Moral distress measurement in animal care workers: a systematic review

OBJECTIVES

The mental health of veterinary and other animal health professionals is significantly impacted by the psychological stressors they encounter, such as euthanasia, witnessing animal suffering and moral distress. Moral distress, initially identified in nursing, arises when individuals are aware of the right action but are hindered by institutional constraints. We aimed to review existing research on moral distress scales among animal care workers by focusing on the identification and psychometric validity of its measurement.

DESIGN

Two-step systematic review. First, we identified all moral distress scales used in animal care research in the eligible original studies. Second, we evaluated their psychometric validity, emphasising content validity, which is a critical aspect of patient-reported outcome measures (PROMs). This evaluation adhered to the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN). The results were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

DATA SOURCES

PubMed, EMBASE and PsycINFO to search for eligible studies published between January 1984 and April 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included original (primary) studies that (1) were conducted in animal care workers; (2) describing either the development of a moral distress scale, or validation of a moral distress scale in its original or modified version, to assess at least one of the psychometric properties mentioned in COSMIN guidelines.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers used standardised methods to search, screen and code included studies. We considered the following information relevant for extraction: study reference, name and reference of the moral distress scale used, psychometric properties assessed and methods and results of their assessments. The collected information was then summarised in a narrative synthesis.

RESULTS

The review identified only one PROM specifically adapted for veterinary contexts: the Measure of Moral Distress for Animal Professionals (MMD-AP), derived from the Measure of Moral Distress for Healthcare Professionals (MMD-HP). Both MMD-HP and MMD-AP were evaluated for the quality of development and content validity. The development quality of both measures was deemed doubtful. According to COSMIN, MMD-HP's content validity was rated as sufficient, whereas MMD-AP's was inconsistent. However, the evidence quality for both PROMs was rated low.

CONCLUSION

This is the first systematic review focused on moral distress measurement in animal care workers. It shows that moral distress is rarely measured using standardised and evidence-based methods and that such methods should be developed and validated in the context of animal care.

PROSPERO REGISTRATION NUMBER

CRD42023422259.

Return of participant-level clinical trial results to participants: pilot of a simplified centralised approach

OBJECTIVES

Public access databases such as clinicaltrials.gov achieve dissemination of clinical trial design and aggregated study results. However, return of participant-level data is rarely done. A key barrier includes the proprietary ownership of data by the sponsor. Additionally, investigators may not have access to centralised data, and per International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) Good Clinical Practice, must maintain the confidentiality of participants. This study piloted an approach to return both individual and aggregate clinical trial data to parents of children participating in a series of open-label clinical trials.

SETTING AND DESIGN

A small biotech company obtained central ethics approval (centralised institutional review board [IRB], non-exempt). The study was advertised via parent advocacy groups. Parents of trial participants were offered the option to contact an employee (coordinator) within the company, requesting return of their child's study results. Ethics approval covered participation in six countries. The study focused on the sequential clinical trials of vamorolone VBP15-002 (NCT02760264) and VBP15-003 (NCT02760277) (post-results).

INTERVENTIONS

Contact initiated by the parent enabled the coordinator to obtain informed consent (and separate General Data Protection Regulations consent), with phone translation when needed. Using date of birth and study site location provided by the parent, the data manager reported the participant number to the coordinator. The coordinator retrieved and compiled data, along with an aggregate summary, which was mailed via a password protected and encrypted memory device to the parent. Prereturn and postreturn surveys were sent to consented parents (n=19; 40% of 48 total trial participants) and investigators.

RESULTS

Prereturn surveys indicated a request for as much data as offered, in all formats offered. Postreturn survey showed high satisfaction with the process and data returned. Survey of the physician site investigators (n=10; 100% participation of investigators) voiced general satisfaction with the process, with some reservations.

CONCLUSIONS

This pilot study demonstrates an innovative, cost-effective, centralised and labour conservative approach to return of participant-level and aggregate data to participants in studies.

Maternal responsibility and omission of complexity: an exploration of the portrayal of gestational diabetes mellitus in Danish written media

OBJECTIVES

Gestational diabetes mellitus (GDM) has implications for the future health of both mother and offspring, and there is a risk that mothers are held responsible and blamed for their own and their offspring's long-term health. The media plays a significant role in shaping public perceptions of health. Therefore, our study aimed to investigate how GDM and women with GDM are portrayed in Danish written media.

DESIGN

We identified written newspaper articles reporting on GDM from 2018 to 2019 and analysed them using thematic network analysis and elements from critical discourse analysis.

RESULTS

In total, 130 articles were included in the analysis. Four themes emerged: (1) ways of introducing GDM, (2) descriptions of causes and prevention of GDM, (3) descriptions of consequences of GDM and (4) value-laden descriptions of GDM. GDM was often mentioned in relation to other conditions or factors and with lack of differentiation. Maternal responsibility was emphasised via oversimplified descriptions of causal relations, descriptions of individual agency and no emphasis on structural causes and preventive measures. GDM was positioned as resulting in 'bad pregnancies' using value-laden wordings.

CONCLUSION

We identified various aspects of how GDM is portrayed in written media. The findings signal the importance of clear, nuanced and respectful communication on GDM, including conveying the complexity of the condition and the role of structural factors.

Factors of hospital ethical climate among hospital nurses in Korea: a protocol for systematic review and meta-analysis

INTRODUCTION

The hospital ethical climate refers to the ethical work environment within a hospital, which may positively or negatively impact individual nurses, nursing organisations and patient care. Most of studies investigating the hospital ethical climate among Korean nurses have been published in Korean. However, papers addressing the hospital ethical climate in Korean were excluded from the systematic review. To enhance our comprehension of the hospital ethical climate, a systematic review specifically focusing on Korean nurses is imperative. Additionally, it is crucial to ascertain the factors associated with the hospital ethical climate and their respective effect sizes through meta-analyses.

METHODS AND ANALYSIS

The systematic search will be conducted for papers published in both Korean and English, encompassing the hospital ethics climate of Korean nurses from 10 database inception to May 2023. Two reviewers will independently review each article based on the inclusion and exclusion criteria, and any differences in opinion will be resolved through discussion and consensus. The study selection process will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram. Quality assessment will be conducted using the Checklist for Analytical Cross-Sectional Studies provided by Joanna Briggs Institute. Effect size will be analysed using Comprehensive Meta-Analysis software V.2.0. The results of this study will identify factors related to the hospital ethical climate and the effect size of these factors among nurses in Korea.

ETHICS AND DISSEMINATION

Ethical approval is not required, as the data will be collected from existing literature. Findings will be disseminated through peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42022379812.

Stakeholders' perspectives on clinical trial acceptability and approach to consent within a limited timeframe: a mixed methods study

OBJECTIVES

The Bronchiolitis Endotracheal Surfactant Study (BESS) is a randomised controlled trial to determine the efficacy of endo-tracheal surfactant therapy for critically ill infants with bronchiolitis. To explore acceptability of BESS, including approach to consent within a limited time frame, we explored parent and staff experiences of trial involvement in the first two bronchiolitis seasons to inform subsequent trial conduct.

DESIGN

A mixed-method embedded study involving a site staff survey, questionnaires and interviews with parents approached about BESS.

SETTING

Fourteen UK paediatric intensive care units.

PARTICIPANTS

Of the 179 parents of children approached to take part in BESS, 75 parents (of 69 children) took part in the embedded study. Of these, 55/69 (78%) completed a questionnaire, and 15/69 (21%) were interviewed. Thirty-eight staff completed a questionnaire.

