Changing Ideas Research Articles

Improving the primary care clinical testing process in southwest Scotland: a systems-based approach

IntroductionAcross all healthcare environments, inadequately specified patient test requests are commonly encountered and can lead to wasted clinician time and healthcare resources, in addition to either missed or unnecessary testing...

Implementation of a Nurse-Initiated Antibiotic Time-Out (NATO) in Childhood Cancer Patients in Central America

Abstract Background Children with cancer are at high risk for infection and frequently require antimicrobials. Antimicrobial stewardship (AMS) interventions can mitigate toxicity and development of antibiotic resistance yet the pharmacy and infectious diseases specialists who usually perform AMS are often absent in global settings. We report our experience testing a novel intervention to shift the antibiotic timeout to nurses in six pediatric oncology units in Central America. Methods The Nurse-initiated Antibiotic Timeout (NATO) is a scripted conversation between nurses and physicians to reevaluate antibiotic appropriateness after 48 to 72 hours of empiric use for febrile neutropenia. First, we performed a baseline assessment of AMS capacity using the WHO Practical Toolkit for AMS Programmes checklist. Based on these results, sites tailored a generic implementation plan emphasizing educational and documentation tools and iterative PDSA (Plan-Do, Study-Act) cycles to improve implementation and effectiveness outcomes. Results All sites collected antimicrobial use data for a minimum of two months. Four sites then piloted NATO, producing change ideas, including changes to documentation tools, antimicrobial decision categories, communication processes, and times. From August 2022 – October 2023, NATO was performed in 53.4% of febrile neutropenia episodes in the three sites reporting data. Sites had substantial NATO performance rate variation from month to month. Sites reported changes in antimicrobial therapy in 47% of episodes after a 6-month period (Figure 1). Conclusion The difference in performance rate of NATO underscores the importance of real-time reporting to adjust AMS implementation strategies. The change ideas developed by each site differed, however, core tools emerged, which will support AMS in other global settings. Next steps include comparing antimicrobial use pre- and post-intervention and determining a sustainability and scalability plan. Figure 1. Incidence of change in antibiotic therapy over time.

‘Why, it’s like Belgium!’: the Women’s International League in the Irish War of Independence 1919–1921

ABSTRACT This article demonstrates how the Women’s International League (WIL) dealt with the changing ideas of nationhood, internationalism, imperialism, and freedom when supporting the cause of Irish independence. Their actions included seeking to protect Britain’s good name while simultaneously criticising that very same nation for its war in Ireland. The ‘small nations’ rhetoric that had emerged during the First World War was used by British feminists to divorce the atrocities of the British Crown force, the Black and Tans, from the wider colonial experience of oppression. Comparing the occupation of Ireland in 1919–1921 to that of Belgium during the First World War enabled British internationalist-feminists to support the sovereignty of Ireland’s nationhood, without necessarily having to engage with the colonial dimension or history of the conflict. This entirely changed the parameters within which British feminists could show solidarity with the Irish republicans while still maintaining positive views of British imperialism and the empire.

Unravelling the “Ethos of Change” in African Urban Margins: Institutions, Stigmas, Experiences

Abstract How are desirable futures conceived in the African urban margins? What trajectories do individuals use to get there? And who decides what constitutes a desirable future? This special issue proposes the “ethos of change” as an analytical concept to better understand how urban margins in Africa shape specific lives and, in particular, aspirations for change. “Ethos of change” is a broad set of embodied norms, (self) narratives, and routine practices driving the trajectory of personal change to escape an initial self and environment that are both internalised as unsatisfactory and dishonourable. Based on case studies from Kenya, Cameroon, and Burkina Faso, analyses in this special issue focus on how individuals construct their experiences of violence, (de)radicalisation, displacement, and the intervention of large-scale state programmes. This introductory article offers an institutional framework for comprehending the other articles that constitute the special issue and summarises their contents. Additionally, it assesses how the special issue’s contribution advances our understanding of how to reconsider Africa’s urban margins as spaces for the production of difference, where individuals appropriate the idea of change with its modalities amidst multiple facets of stigma and symbolic violence in African urban margins.

