome (IRDS). Following the use of a reversed I/E ratio (inspiration exceeding expiration), changes in oxygenation were very variable but improvements were seen most consistently in babies weighing greater than 1,750 g and less than 850 g. The use of reversed I/E ratios seemed less efficient than positive end-expiratory pressure in raising TcPO2 for the same increase in mean airway pressure. Changes from a 1:1 ratio to a normal I/E ratio, in which expiratory time exceeded inspiratory time by 50-100%, led to more marked and consistent falls in TcPO2. We conclude that a flexible attitude toward the use of I/E ratios should be adopted to avoid raising mean airway pressure needlessly.