RESULTS

Parents and staff found the trial acceptable. All constructs of the Adapted Theoretical Framework of Acceptability were met. Parents viewed surfactant as being low risk and hoped their child's participation would help others in the future. Although parents supported research without prior consent in studies of time critical interventions, they believed there was sufficient time to consider this trial. Parents recommended that prospective informed consent should continue to be sought for BESS. Many felt that the time between the consent process and intervention being administered took too long and should be 'streamlined' to avoid delays in administration of trial interventions. Staff described how the training and trial processes worked well, yet patients were missed due to lack of staff to deliver the intervention, particularly at weekends.

CONCLUSION

Parents and staff supported BESS trial and highlighted aspects of the protocol, which should be refined, including a streamlined informed consent process. Findings will be useful to inform proportionate approaches to consent in future paediatric trials where there is a short timeframe for consent discussions.

TRIAL REGISTRATION NUMBER

ISRCTN11746266.

Comparative survey among paediatricians, nurses and health information technicians on ethics implementation knowledge of and attitude towards social experiments based on medical artificial intelligence at children's hospitals in Shanghai: a cross-sectional study

OBJECTIVES

Implementing ethics is crucial to prevent harm and promote widespread benefits in social experiments based on medical artificial intelligence (MAI). However, insufficient information is available concerning this within the paediatric healthcare sector. We aimed to conduct a comparative survey among paediatricians, nurses and health information technicians regarding ethics implementation knowledge of and attitude towards MAI social experiments at children's hospitals in Shanghai.

DESIGN AND SETTING

A cross-sectional electronic questionnaire was administered from 1 July 2022 to 31 July 2022, at tertiary children's hospitals in Shanghai.

PARTICIPANTS

All the eligible individuals were recruited. The inclusion criteria were as follows: (1) should be a paediatrician, nurse and health information technician, (2) should have been engaged in or currently participating in social experiments based on MAI, and (3) voluntary participation in the survey.

PRIMARY OUTCOME

Ethics implementation knowledge of and attitude to MAI social experiments among paediatricians, nurses and health information technicians.

RESULTS

There were 137 paediatricians, 135 nurses and 60 health information technicians who responded to the questionnaire at tertiary children's hospitals. 2.4-9.6% of participants were familiar with ethics implementation knowledge of MAI social experiments. 31.9-86.1% of participants held an 'agree' ethics implementation attitude. Health information technicians accounted for the highest proportion of the participants who were familiar with the knowledge of implementing ethics, and paediatricians or nurses accounted for the highest proportion among those who held 'agree' attitudes.

CONCLUSIONS

There is a significant knowledge gap and variations in attitudes among paediatricians, nurses and health information technicians, which underscore the urgent need for individualised education and training programmes to enhance MAI ethics implementation in paediatric healthcare.

War and disaster are forcing a major rethink around mass casualty management

Mass casualty events (MASCAL) do not follow the same rules as typical major incidents. In the West at least, the latter often occur in stable, networked trauma systems, whereas MASCAL are characterised by overwhelming numbers of patients, compounded by protracted scene and transport times, decompensated response systems and significant disruption to infrastructure, command and control.This paper describes the 8Ds approach being taken by the UK Defence Medical Services and the North Atlantic Treaty Organization Emergency Medicine Panel framework to approach MASCAL. The eight domains were derived from literature about management of casualties in the World Wars, and also from approaches taken by civilian health systems as they struggle to manage increasing demand. They are: distribute; decompress; delay; delegate; deliver faster and deliver better; dynamic levels of care; and de-escalate These domains will allow a structured approach to research and innovate around MASCAL, informing better guidelines for their management.

Ethics and legal requirements for data linkage in 14 European countries for children with congenital anomalies

INTRODUCTION

Linking healthcare data sets can create valuable resources for research, particularly when investigating rare exposures or outcomes. However, across Europe, the permissions processes required to access data can be complex. This paper documents the processes required by the EUROlinkCAT study investigators to research the health and survival of children with congenital anomalies in Europe.

METHODS

Eighteen congenital anomaly registries in 14 countries provided information on all the permissions required to perform surveillance of congenital anomalies and to link their data on live births with available vital statistics and healthcare databases for research. Small number restrictions imposed by data providers were also documented.

RESULTS

The permissions requirements varied substantially, with certain registries able to conduct congenital anomaly surveillance as part of national or regional healthcare provision, while others were required to obtain ethics approvals or informed consent. Data linkage and analysis for research purposes added additional layers of complexity for registries, with some required to obtain several permissions, including ethics approvals to link the data. Restrictions relating to small numbers often resulted in a registry's data on specific congenital anomalies being unusable.

CONCLUSION

The permissions required to obtain and link data on children with congenital anomalies varied greatly across Europe. The variation and complexity present a significant obstacle to the use of such data, especially in large data linkage projects. Furthermore, small number restrictions severely limited the research that could be performed for children with specific rare congenital anomalies.

Disparities in sport participation of transgender women: a systematic and scoping review protocol

INTRODUCTION

Transgender women experience disparities in sport participation that are exacerbated by policies from sport organisations and legislation in the USA regulating the participation of transgender women in the category that best aligns with their gender identity. Both transgender and cisgender women are affected by these policies because sport organisations do not have a clear understanding of the effects of gender-affirming hormone therapy on transgender women and the unfair advantage they may have over cisgender women athletes. This article describes a review protocol to understand disparities in sport participation of transgender women.

METHODS AND ANALYSIS

A systematic and scoping review is being conducted. Studies are included if they explore disparities in sport participation (ie, participation rates, real and/or perceived barriers to participation) of transgender women of any age. A search strategy has been developed for PubMed, EMBASE, Web of Science, Cochrane Library and CINAHL. Relevant grey literature will also be scanned. The planned search dates are July and August 2023.

ETHICS AND DISSEMINATION

This review does not directly involve human subjects, so ethical approval is not required. Findings from the systematic review will be disseminated via publications in peer-reviewed journals and conferences.

Approaches to consent in public health research in secondary schools

OBJECTIVES

We assess different approaches to seeking consent in research in secondary schools.

DESIGN

We review evidence on seeking active versus passive parent/carer consent on participant response rates and profiles. We explore the legal and regulatory requirements governing student and parent/carer consent in the UK.

RESULTS

Evidence demonstrates that requiring parent/carer active consent reduces response rates and introduces selection biases, which impact the rigour of research and hence its usefulness for assessing young people's needs. There is no evidence on the impacts of seeking active versus passive student consent but this is likely to be marginal when researchers are directly in communication with students in schools. There is no legal requirement to seek active parent/carer consent for children's involvement in research on non-medicinal intervention or observational studies. Such research is instead covered by common law, which indicates that it is acceptable to seek students' own active consent when they are judged competent. General data protection regulation legislation does not change this. It is generally accepted that most secondary school students age 11+ are competent to provide their own consent for interventions though this should be assessed individually.

CONCLUSION

Allowing parent/carer opt-out rights recognises their autonomy while giving primacy to student autonomy. In the case of intervention research, most interventions are delivered at the level of the school so consent can only practically be sought from head teachers. Where interventions are individually targeted, seeking student active consent for these should be considered where feasible.