Idea Generation Game Design Tool for Health Behavior Change Games

Serious games (SGs) must engage, be entertaining and have a serious purpose to be effective. A health behavior change game (HBCG) can help change poor health behaviors but are difficult to design. One problem is there are few design tools to support developers of these types of games. This paper describes a card-based design tool for use during the idea generation phase of game design. The research question is: To what extent does an idea generation card tool have perceived value for SG designers generating ideas for behavior change games? This paper reports on the deployment of the tool for an HBCG to help individuals improve their diet and levels of physical activity. An evaluation was undertaken using qualitative data gathered through interviews with serious game developers and a focus group conducted with student game designers. Emergent common themes across both data sets were that the tool had practical and emotional value. Practical value in using the cards was found in the card structure, card content and sorting process. Emotional value included the positive feelings of having physical cards in front of them to use, the presentation of ideas and support provided on a topic they knew little about which brought some relief, increasing confidence and allowing for a more creative environment by freeing up their imagination. Negative feelings were also experienced and included participants remaining anxious about the range, complexity and interrelatedness of the concepts they needed to consider.

Posthumanism, Artificial Intelligence and Ishiguro's Klara & the Sun: Can Humanoid Machines attain consciousness?

This paper examines Kazuo Ishiguro's Klara and The Sun through the lens of posthumanism. It uses the textual analysis method to analyze Ishiguro's text as a posthuman novel that depicts the posthuman society where the boundaries between what is human and the nonhuman is blurred. The basic argument is that the aim of Ishiguro's text is two-fold, while it clearly illustrates the inability of the humanoid robot to attain human consciousness, it attempts also to dismantle the anthropocentric view of man. The findings show that Klara, the narrator-protagonist is used as a tool to raise certain questions such as, can humanoids act humanly? And/or can a 'humanoid machine' attain consciousness? More importantly, what it means to be human, in the first place. In doing so, the story attempts to showcase the ruptured boundaries between human and nonhuman and the changing ideas of humankind and its entanglement with the nonhuman world. Further, the interaction between Klara (AF) and other characters in the story is developed in such a way as to illustrate not only the shortcomings of humans regarding faith and affection but, more importantly, the limits of the nonhuman machine. It dismisses the current debate among technology experts that artificial intelligence would soon be able to develop a human-like robot that enjoys similar human emotional signals and reacts exactly like humans. The story simply puts it, despite the defects of humans, nothing can replace humans as those artificial friends (AI) fundamentally lack the kinds of experience that give rise to human-like affect and emotion.

Linguistic dynamics and language policy in Kazakhstan

The research relevance of language policy methods, as well as the current language processes in society, is predefined by an urgent need to form nation-states with their own language and culture. The research aims to create an idea of the language changes in Kazakhstan during the period of independence and assess the language policy and its prospects at the present stage. The research employed the following methods: comparative-comparative, statistical (basic), analytical-synthetic, and graphic (auxiliary). This research examined the main parameters of language modernisation in Kazakhstan in recent years, studying the key perspectives regarding language policy. The results of the population census in Kazakhstan for 1999, 2009 and 2021 were analysed in the research. Statistical data was presented in the form of figure diagrams and in tabular form to increase the efficiency of the perception of information at the expense of clarity. A comparison was made between different stages of the formation of the Kazakh language identity (from the beginning of the twentieth century to the modern stage). Particular attention was paid to the study of the parameters of the educational system and the implementation of the concept of the trinity of languages studied within the framework of secondary and higher schools. The modern language policy of Kazakhstan was evaluated in terms of the prospects for the coming years (up to 2025). The dynamics of changes concerning the language in Kazakh society were tracked. This research can be used for further linguistic research related to sociolinguistic surveys, studying the language situation in different countries around the world, and forming an idea of how different methods work in the field of language modernisation.

Reducing healthcare waste by eliminating exam table paper in a primary care practice: a sustainable quality improvement initiative.