Implementation of a culturally competent APOL1 genetic testing programme into living donor evaluation: A two-site, non-randomised, pre-post trial design

INTRODUCTION

While living donor (LD) kidney transplantation is the optimal treatment for patients with kidney failure, LDs assume a higher risk of future kidney failure themselves. LDs of African ancestry have an even greater risk of kidney failure post-donation than White LDs. Because evidence suggests that Apolipoprotein L1 (APOL1) risk variants contribute to this greater risk, transplant nephrologists are increasingly using APOL1 genetic testing to evaluate LD candidates of African ancestry. However, nephrologists do not consistently perform genetic counselling with LD candidates about APOL1 due to a lack of knowledge and skill in counselling. Without proper counselling, APOL1 testing will magnify LD candidates' decisional conflict about donating, jeopardising their informed consent. Given cultural concerns about genetic testing among people of African ancestry, protecting LD candidates' safety is essential to improve informed decisions about donating. Clinical 'chatbots', mobile apps that provide genetic information to patients, can improve informed treatment decisions. No chatbot on APOL1 is available and no nephrologist training programmes are available to provide culturally competent counselling to LDs about APOL1. Given the shortage of genetic counsellors, increasing nephrologists' genetic literacy is critical to integrating genetic testing into practice.

METHODS AND ANALYSIS

Using a non-randomised, pre-post trial design in two transplant centres (Chicago, IL, and Washington, DC), we will evaluate the effectiveness of culturally competent APOL1 testing, chatbot and counselling on LD candidates' decisional conflict about donating, preparedness for decision-making, willingness to donate and satisfaction with informed consent and longitudinally evaluate the implementation of this intervention into clinical practice using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework.

ETHICS AND DISSEMINATION

This study will create a model for APOL1 testing of LDs of African ancestry, which can be implemented nationally via implementation science approaches. APOL1 will serve as a model for integrating culturally competent genetic testing into transplant and other practices to improve informed consent. This study involves human participants and was approved by Northwestern University IRB (STU00214038). Participants gave informed consent to participate in the study before taking part.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04910867. Registered 8 May 2021, https://register.

CLINICALTRIALS

gov/prs/app/action/SelectProtocol?sid=S000AWZ6&selectaction=Edit&uid=U0001PPF&ts=7&cx=-8jv7m2 ClinicalTrials.gov Identifier: NCT04999436. Registered 5 November 2021, https://register.

CLINICALTRIALS

gov/prs/app/action/SelectProtocol?sid=S000AYWW&selectaction=Edit&uid=U0001PPF&ts=11&cx=9tny7v.

Moral distress among intensive care unit professions in the UK: a mixed-methods study

OBJECTIVE

To assess the experience of moral distress among intensive care unit (ICU) professionals in the UK.

DESIGN

Mixed methods: validated quantitative measure of moral distress followed by purposive sample of respondents who underwent semistructured interviews.

SETTING

Four ICUs of varying sizes and specialty facilities.

PARTICIPANTS

Healthcare professionals working in ICU.

RESULTS

227 questionnaires were returned and 15 interviews performed. Moral distress occurred across all ICUs and professional demographics. It was most commonly related to providing care perceived as futile or against the patient's wishes/interests, followed by resource constraints compromising care. Moral distress score was independently influenced by profession (p=0.02) (nurses 117.0 vs doctors 78.0). A lack of agency was central to moral distress and its negative experience could lead to withdrawal from engaging with patients/families. One-third indicated their intention to leave their current post due to moral distress and this was greater among nurses than doctors (37.0% vs 15.0%). Moral distress was independently associated with an intention to leave their current post (p<0.0001) and a previous post (p=0.001). Participants described a range of individualised coping strategies tailored to the situations faced. The most common and highly valued strategies were informal and relied on working within a supportive environment along with a close-knit team, although participants acknowledged there was a role for structured and formalised intervention.

CONCLUSIONS

Moral distress is widespread among UK ICU professionals and can have an important negative impact on patient care, professional wellbeing and staff retention, a particularly concerning finding as this study was performed prior to the COVID-19 pandemic. Moral distress due to resource-related issues is more severe than comparable studies in North America. Interventions to support professionals should recognise the individualistic nature of coping with moral distress. The value of close-knit teams and supportive environments has implications for how intensive care services are organised.

Evaluation of the US detention standards to protect the health and dignity of migrants: a systematic review of national health standards

OBJECTIVE

The US government detains hundreds of thousands of migrants across a network of facilities each year. This research aims to evaluate the completeness of standards across US detention agencies to protect the health and dignity of migrants.

DESIGN

Five documents from three US agencies were examined in a systematic review: Immigration and Customs Enforcement (ICE; 3), Customs and Border Protection (CBP; 1) and Office of Refugee Resettlement (ORR; 1). Standards within five public health categories (health, hygiene, shelter, food and nutrition, protection) were extracted from each document and coded by subcategory and area. Areas were classified as critical, essential or supportive. Standards were measured for specificity, measurability, attainability, relevancy and timeliness (SMART), resulting in a sufficiency score (0%-100%). Average sufficiency scores were calculated for areas and agencies.

RESULTS

711 standards were extracted within 5 categories, 12 subcategories and 56 areas. 284 standards of the 711 standards were included in multiple (2-7) areas, resulting in 1173 standards counted as many times as each was included. On average, 85.4% of standards were specific, 87.1% measurable, 96.6% attainable and 74.9% time-bound. All standards were considered relevant. CBP standards were the least sufficient across all other SMART components, when compared with ICE and ORR.

CONCLUSIONS

There are disparate detention standards based on agencies' mandates and type of facility contracts. Migrants should be ensured of their public health rights and services in all spaces they occupy, and for any length of time regardless of who manages the facility. As long as detention remains a policy, the US should develop comprehensive, consistent and complementary standards for all detention facilities or pursue alternatives to detention.

Public reporting of clinical trial findings as an ethical responsibility to participants: a qualitative study

OBJECTIVE

To understand how the experiences and views of trial participants, trial investigators and others connected to clinical trial research relate to whether researchers have a duty to participants to publicly report research findings.

DESIGN

Qualitative interview study.

SETTING

Semistructured interviews held in person or by telephone between March 2019 and April 2021 with participants in the Canadian provinces of Alberta, British Columbia and Ontario.

PARTICIPANTS

34 participants, including 10 clinical trial participants, 17 clinical trial investigators, 1 clinical research coordinator, 3 research administrators and 3 research ethics board members.

ANALYSIS

We conducted a thematic analysis, including qualitative coding of interview transcripts and identification of key themes.

MAIN OUTCOME MEASURES

Key themes identified through qualitative coding of interview data.

RESULTS

Most clinical trial participants felt that reporting clinical trial results is important. Accounts of trial participants suggest their contributions are part of a reciprocal relationship involving the expectation that research will advance medical knowledge. Similarly, comments from trial investigators suggest that reporting trial results is part of reciprocity with trial participants and is a necessary part of honouring informed consent. Accounts of trial investigators suggest that when drug trials are not reported, this may undermine informed consent in subsequent trials by withholding information on harms or efficacy relevant to informed decisions on whether to conduct or enroll in future trials of similar drugs.

CONCLUSION

The views of trial participants, trial investigators and others connected to clinical trial research in Canada suggest that researchers have an obligation to participants to publicly report clinical trial results and that reporting results is necessary for honouring informed consent.

Evaluating a clinical ethics committee (CEC) implementation process in an oncological research hospital: protocol for a process evaluation study using normalisation process theory (EvaCEC)

INTRODUCTION

A Clinical Ethics Committee (CEC) is a multi-professional service whose aim is to support healthcare professionals (HPs) and healthcare organisations to deal with the ethical issues of clinical practice.Although CEC are quite common worldwide, their successful implementation in a hospital setting presents many challenges.EVAluating a Clinical Ethics Committee implementation process (EvaCEC) will evaluate the implementation of a CEC in a comprehensive cancer centre in Northern Italy 16 months after its establishment.

METHODS AND ANALYSIS

EvaCEC is a mixed-method study with a retrospective quantitative analysis and a prospective qualitative evaluation by a range of data collection tools to enable the triangulation of data sources and analysis. Quantitative data related to the amount of CEC activities will be collected using the CEC's internal databases. Data on the level of knowledge, use and perception of the CEC will be collected through a survey with closed-ended questions disseminated among all the HPs employed at the healthcare centre. Data will be analysed with descriptive statistics.The Normalisation Process Theory (NPT) will be used for the qualitative evaluation to determine whether and how the CEC can be successfully integrated into clinical practice. We will perform one-to-one semistructured interviews and a second online survey with different groups of stakeholders who had different roles in the implementation process of the CEC. Based on NPT concepts, the interviews and the survey will assess the acceptability of the CEC within the local context and needs and expectations to further develop the service.

ETHICS AND DISSEMINATION

The protocol has been approved by the local ethics committee. The project is co-chaired by a PhD candidate and by a healthcare researcher with a doctorate in bioethics and expertise in research. Findings will be disseminated widely through peer-reviewed publications, conferences and workshops.

TRIAL REGISTRATION NUMBER

NCT05466292.

Learning from stakeholders to inform good practice guidance on consent to research in intensive care units: a mixed-methods study

OBJECTIVES

Obtaining informed consent from patients in intensive care units (ICUs) prior to enrolment in a study is practically and ethically complex. Decisions about the participation of critically ill patients in research often involve substitute decision makers (SDMs), such as a patient's relatives or doctors. We explored the perspectives of different stakeholder groups towards these consent procedures.

DESIGN AND METHODS

Mixed-methods study comprising surveys completed by ICU patients, their relatives and healthcare practitioners in 14 English ICUs, followed by qualitative interviews with a subset of survey participants. Empirical bioethics informed the analysis and synthesis of the data. Survey data were analysed using descriptive statistics of Likert responses, and analysis of interview data was informed by thematic reflective approaches.

RESULTS

Analysis included 1409 survey responses (ICU patients n=333, relatives n=488, healthcare practitioners n=588) and 60 interviews (ICU patients n=13, relatives n=30, healthcare practitioners n=17). Most agreed with relatives acting as SDMs based on the perception that relatives often know the patient well enough to reflect their views. While the practice of doctors serving as SDMs was supported by most survey respondents, a quarter (25%) disagreed. Views were more positive at interview and shifted markedly depending on particularities of the study. Participants also wanted reassurance that patient care was prioritised over research recruitment. Findings lend support for adaptations to consent procedures, including collaborative decision-making to correct misunderstandings of the implications of research for that patient. This empirical evidence is used to develop good practice guidance that is to be published separately.

CONCLUSIONS

Participants largely supported existing consent procedures, but their perspectives on these consent procedures depended on their perceptions of what the research involved and the safeguards in place. Findings point to the importance of explaining clearly what safeguards are in place to protect the patient.

Do doctors and other healthcare professionals know overdiagnosis in screening and how are they dealing with it? A protocol for a mixed methods systematic review

INTRODUCTION

Overdiagnosis is the diagnosis of a disease that would never have caused any symptom or problem. It is a harmful side effect of screening and may lead to unnecessary treatment, costs and emotional drawbacks. Doctors and other healthcare professionals (HCPs) have the opportunity to mitigate these consequences, not only by informing their patients or the public but also by adjusting screening methods or even by refraining from screening. However, it is unclear to what extent HCPs are fully aware of overdiagnosis and whether it affects their screening decisions. With this systematic review, we aim to synthesise all available research about what HCPs know and think about overdiagnosis, how it affects their position on screening policy and whether they think patients and the public should be informed about it.

METHODS AND ANALYSIS

We will systematically search several databases (MEDLINE, Embase, Web of Science, Scopus, CINAHL and PsycArticles) for studies that directly examine HCPs' knowledge and subjective perceptions of overdiagnosis due to health screening, both qualitatively and quantitatively. We will optimise our search by scanning reference and citation lists, contacting experts in the field and hand searching abstracts from the annual conference on 'Preventing Overdiagnosis'. After selection and quality appraisal, we will analyse qualitative and quantitative findings separately in a segregated design for mixed-method reviews. The data will be examined and presented descriptively. If the retrieved studies allow it, we will review them from a constructivist perspective through a critical interpretive synthesis.

ETHICS AND DISSEMINATION

For this type of research, no ethical approval is required. Findings from this systematic review will be published in a peer-reviewed journal and presented at the annual congress of 'Preventing Overdiagnosis'. In addition, the results will serve as guidance for further research on this topic.

PROSPERO REGISTRATION NUMBER

CRD42021244513.

Black sickle cell patients' lives matter: healthcare, long-term shielding and psychological distress during a racialised pandemic in England - a mixed-methods study

OBJECTIVE

To understand the psychological and social impact of shielding on people with sickle cell disorders and their carers in the Midlands region of England. This region was badly affected during the pandemic, with the city of Birmingham having some of the highest rates of COVID-19 deaths.

DESIGN

A mixed-methods project with a quantitative survey on shielding and adapted SF36 V.2 questionnaire, which was supplemented by qualitative semistructured interviews analysed using interpretive phenomenological analysis (IPA).

PARTICIPANTS

Fifty-one participants who were predominantly of Black Caribbean or Black African heritage anonymously took part in the online survey. We supplemented this with eight in-depth semistructured interviews with adults with sickle cell disorders using IPA.

RESULTS

The adapted 36-Item Short Form Survey (SF36) version 2 (V. 2) survey indicated worse quality of life and mental health. The open-ended questions from the adapted survey also identified shielding concerns about hospital care, pain management and knowledge of sickle cell by healthcare professionals. From the interviews, it emerged that the racialised element of the pandemic caused significant psychological distress for a population group that had to regularly access hospitals. It was noted that psychological health needs both during a pandemic and outside of it were poorly understood and became invisible in services. The psychological impact of experiences of hospital care as well as growing up with an invisible chronic condition were important to understand psychologically.

Moral and exhausting distress working in the frontline of COVID-19: a Swedish survey during the first wave in four healthcare settings

OBJECTIVES

To describe the prevalence and sources of experienced moral stress and anxiety by Swedish frontline healthcare staff in the early phase of COVID-19.

DESIGN

Cross-sectional survey, quantitative and qualitative.

PARTICIPANTS AND SETTING

1074 healthcare professionals (75% nurses) in intensive, ward-based, primary and municipal care in one Swedish county.

MEASURES

A study-specific closed-ended and an open-ended questionnaire about moral stress and the Generalised Anxiety Disorder 7-item scale measuring anxiety, followed by an open question about anxiety.

FINDINGS

Moral stress was experienced by 52% of respondents and anxiety by 40%. Moral stress in concern for others attributed to institutional constraints comprised experiences of being deprived of possibilities to respond to humane and professional responsibility. Staff experienced being restricted in fulfilling patients' and families' need for closeness and security as well as being compelled to provide substandard and inhumane care. Uncertainty about right and good, without blame, was also described. However, a burdensome guilt also emerged as a moral distress, blaming oneself. This comprised feeling complicit in the spread of COVID-19, inadequacy in care and carrying patients' suffering. Staff also experienced an exhausting distress as a self-concern in an uncontrollable work situation. This comprised a taxing insecurity by being in limbo, being alone and fear of failing, despair of being deprived control by not being heard; unable to influence; distrusting management; as well as an excessive workload.