Climate change is now the greatest threat to human survival. The healthcare system contributes significantly to global pollution and greenhouse gas emissions. Individual practitioners play an important role in helping to reduce these impacts in day-to-day practice. Deimplementation of unnecessary processes and products, such as exam table paper, in medical offices is one simple approach to incorporating principles of planetary health into practice. All quality improvement (QI) projects must start to consider environmental impacts to fully evaluate change ideas. We designed a single Plan-Do-Study-Act cycle using the Institute for Health Improvement Model for Improvement. We removed the exam table paper from our primary care office and measured changes in staff time, laundry, financial costs, paper use and carbon dioxide (CO2) emissions. Eliminating exam table paper in our clinic resulted in modest annual cost savings of $C718 and improved staff efficiency and motivation to introduce other green office practices. In our clinic alone, this change will save 8.2 km of exam table paper, 10 trees and 148 kg of CO2e (equivalent to driving 1233 km) every year. There were no negative consequences or feedback. This simple QI project demonstrates the feasibility of implementing a small change in a primary care clinic that can improve environmental sustainability with multiple co-benefits. If all family physicians in Canada eliminated exam table paper in their offices, it would result in savings of approximately 95 940 km of paper, 121 680 trees, $C8 400 600 and 3054 T CO2 emissions, equivalent to driving around the world 360 times.

Improving the Monitoring and Management of Clozapine-Induced Gastrointestinal Hypomotility (CIGH) in Community Mental Health Services: A Quality Improvement Approach.

Clozapine is the only approved antipsychotic for refractory schizophrenia to date. It can cause a range of serious and fatal adverse effects, including Clozapine-Induced Gastrointestinal Hypomotility (CIGH). While guidance is readily available to help manage CIGH effectively in hospital inpatients, practical recommendations applicable to the community (outpatient) setting are lacking. This project set out to improve the prevention, detection and management of CIGH in psychiatric outpatients. An initial baseline audit followed by quality improvement work was undertaken in a busy support worker-run community clozapine clinic focusing on, education and training, risk assessments and clinical documentation. The project was registered and managed using the Life QI web-based platform, where a set of primary and secondary drivers were defined and change ideas were executed. Qualitative and quantitative data were collected over a three-month period, demonstrating a significant improvement in clinical documentation (up from 36% to 99%). 23% of enhanced risk assessments resulted in treatment recommendations, modifiable risk factors were proactively discussed in 53% of clinic appointments and 65% of patients were provided with additional written information on CIGH. It was evident from staff and our patient feedback that further efforts would be required to continue to raise awareness about harms of unmanaged constipation among this client group. Future approaches may include enhanced collaborative efforts with primary care, and improving the skill mix in existing clozapine clinics, which could include the utilisation of mental health pharmacists.

Preoperative Multidisciplinary Team Huddle Improves Communication and Safety for Unscheduled Cesarean Deliveries: A System Redesign Using Improvement Science.

Optimal communication between care teams is a critical component in providing safe, timely, and appropriate patient care. Labor and delivery (L&D) units experience rapidly changing clinical scenarios often requiring escalation in care and unplanned cesarean deliveries (CDs). The University of Cincinnati Medical Center (UCMC) is a 550-bed academic level 4 maternal care center with a 13-bed L&D unit in Cincinnati, OH. There are approximately 2500 deliveries/y with a CD rate of 33%. The L&D unit is staffed with dedicated anesthesia personnel 24 hours a day. In our L&D unit, there was widespread dissatisfaction with multidisciplinary communication surrounding unscheduled CD. Near-miss safety events in our obstetric unit were attributed to preoperative communication failures. Initial surveys identified challenges in preoperative communication among nursing, anesthesiology, and obstetric teams leading to potential risk for compromised care. Using the UC Health Performance Improvement Way, we first sought to understand the process leading up to unscheduled CD. Change ideas were developed based on observed failures in communication. Interventions were tested and refined through iterative plan-do-study-act (PDSA) cycles. One key intervention was the introduction of a bedside, multidisciplinary, patient-centered, pre-CD huddle attended by nursing, anesthesia, and obstetrics representatives using a standard checklist for critical information. Qualitative patient feedback was elicited to inform change efforts. We compared patient and procedure characteristics from the baseline and huddle implementation phases. Our primary outcome measure was the satisfaction of care team members with communication around unscheduled CD. A secondary outcome was the general anesthesia (GA) rate for unscheduled CD. Our key process measure was adherence to the preoperative huddle. We tracked decision-to-incision interval (DTI) as a balancing measure. Huddle adherence reached 96% for unscheduled CD within 6 months of testing and implementation. A combined survey of anesthesia, nursing, and obstetrics showed that satisfaction scores related to unscheduled CD communication improved from 3.3/5 to 4.7/5 after huddle implementation. The rate of GA use and the median DTI remained unchanged. Patients felt more engaged and reported positive experiences by being a part of the huddle discussion. In an academic obstetric unit, communication failures surrounding unscheduled CD were identified as a contributor to staff dissatisfaction and perception of safety risk. Implementation of a bedside multidisciplinary pre-CD huddle improved communication between teams and contributed to creating a culture of safety without causing significant delays in care.