CONCLUSIONS

We have not only contributed with knowledge about experiences of being in the frontline of COVID-19, but also with an understanding of a demarcation between moral stress/distress as a concern for patients and family, and exhausting distress in work situation as self-concern. A lesson for management is that ethics support should first include acknowledgement of self-concern and mitigation of guilt before any structured ethical reflection. Preventive measures for major events should focus on connectedness between all parties concerned, preventing inhumane care and burn-out.

Acceptability of donor funding for clinical trials in the UK: a qualitative empirical ethics study using focus groups to elicit the views of research patient public involvement group members, research ethics committee chairs and clinical researchers

OBJECTIVES

The Plutocratic Proposal is a novel method of funding early phase clinical trials where a single donor funds the entire trial and in so doing secures a place on it. The aim of this study was to identify and explore concerns that may be raised by UK research ethics committees (RECs) when reviewing clinical trials funded in this way.

DESIGN

Empirical ethics combining ethical analysis and qualitative data from three focus groups held online using Frith's symbiotic approach. Data were analysed using inductive thematic approach informed by the study aims and ethical analysis.

PARTICIPANTS

22 participants were recruited: 8 research patient public involvement group members, 7 REC chairs and 7 clinical researchers. All were based in the UK.

RESULTS

With one exception, participants thought the Plutocratic Proposal may be 'all things considered' acceptable, providing their concerns were met, primary of which was upholding scientific integrity. Other concerns discussed related to the acceptability of the donor securing a place on the trial including: whether this was an unfair distribution of benefits, disclosing the identity of the donor as the funder, protecting the donor from exploitation and funding a single study with multiple donors on the same terms. Some misgivings fell outside the usual REC purview: detrimental impact of donors of bad character, establishing the trustworthiness of the matching agency and its processes and optimising research funding and resources. Despite their concerns, participants recognised that because the donor funds the whole trial, others would also potentially benefit from participating.

CONCLUSIONS

We identified concerns about the Plutocratic Proposal. UK RECs may be open to approving studies if these can be addressed. Existing governance processes will do some of this work, but additional REC guidance, particularly in relation to donors securing a place on the trial, may be necessary to help RECs navigate ethical concerns consistently.

Establishing a multistakeholder research agenda: lessons learned from a James Lind Alliance Partnership

OBJECTIVE

The James Lind Alliance (JLA) offers a method for better aligning health and care agenda's with the needs of patients, carers and clinicians by bringing them together in a Priority Setting Partnership (PSP). In this paper, we draw attention to crucial lessons learnt when establishing such a shared research agenda.

KEY ARGUMENTS

Having specific strategies and plans in place for maximising dialogic processes in a PSP can help facilitate and maintain trust, innovation and equal inclusion.

CONCLUSION

Eight lessons learnt have been formulated, based on our observations and reflections on the JLA PSP and our expertise on patient participation and participatory research.

Community engagement in research in sub-Saharan Africa: approaches, barriers, facilitators, ethical considerations and the role of gender - a systematic review protocol

INTRODUCTION

Meaningful community engagement (CE) is increasingly being considered the major determinant of successful research, innovation and intervention uptake. Community leaders, policy makers and funders have expressed the need to engage communities in research. CE in research empowers the host community to participate in addressing its own health needs and health disparities while ensuring that researchers understand community priorities. Thus, appropriate CE opens a unique way to promote coproduction, coimplementation and coevaluation, which may strengthen both the sense of inclusion, ownership and the effectiveness of the research life-cycle. The aim of this review is to synthesise available evidence on how to engage communities in research in a gender-sensitive, ethical, culture-appropriate and sustainable way in sub-Saharan Africa (SSA). This protocol has been developed following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols and follows the guidance provided by the Cochrane Handbook for Systematic Reviews.

METHODS AND ANALYSIS

A combination of key text words and medical subject headings such as 'Community Engagement' or 'Community Involvement' will be used to search 009 databases for all literature published between 1 January 2000 and 31 July 2021. Citations retrieved from database searches will be exported into EndNote X9 to remove duplicate citations and imported into Rayyan QCRI for screening. Two independent reviewers will conduct the screening and data extraction process. Disagreements between review authors will be resolved through discussions, consensus a third reviewer serving as a tiebreaker. The risk of bias will be assessed using the 10-item Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. The three-staged process described by Thomas and Harden will be used for the thematic and narrative synthesis of findings.

ETHICS AND DISSEMINATION

This is a systematic review which uses already collected data thus ethical approval not required. Findings will be published in an open access peer-reviewed journal and presented in relevant conferences and workshops.

PROSPERO REGISTRATION NUMBER

This protocol has been submitted for registration in PROSPERO and has been published under registration number CRD42021282503 .

Deferred consent in emergency obstetric research: findings from qualitative interviews with women and recruiters in the ACROBAT pilot trial for severe postpartum haemorrhage

OBJECTIVE

The ACROBAT pilot trial of early cryoprecipitate for severe postpartum haemorrhage used deferred consent procedures. Pretrial discussions with a patient and public involvement group found mixed views towards deferred consent. This study aimed to build an understanding of how the deferred consent procedures worked in practice, to inform plans for a full-scale trial.

SETTING

Qualitative interview study within a cluster-randomised pilot trial, involving four London maternity services.

PARTICIPANTS

Individual interviews were conducted postnatally with 10 women who had received blood transfusion for severe postpartum haemorrhage and had consented to the trial. We also interviewed four 'recruiters'-two research midwives and two clinical trials practitioners who conducted trial recruitment.

RESULTS

Consent procedures in the ACROBAT pilot trial were generally acceptable and the intervention was viewed as low risk, but most women did not remember much about the consent conversation. As per trial protocol, recruiters sought to consent women before hospital discharge, but this time pressure had to be balanced against the need to ensure women were not approached when distressed or very unwell. Extra efforts had to be made to communicate trial information to women due to the exhaustion of their recovery and competing demands for their attention. Participant information was further complicated by explanations about the cluster design and change in transfusion process, even though the consent sought was for access to medical data.

CONCLUSION

Our findings indicate that deferred consent procedures raise similar concerns as taking consent when emergency obstetric research is occurring-that is, the risk that participants may conflate research with clinical care, and that their ability to process trial information may be impacted by the stressful nature of recovery and newborn care. A future trial may support more meaningful informed consent by extending the window of consent discussion and ensuring trial information is minimal and easy to understand.

TRIAL REGISTRATION NUMBER

ISRCTN12146519.

Who is at the centre of what? A scoping review of the conceptualisation of 'centredness' in healthcare

OBJECTIVES

We aimed to identify the core elements of centredness in healthcare literature. Our overall research question is: How has centredness been represented within the health literature published between 1990 and 2019?

METHODS

A scoping review across five databases (Medline (Ovid), PsycINFO, CINAHL, Embase (Ovid) and Scopus; August 2019) to identify all peer-reviewed literature published since 1990 that focused on the concept of centredness in any healthcare discipline or setting. Screening occurred in duplicate by a multidisciplinary, multinational team. The team met regularly to iteratively develop and refine a coding template that was used in analysis and discuss the interpretations of centredness reported in the literature.

RESULTS

A total of 23 006 title and abstracts, and 499 full-text articles were screened. A total of 159 articles were included in the review. Most articles were from the USA, and nursing was the disciplinary perspective most represented. We identified nine elements of centredness: Sharing power; Sharing responsibility; Therapeutic relationship/bond/alliance; Patient as a person; Biopsychosocial; Provider as a person; Co-ordinated care; Access; Continuity of care. There was little variation in the concept of centredness no matter the preceding word (eg, patient-/person-/client-), healthcare setting or disciplinary lens. Improving health outcomes was the most common justification for pursuing centredness as a concept, and respect was the predominant driving value of the research efforts. The patient perspective was rarely included in the papers (15% of papers).