Feminist Writing As a Healing Force for Personal Growth: Managing Pain In Black Milk By Elif Shafak

This research analyzes Elif Shafak’s Black Milk: On Writing, Motherhood, and the Harem Within (2011) memoir. It is significant for understanding the layers of feminism and how the idea of motherhood changes after postpartum stress. In this memoir, the role of women in feminist discourse demonstrates a motherhood with stress, and it discusses how to manage pain. In addition, the writer tries to highlight the relationship between women and their social performances and responsibilities. This research aims to examine the body, women, and the motherhood relation from women’s perspective. Women’s issues of postpartum depression, stress management, and economic productivity are analyzed through Black Milk. Shafak’s pregnancy and her understanding of womanhood created a conflict in her life for which she struggled to manage her pain. Feminism is an important part of women’s lives. Women’s mental breakdown calls for a rest cure, during which she discovers challenge.

Opportunistic Change During a Punctuation: How and When the Front Lines Can Drive Bursts of Incremental Change

Environmental jolts can trigger more conducive conditions for driving change in organizations. However, punctuated equilibrium theories of organizational change concentrate on top managers’ implementation of de novo radical changes after jolts. Existing research has not examined frontline-driven, incremental change efforts during these periods of disrupted stasis, despite the value of frontline change ideas. We develop a process model to explain how and when those on an organization’s front lines can leverage a jolt to opportunistically implement long-desired change ideas in ways that promote their retention. We conducted a two-year qualitative field study at a hospital during the Covid-19 pandemic, examining the trajectories of 33 premeditated change ideas raised by frontline staff. By comparing ideas that persisted to become part of normal operations with those that failed to be selected or retained, we identified practices and conditions that promoted the selection and retention of frontline change ideas. Our study suggests that frontline change advocates can seed the long-term retention of “shovel-ready” ideas—as opposed to de novo ideas—after a jolt by rapidly and opportunistically deploying a novel set of practices before the brief window of opportunity created by lessened constraints and increased managerial receptivity closes. Prior theories of change largely assume frontline-driven change to be slow and continuous, proceeding in a one-off fashion; we explain how and when frontline change can instead occur in rapid, opportunistic bursts. This study advances theories of punctuated equilibrium and bottom-up change in organizations by unearthing an alternative way that change can be intentionally accomplished in organizations. Supplemental Material: The online appendix is available at https://doi.org/10.1287/orsc.2021.15120 .

Patient and caregiver perspectives on causes and prevention of ambulatory adverse events: multilingual qualitative study

ContextAmbulatory adverse events (AEs) affect up to 25% of the global population and cause over 7 million preventable hospital admissions around the world. Though patients and caregivers are key actors...

Quality assurance of science and technology universities in Bangladesh: a catalyst for sustainable employment during the 4IR

Purpose This study aims to report the quality of Bangladesh's science and technology universities (STUs) in ensuring sustainable employment of graduates during the Fourth Industrial Revolution (4IR) by assessing their vigilance in skill development activities and exploring students’ perspectives on the university. Design/methodology/approach This research used mixed methods: a close-ended five-point Likert scale questionnaire to understand students’ perspectives and a thematic analysis of the interviews of students, faculties, policymakers and relevant stakeholders. The data was collected through a random sampling method where 1,000 university students took part in the quantitative analysis along with other respondents for the qualitative portion. The analysis was done with a 99% confidence level and a 4.5% margin of error. Findings Bangladesh's STUs still have a long way to go to ensure quality education and generate sustainable employment for their graduates. The universities' preparation to comprehend the 4IR is not at the expected level. In addition, despite students' favourable perception of universities as providers of qualified labour, there is a significant mismatch between supply and demand. Research limitations/implications This research has some limitations regarding time and resources. Due to the limited number of responses from a few universities, this study's findings might only apply to some of the STUs of other countries. This study provided several recommendations for providing quality education to the STUs of Bangladesh. Practical implications The findings of this study indicate that there is still a crucial gap between the initiatives of STUs and the employment market, which prevents graduates from offering the necessary skills to achieve sustainable employment. The findings also support the idea of significant changes in the approach of these universities to address the mentioned issues. Social implications This study suggests collaboration among social actors, relevant stakeholders, STU authorities, education experts and government officials to ensure a demand-based curriculum for the students. The relevant stakeholders should come forward to ensure advanced technologies and internet connectivity in the STUs. Originality/value The data set used in this study is significantly large and varies in the number of institutions, departments and socioeconomic backgrounds of the students, faculties, policymakers and various stakeholders. Furthermore, the capacity of scientific and technology institutions to guarantee sustainable employment through quality assurance in education has also not been recently evaluated in Bangladesh.

‘I was having an anxiety attack and they pepper sprayed me': police apprehension in mental health contexts in Australia

ABSTRACT Police attendance in mental health contexts is often traumatic for the person in crisis, their family and first responders. Existing literature on police involvement in mental health responses tends to focus on police perspectives. Scholarship exploring lived experience perspectives is limited, yet is crucial for informing programmes, policies and reforms. We present findings from one of the first projects co-produced with people with lived experiences of being apprehended by police under mental health legislation. Interviews were conducted with twenty participants who had experience(s) of police apprehension across Australia. Findings highlight the social disadvantage experienced by participants prior to being apprehended and that use of force (such as tasering, pepper spraying and restraining in locked police vans) was common and over-used. Our study identified that police apprehension has lasting and wide-ranging impacts, leading to loss of employment, trauma, property damage, negative self-perceptions, discrimination, and fear of future police responses. Some participants were also apprehended by police while experiencing family violence and were misidentified as perpetrators. We argue police use of force mirrors the use of force within mental health services, with participants not experiencing a clear separation between police and mental health responses. The article shares participants’ ideas for change, including response models based on human rights, police non-attendance and peer-led initiatives. Our findings suggest the need for investment in alternatives to police responses and further research involving lived experience perspectives to inform out understanding of mental health crisis responses.

The Experiences of Volunteer Teachers in the E-Tulay Program

The main focus of this research is the lived experiences of volunteer teachers in the E-Tulay program. The present study aims to determine the lived experiences and the meaning of being a volunteer teacher. Six co-researchers for this study were all volunteer teachers in E-Tulay from 2021-2023. The lived experiences of the primary researcher were also included in the dataset following the hermeneutical phenomenological framework and methodology which was used to guide the study. Based on the interpretation of the generated lived experiences, symbolic representations of being an E-Tulay teacher, internal and external forces that affect volunteerism, pakikipagkapwa-tao, personal and professional growth of volunteer teachers, volunteers’ acknowledgments and rewards and spearheading E-Tulay in action emerged as the core themes. Furthermore, the composite textural-structural description exposes the constant idea of change, commitment, and contribution in the lived experiences that comprise the essence of being an E-Tulay volunteer teacher. A poem based on the lived experiences of the volunteer teachers was constructed based on the aforementioned core themes and essences, representing the synthesis of the lived experiences of the co-researchers.

Enhancing nutritional formula expiry monitoring: A quality improvement project in a tertiary-level hospital in Riyadh, Saudi Arabia.

Nutrition is a vital part of any treatment plan. This may include providing nutritional formulas during hospitalization and afterward. However, reported incidents showed that we had issues with nutritional formula expiry monitoring at our hospital with low compliance to Joint Commission International Standards (MMU.3.1): "There is a process for storage of medications and nutritional products that require special consideration." Therefore, a "Nutritional Formula Expiry Monitoring" project was created to decrease hospital safety incidents related to expired nutritional formulas from an average of 28 in 2015 to zero by 2018. A quality improvement model was developed to map the existing formula processes. Several proposed ideas were tested including performing a hospital-wide audit to examine possible risks and practices, developing a hospital policy, flow charts, forms, and audit tools, and providing educational presentations. A total of 40 units in the hospital were included in the implementation. After implementing all the change ideas, the system for monitoring the expiry of the nutritional formula was standardized, and the number of reported incidents related to the nutritional formula decreased from 28 in the third quarter of 2015 to one in the first quarter of 2018. This project provided step-by-step instructions for improving storing, delivering, and monitoring of nutritional formula. Consequently, the incidences of expired formula and cost wasting were successfully decreased, which increased safe administration and prevented patients from receiving expired nutritional formula. This project can be implemented in various healthcare settings.