CONCLUSIONS

Centredness is consistently conceptualised, regardless of the preceding word, disciplinary lens or nation of origin. Further research should focus on centring the patient perspective and prioritise research that considers more diverse cultural perspectives.

Assessing the impact of predatory journals on policy and guidance documents: a cross-sectional study protocol

INTRODUCTION

Many predatory journals fail to follow best publication practices. Studies assessing the impact of predatory journals have focused on how these articles are cited in reputable academic journals. However, it is possible that research from predatory journals is cited beyond the academic literature in policy documents and guidelines. Given that research used to inform public policy or government guidelines has the potential for widespread impact, we will examine whether predatory journals have penetrated public policy.

METHODS AND ANALYSIS

This is a descriptive study with no hypothesis testing. Policy documents that cite work from the known predatory publisher OMICS will be downloaded from the Overton database. Overton collects policy documents from over 1200 sources worldwide. Policy documents will be evaluated to determine how the predatory journal article is used. We will also extract epidemiological details of the policy documents, including: who funded their development, the discipline the work is relevant to and the name of the organisations producing the policy. The record of scholarly citations of the identified predatory articles will also be examined. Findings will be reported with descriptive statistics using counts and percentages.

ETHICS AND DISSEMINATION

No ethical approval was required for this study since it does not involve human or animal research. Study findings will be discussed at workshops on journalology and predatory publishing and will be disseminated through preprint, peer-reviewed literature and conference presentations.

Cardiac donation after circulatory determination of death: protocol for a mixed-methods study of healthcare provider and public perceptions in Canada

INTRODUCTION

Cardiac transplantation remains the best treatment for patients with end-stage heart disease that is refractory to medical or device therapies, however, a major challenge for heart transplantation is the persistent discrepancy between the number of patients on waiting lists and the number of available hearts. While other countries (eg, UK, Australia and Belgium) have explored and implemented alternative models of transplantation, such as cardiac donation after circulatory determination of death (DCDD) to alleviate transplantation wait times, ethical concerns have hindered implementation in some countries. This study aims to explore the attitudes and opinions of healthcare providers and the public about cardiac DCDD in order to identify and describe opportunities and challenges in ensuring that proposed cardiac DCDD procedures in Canada are consistent with Canadian values and ethical norms.

METHODS AND ANALYSIS

This study will include two parts that will be conducted concurrently. Part 1 is a qualitative study consisting of semi-structured interviews with Canadian healthcare providers who routinely care for organ donors and/or transplant recipients to describe their perceptions about cardiac DCDD. Part 2 is a convergent parallel mixed-methods design consisting of a series of focus groups and follow-up surveys with members of the Canadian general public to describe their perceptions about cardiac DCDD.

ETHICS AND DISSEMINATION

This study has been approved by the Research Ethics Board at Western University. The findings will be presented at regional and national conferences and reported in peer-reviewed publications.

Awareness and attitudes of the Lebanese population with regard to physician-pharmaceutical company interaction: a survey study

OBJECTIVE

To assess the awareness and attitudes of the general public in Lebanon regarding the interactions between physicians and pharmaceutical companies.

SETTING

Primary healthcare clinics and shopping malls in the Greater Beirut Area.

PARTICIPANTS

263 participants completed the questionnaire, of whom 62% were female and 38% were male. Eligible participants were Arabic-speaking or English-speaking adults (age≥18 years) residing in Lebanon for at least 5 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Awareness, attitudes and beliefs of the general public.

RESULTS

263 out of 295 invited individuals (89% completion rate) completed the questionnaire. While the majority of participants were aware of pharmaceutical company presence (or absence) in physicians' offices (range of 71-76% across questions), smaller percentages were aware of gift-related practices of physicians (range of 26-69% across questions). 40% thought that the acceptance of small gifts or meals by physicians is wrong/unethical. The percentage of participants reporting lower trust in physicians due to their participation in various pharmaceutical company-related activities ranged from 12% to 45% (the highest percentage being for large gifts). Participants who reported receiving free medication samples were significantly more likely to consider physicians' acceptance of small gifts as 'not a problem' than 'unethical' (OR=1.53; p=0.044).

CONCLUSIONS

Participants in our survey were generally more aware of pharmaceutical company presence (or absence) in physicians' offices than of gift-related practices of physicians. While the level of trust was not affected for the majority of participants for various types of interactions, it was affected the most for accepting large gifts.

Exploring the experiences of substitute decision-makers with an exception to consent in a paediatric resuscitation randomised controlled trial: study protocol for a qualitative research study

INTRODUCTION

Prospective informed consent is required for most research involving human participants; however, this is impracticable under some circumstances. The Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS) outlines the requirements for research involving human participants in Canada. The need for an exception to consent (deferred consent) is recognised and endorsed in the TCPS for research in individual medical emergencies; however, little is known about substitute decision-maker (SDM) experiences. A paediatric resuscitation trial (SQUEEZE) (NCT01973907) using an exception to consent process began enrolling at McMaster Children's Hospital in January 2014. This qualitative research study aims to generate new knowledge on SDM experiences with the exception to consent process as implemented in a randomised controlled trial.

METHODS AND ANALYSIS

The SDMs of children enrolled into the SQUEEZE pilot trial will be the sampling frame from which ethics study participants will be derived.

DESIGN

Qualitative research study involving individual interviews and grounded theory methodology.

PARTICIPANTS

SDMs for children enrolled into the SQUEEZE pilot trial.

SAMPLE SIZE

Up to 25 SDMs. Qualitative methodology: SDMs will be invited to participate in the qualitative ethics study. Interviews with consenting SDMs will be conducted in person or by telephone, taped and professionally transcribed. Participants will be encouraged to elaborate on their experience of being asked to consent after the fact and how this process occurred.

ANALYSIS

Data gathering and analysis will be undertaken simultaneously. The investigators will collaborate in developing the coding scheme, and data will be coded using NVivo. Emerging themes will be identified.

ETHICS AND DISSEMINATION

This research represents a rare opportunity to interview parents/guardians of critically ill children enrolled into a resuscitation trial without their knowledge or prior consent. Findings will inform implementation of the exception to consent process in the planned definitive SQUEEZE trial and support development of evidence-based ethics guidelines.

Support of public-private partnerships in health promotion and conflicts of interest

OBJECTIVES

Public-private partnerships (PPPs) are considered key elements in the development of effective health promotion. However, there is little research to back the enthusiasm for these partnerships. Our objective was to describe the diversity of visions on PPPs and to assess the links between the authors and corporations engaged in such ventures.

METHODS

We reviewed the scientific literature through PubMed in order to select all articles that expressed a position or recommendation on governments and industries engaging in PPPs for health promotion. We included any opinion paper that considered agreements between governments and corporations to develop health promotion. Papers that dealt with healthcare provision or clinical preventive services and those related to tobacco industries were excluded. We classified the articles according to the authors' position regarding PPPs: strongly agree, agree, neutral, disagree and strongly disagree. We related the type of recommendation to authors' features such as institution and conflicts of interest. We also recorded whether the recommendations were based on previous assessments.