A Quality Improvement Initiative to Increase Confirmation of Prehospital Endotracheal Tube Placement at Emergency Department Transfer of Care

Objectives Rates of prehospital unplanned extubation (UE) range from 0 to 25% and are the result of many factors, including patient movement. Transfer of care of intubated patients to the emergency department (ED) involves significant patient movement and represents a high-risk event for UE. Frequent confirmation of endotracheal tube (ETT) placement is imperative for early recognition of UE and to minimize patient harm. Methods Local Practice—Our baseline rate of verbal ETT position confirmation with a member of the ED team during ED transfer of care was 74%. Our goal was to increase this practice to >90% in six months. This project was completed in partnership with Toronto Paramedic Services. Prehospital electronic patient care records (ePCRs) were reviewed weekly to determine the proportion of intubated patients who had ETT placement confirmed in the ED at transfer of care. Interventions—Pre- and post-project paramedic focus groups were conducted to identify potential drivers, change ideas, and project feedback. Three staggered interventions were introduced over five months: (1) memorandums to paramedics, ED chiefs and respiratory therapy leads, (2) individualized paramedic feedback e-mails, and (3) ePCR changes and closing rules. Results The pre-project focus group identified several potential drivers, such as physical barriers, interprofessional relationships, and communication. ETT confirmation remained ≥90% for the last eight weeks and interventions resulted in special cause variation. Median cases without verbal confirmation between paramedics and ED staff reduced from 5/week (IQR 2.5, 6.5) to 1/week (IQR 0, 2). UE was identified in 0.6% (2/340) of patients with ETT confirmation. The post-project focus group noted improvements in perceived accountability, interprofessional relationships, and satisfaction with interventions. Conclusion Through a series of interventions, we improved the rate of ETT confirmation during ED transfer of care. Although rates of UE were low, improvement in ETT confirmation may lead to faster recognition of UE when it does occur thereby mitigating complications. The observed improvement was sustained after interventions ended.

The Danger of Counter-Transference and Need for Patient Voice in A. M. Homes’s In a Country of Mothers (1993) and Lidia Yuknavitch’s Dora: A Headcase (2012): “Story It”

Abstract A. M. Homes’s In a Country of Mothers (1993) and Lidia Yuknavitch’s Dora: A Headcase (2012) offer fictional representations of the therapeutic process. Each features a female patient who is victimized by a therapist who allows their own counter-transference to prevent the patient’s voice from emerging. Instead of healing, these transferences impose therapist-directed narratives on young women who need to tell their own stories of loss and confusion. After tracing Freud’s changing ideas on transference, this article presents literary examples of counter-transference gone awry. In a Country of Mothers features a therapist who believes her patient is the daughter she gave up for adoption and who uses her own counter-transference to propel a dangerous relationship between the two women; Dora: A Headcase offers a modern-day rewriting of Freud’s “Dora” case study by a teen who resists the counter-transference of her therapist by writing her own story. This examination of literary counter-transference problematizes the supposed neutrality of the therapist and stresses the importance of patient voice in psychotherapeutic healing.

Translation tools in multilingual Korean films: changing ideas of translation

ABSTRACT This article examines Bong Joon-ho's, Snowpiercer and Park Chan-wook's, Decision to Leave with a view to identifying how different languages are used for characterization and a narrative, and the extent to which the meanings encoded in the interplay of different languages in the film are delivered to the audiences relying exclusively on English subtitles. We focus on the role played by these different languages and a translation device (e.g. translation machines) appearing in films. We argue that both translation devices and different languages used are carefully designed and devised by the directors not only to contribute to audiences’ meaning-making processes and to enhance affective engagement with the film but also to challenge linguistic hierarchies. Translation machines are even used to defamiliarize languages used by characters and to maximize audiences’ experiences. Yet, these are not necessarily considered during translation, which may deprive audiences relying on subtitles of affective experiences. This study ultimately argues that the differing approaches to representing translation demonstrate different public understandings of translation.