RESULTS

Of 46 papers analysed, 21 articles (45.6%) stated that PPPs are helpful in promoting health, 1 was neutral and 24 (52.1%) were against such collaborations. 26 papers (57%) set out conditions to assure positive outcomes of the partnerships. Evidence for or against PPPs was mentioned in 11 papers that were critical or neutral (44%) but not in any of those that advocated collaboration. Where conflicts were declared (26 papers), absence of conflicts was more frequent in critics than in supporters (86% vs 17%).

CONCLUSIONS

Although there is a lack of evidence to support PPPs for health promotion, many authors endorse this approach. The prevalence of ideas encouraging PPPs can affect the intellectual environment and influence policy decisions. Public health researchers and professionals must make a contribution in properly framing the PPP issue.

How do authors of systematic reviews deal with research malpractice and misconduct in original studies? A cross-sectional analysis of systematic reviews and survey of their authors

OBJECTIVES

To study whether systematic reviewers apply procedures to counter-balance some common forms of research malpractice such as not publishing completed research, duplicate publications, or selective reporting of outcomes, and to see whether they identify and report misconduct.

DESIGN

Cross-sectional analysis of systematic reviews and survey of their authors.

PARTICIPANTS

118 systematic reviews published in four journals (Ann Int Med, BMJ, JAMA, Lancet), and the Cochrane Library, in 2013.

MAIN OUTCOMES AND MEASURES

Number (%) of reviews that applied procedures to reduce the impact of: (1) publication bias (through searching of unpublished trials), (2) selective outcome reporting (by contacting the authors of the original studies), (3) duplicate publications, (4) sponsors' and (5) authors' conflicts of interest, on the conclusions of the review, and (6) looked for ethical approval of the studies. Number (%) of reviewers who suspected misconduct are reported. The procedures applied were compared across journals.

RESULTS

80 (68%) reviewers confirmed their data. 59 (50%) reviews applied three or more procedures; 11 (9%) applied none. Unpublished trials were searched in 79 (66%) reviews. Authors of original studies were contacted in 73 (62%). Duplicate publications were searched in 81 (69%). 27 reviews (23%) reported sponsors of the included studies; 6 (5%) analysed their impact on the conclusions of the review. Five reviews (4%) looked at conflicts of interest of study authors; none of them analysed their impact. Three reviews (2.5%) looked at ethical approval of the studies. Seven reviews (6%) suspected misconduct; only 2 (2%) reported it explicitly. Procedures applied differed across the journals.

CONCLUSIONS

Only half of the systematic reviews applied three or more of the six procedures examined. Sponsors, conflicts of interest of authors and ethical approval remain overlooked. Research misconduct is sometimes identified, but rarely reported. Guidance on when, and how, to report suspected misconduct is needed.

'Just so you know, the patient is staff': healthcare professionals' perceptions of caring for healthcare professional-patients

OBJECTIVE

To explore healthcare professionals' conceptions of the care of patients who are also healthcare professionals.

DESIGN

Explorative, with a qualitative, phenomenographic approach.

PARTICIPANTS AND SETTING

16 healthcare personnel within different professions (doctors, nurses, assistant nurses, physiotherapists, occupational therapists) were interviewed about the care of 32 patients who were themselves members of different healthcare professions, in one healthcare organisation in Sweden.

RESULTS

The care of patients who are healthcare professionals was conceived in five different ways, as: usual, dutiful, prioritised and secure, insecure and responsive. An initial conception was that their care was usual, just as for any other patient, and also a perceived duty to treat them and to protect their right to be a patient--as any other patient. Exploring further, informants described that these patients did receive secure and prioritised care, as the informants experienced making a greater commitment, especially doctors giving privileges to doctor-patients. A conception of insecure care infused the informants' descriptions. This comprised of them feeling intimidated in their professional role, feeling affected by colleagues' stressful behaviour and ambiguity whether the healthcare professional-patient could be regarded as a competent professional. The deepest way of understanding care seemed to be responsive care, such as acknowledging and respecting the patient's identity and responding to their wishes of how treatment was to be met.

CONCLUSIONS

Caring for healthcare professionals seems to trigger different ethical approaches, such as deontology and ethics of care. According to ethics of care, the findings may indeed suggest that these patients should be cared for just as any other patients would be, but only if this means that they are cared for as persons, that is, they are given 'person-centred care'. This would imply balancing between acknowledging the vulnerable patient in the colleague and acknowledging the identity of the colleague in the patient.

Caught between intending and doing: older people ideating on a self-chosen death

OBJECTIVES

The aim of this paper is to provide insight into what it means to live with the intention to end life at a self-chosen moment from an insider perspective.

SETTING

Participants who lived independent or semidependent throughout the Netherlands.

PARTICIPANTS

25 Dutch older citizens (mean age of 82 years) participated. They were ideating on a self-chosen death because they considered their lives to be no longer worth living. Inclusion criteria were that they: (1) considered their lives to be 'completed'; (2) suffered from the prospect of living on; (3) currently wished to die; (4) were 70 years of age or older; (5) were not terminally ill; (6) considered themselves to be mentally competent; (7) considered their death wish reasonable.

DESIGN

In this qualitative study, in-depth interviews were carried out in the participants' everyday home environment (median lasting 1.56 h). Verbatim transcripts were analysed based on the principles of phenomenological thematic analysis.

RESULTS

The liminality or 'in-betweenness' of intending and actually performing self-directed death (or not) is characterised as a constant feeling of being torn explicated by the following pairs of themes: (1) detachment and attachment; (2) rational and non-rational considerations; (3) taking control and lingering uncertainty; (4) resisting interference and longing for support; (5) legitimacy and illegitimacy.

CONCLUSIONS

Our findings show that the in-between period emerges as a considerable, existential challenge with both rational and non-rational concerns and thoughts, rather than a calculative, coherent sum of rational considerations. Our study highlights the need to take due consideration of all ambiguities and ambivalences present after a putatively rational decision has been made in order to develop careful policy and support for this particular group of older people.

Bereaved relatives' experiences during the incurable phase of cancer: a qualitative interview study

OBJECTIVE

To examine bereaved relatives' experiences from time of diagnosis of incurable cancer until death with specific emphasis on their role in the (end-of-life) decision-making concerning chemotherapy.

DESIGN

Qualitative interview study.

SETTING

Hospital-based.

PARTICIPANTS AND METHODS

In-depth interviews with 15 close relatives of patients who died from non-small cell lung cancer or pancreatic cancer, using a thematic content analysis.

RESULTS

All relatives reported that patients' main reason to request chemotherapy was the possibility to prolong life. Relatives reported that patients receiving chemotherapy had more difficulty to accept the incurable nature of their disease than patients who did not. They mostly followed the patients' treatment wish and only infrequently suggested ceasing chemotherapy (because of side effects) despite sometimes believing that this would be a better option. Relatives continuously tried to support the patient in either approaching the death or in attaining hope to continue life satisfactorily. Most relatives considered the chemotherapy period meaningful, since it sparked patients' hope and was what patients wanted. Cessation of chemotherapy caused a relief but coincided with physical deterioration and an increased caregivers' role; many relatives recalled this latter period as more burdensome.

CONCLUSIONS

Relatives tend to follow patients' wish to continue or cease chemotherapy, without expressing their own feelings, although they were more inclined to opt cessation. They experience a greater caregiver role after cessation and their feelings of responsibility associated with the disease can be exhausting. More attention is needed to reduce relatives' distress at the end of life, also to fully profit from this crucial form of (informal) healthcare.

Hearing the voices of children: self-reported information on children's experiences during research procedures: a study protocol

INTRODUCTION

In paediatric research, there is a tension between what you can ask from a child and what is needed for the development of evidence-based treatments. To find an optimal balance in conducting clinical research and protecting the child, it is necessary to have empirical data on children's experiences. Until now, there are scarce empirical data on the experiences from the perspective of the child. In this manuscript, we describe the protocol of a two-phase study measuring children's self-reported experiences during research procedures.

METHODS AND ANALYSIS

In the first phase of our study, we aim to interview approximately 40 children (6-18 years) about their self-reported experiences during research procedures. In the second phase, we will develop a questionnaire to measure children's experiences during research procedures in a quantitative way. We will use the interview outcomes for the development of this questionnaire. Next, we will measure the experiences of children during seven research procedures with this questionnaire. A one-month follow-up is conducted to investigate the emotional impact of the research procedures on the children. Children will be recruited from different research studies in three academic children's hospitals in the Netherlands.

ETHICS AND DISSEMINATION

The ethics committee of the VU University medical center evaluated both studies and indicated that there was no risk/discomfort associated, stating that both phases are exempt from getting approval under the Dutch Law. Dissemination of results will occur by conference presentations and peer-reviewed publications. The findings of our project can help Institutional Review Boards and paediatric researchers when evaluating the discomforts of research procedures described in study protocols or when designing a study. Information on experiences of children involved in previous studies may also help children and parents in future research with their decision-making about participation in clinical research, or parts thereof.

A critical appraisal of clinical trials conducted and subsequent drug approvals in India and South Africa

OBJECTIVES

To assess the relation between the number of clinical trials conducted and respective new drug approvals in India and South Africa.

DESIGN

Construction and analysis of a comprehensive database of completed randomised controlled clinical trials based on clinicaltrials.gov from 1 January 2005 to 31 December 2010 and drug approval data from 2006 until 2013 for India and South Africa.

SETTING

USA, the EU, India and South Africa.

MAIN OUTCOME MEASURES

Percentage of completed randomised clinical trials for an Investigational Medicinal Product (IMP) leading to new drug approval in India and South Africa.

RESULTS

A total of 622 eligible randomised controlled trials were identified as per search criteria for India and South Africa. Clustering them for the same sponsor and the same Investigational New Drug (IND) resulted in 453 eligible trials, that is, 224 for India and 229 for South Africa. The distribution of the market application approvals between the EU/USA as well as India and South Africa revealed that out of clinical trials with the participation of test centres in India and/or South Africa, 39.6% (India) clinical trials and 60.1% (South Africa) clinical trials led to market authorisation in the EU/USA without a New Drug Application (NDA) approval in India or South Africa.

CONCLUSIONS

Despite an increase in clinical trial activities, there is a clear gap between the number of trials conducted and market availability of these new drugs in India and South Africa. Drug regulatory authorities, investigators, institutional review boards and patient groups should direct their efforts to ensuring availability of new drugs in the market that have been tested and researched on their population.

Honorary authorship in postgraduate medical training

OBJECTIVES

To determine whether postgraduate medical trainees are exposed to honorary authorship, whether they are aware of the topic and if they believe that further support and education concerning this issue is needed.

METHODS

Postgraduate medical trainees were contacted by email with a link to our questionnaire on two occasions (2 and 26 February 2014) and then contacted in person (June-November 2014). The questionnaire topics included demographics, authorship practice beliefs and experience, and authorship policy-related questions. We also determined the proportion of perceived, International Committee of Medical Journal Editors (ICMJE)-defined and unperceived honorary authorship in the respondent group.

RESULTS

The response rate was 27.7%. The prevalence of perceived, ICMJE-defined and unperceived honorary authorship was 38.1%, 57.3% and 24.2%, respectively; 90.1% were unaware of the ICMJE authorship criteria, 92.6% were unaware of a support system for authorship disputes, but 91.8% believed such a system should be implemented and 93.3% believed medical trainees and faculty should be instructed on authorship guidelines.

CONCLUSIONS

A paradigm shift from the current system is needed, where enforcement of ethical authorship practices is shifted away from journal editors. Instruction on the topic should be provided to medical trainees throughout medical school and continued during further training. A process should also be outlined to resolve authorship disputes. These measures may encourage researchers to have an open discussion on the topic prior to the commencement of a research project, and to resolve authorship conflicts in a constructive manner. We also hope this paper encourages further work on the topic.

Professionalism dilemmas, moral distress and the healthcare student: insights from two online UK-wide questionnaire studies

OBJECTIVE

To understand the prevalence of healthcare students' witnessing or participating in something that they think unethical (professionalism dilemmas) during workplace learning and examine whether differences exist in moral distress intensity resulting from these experiences according to gender and the frequency of occurrence.

DESIGN

Two cross-sectional online questionnaires of UK medical (study 1) and nursing, dentistry, physiotherapy and pharmacy students (study 2) concerning professionalism dilemmas and subsequent distress for (1) Patient dignity and safety breaches; (2) Valid consent for students' learning on patients; and (3) Negative workplace behaviours (eg, student abuse).

PARTICIPANTS AND SETTING

2397 medical (67.4% female) and 1399 other healthcare students (81.1% female) responded.

MAIN RESULTS

The most commonly encountered professionalism dilemmas were: student abuse and patient dignity and safety dilemmas. Multinomial and logistic regression identified significant effects for gender and frequency of occurrence. In both studies, men were more likely to classify themselves as experiencing no distress; women were more likely to classify themselves as distressed. Two distinct patterns concerning frequency were apparent: (1) Habituation (study 1): less distress with increased exposure to dilemmas 'justified' for learning; (2) Disturbance (studies 1 and 2): more distress with increased exposure to dilemmas that could not be justified.

CONCLUSIONS

Tomorrow's healthcare practitioners learn within a workplace in which they frequently encounter dilemmas resulting in distress. Gender differences could be respondents acting according to gendered expectations (eg, males downplaying distress because they are expected to appear tough). Habituation to dilemmas suggests students might balance patient autonomy and right to dignity with their own needs to learn for future patient benefit. Disturbance contests the 'accepted' notion that students become less empathic over time. Future research might examine the strategies that students use to manage their distress, to understand how this impacts of issues such as burnout and/or leaving the profession.

Patient reported outcome measures in military patients with shoulder instability

OBJECTIVES

The Oxford Shoulder Instability Score (OSIS) is a measure of functional impairment of the upper limb, but it is unclear how it translates into military patients where lower scores, implying higher function, may still be insufficient to meet the increased demands of military service and necessitating surgery. This study aimed to compare OSIS in military and civilian patients undergoing shoulder stabilisation surgery.

METHODS

We undertook a prospective, blinded cohort-controlled study with a null hypothesis that there was no difference in the Oxford Instability Scores between military and civilian patient groups. 40 patients were required in each group. A prospective clinical data base (iParrot, ByResults, Oxford, UK) was interrogated for consecutive patients undergoing shoulder stabilisation surgery at a single centre. The senior author-blinded to the outcome score-matched patients according to age, gender and diagnosis. Statistical analysis showed the data to be normally distributed and a paired samples t test was used to compare the two groups.

RESULTS

110 patients were required to provide a matched cohort of 40 in each group (70 male, 10 female subjects). Age distribution was 16-19 years (n=6); 20-24 years (n=28); 25-29 (n=16); 30-34 (n=12); 35-49 (n=12); and 40-44 (n=6). 72 patients (90%) had polar group 1 instability and eight patients (10%) had polar group 2 instability. The mean OSIS in the civilian group was 17.25 and in the military group 18.25. There was no statistical difference between the two groups (p=0.395).

CONCLUSIONS

This study supports the use of the OSIS to assess military patients with shoulder instability and monitor the progress of their condition.