Decisive Juncture Research Articles

Investigating Leadership: Reflections on the methodological choices used to research how allied health clinicians are enabled to step into health systems leadership roles

This article examines the methodological choices made for a research study into Health Systems Leadership. Reflections on key learnings are provided as a way of offering insight for researchers navigating these decisions for the first time. Embarking on qualitative research to effect change is purposeful but challenging; choosing the most appropriate methodology and methods can often be confounding and stressful for new researchers. This article explores the decision to use Interpretive Descriptive methodology with an Appreciative Inquiry lens and makes visible decision junctures in the development of this research. Literature provides a wealth of expert guidance and excellent insights into research methodology and methods. However, very little expounds on the learnings of those who have gone before and what their insights and learnings may be. Research into allied health clinicians and their journey into health systems leadership roles provides an opportunity to reflect on an applied research journey.

Toward Shared Decision-Making in Degenerative Cervical Myelopathy: Protocol for a Mixed Methods Study.

Health care decisions are a critical determinant in the evolution of chronic illness. In shared decision-making (SDM), patients and clinicians work collaboratively to reach evidence-based health decisions that align with individual circumstances, values, and preferences. This personalized approach to clinical care likely has substantial benefits in the oversight of degenerative cervical myelopathy (DCM), a type of nontraumatic spinal cord injury. Its chronicity, heterogeneous clinical presentation, complex management, and variable disease course engenders an imperative for a patient-centric approach that accounts for each patient's unique needs and priorities. Inadequate patient knowledge about the condition and an incomplete understanding of the critical decision points that arise during the course of care currently hinder the fruitful participation of health care providers and patients in SDM. This study protocol presents the rationale for deploying SDM for DCM and delineates the groundwork required to achieve this. The study's primary outcome is the development of a comprehensive checklist to be implemented upon diagnosis that provides patients with essential information necessary to support their informed decision-making. This is known as a core information set (CIS). The secondary outcome is the creation of a detailed process map that provides a diagrammatic representation of the global care workflows and cognitive processes involved in DCM care. Characterizing the critical decision points along a patient's journey will allow for an effective exploration of SDM tools for routine clinical practice to enhance patient-centered care and improve clinical outcomes. Both CISs and process maps are coproduced iteratively through a collaborative process involving the input and consensus of key stakeholders. This will be facilitated by Myelopathy.org, a global DCM charity, through its Research Objectives and Common Data Elements for Degenerative Cervical Myelopathy community. To develop the CIS, a 3-round, web-based Delphi process will be used, starting with a baseline list of information items derived from a recent scoping review of educational materials in DCM, patient interviews, and a qualitative survey of professionals. A priori criteria for achieving consensus are specified. The process map will be developed iteratively using semistructured interviews with patients and professionals and validated by key stakeholders. Recruitment for the Delphi consensus study began in April 2023. The pilot-testing of process map interview participants started simultaneously, with the formulation of an initial baseline map underway. This protocol marks the first attempt to provide a starting point for investigating SDM in DCM. The primary work centers on developing an educational tool for use in diagnosis to enable enhanced onward decision-making. The wider objective is to aid stakeholders in developing SDM tools by identifying critical decision junctures in DCM care. Through these approaches, we aim to provide an exhaustive launchpad for formulating SDM tools in the wider DCM community. DERR1-10.2196/46809.

Treatment-related decisional conflict in pre-dialysis chronic kidney disease patients in Singapore: Prevalence and determinants.

In advanced chronic kidney disease (CKD), patients face complex decisions related to renal replacement modality that can cause decisional conflict and delay. This study aimed to evaluate the prevalence of severe decisional conflict across decision types and to identify the psychosocial and clinical factors associated with decisional conflict in this population. Observational cross-sectional study. Patients with CKD in renal care were recruited. The Decisional Conflict Scale (DCS), Functional, Communicative, and Critical Health Literacy (FCCHL), Health Literacy Questionnaire (HLQ), Hospital Anxiety and Depression Scale (HADS), Brief Illness Perception Questionnaire (BIPQ), and the Kidney-disease Quality of Life (KDQOL) questionnaires were used. Clinical data were obtained from medical records. Bivariate and multivariable logistic regression models were used to identify predictors of severe decisional conflict (DCS score ≥ 37.5). Participants (N = 190; response rate = 56.7%; mean age = 62.8 ± 10.8) reported moderate levels of decisional conflict (29.7 ± 14.5). The overall prevalence of severe decisional conflict was 27.5% (n = 46) with no significant differences across decision types (dialysis, modality, access). Ethnicity (Chinese), marital status (married), BIPQ treatment control, coherence, KDQOL staff encouragement, and all health literacy domains, except functional health literacy, were significant predictors of decisional conflict in the unadjusted models. In the multivariable model, only the health literacy domains of FCCHL Communicative, and HLQ Active Engagement remained significant. Even after pre-dialysis education, many CKD patients in this study still report severe decisional conflict, with rates remaining substantial across decision junctures. The associations of decisional conflict and health literacy skills related to communication and engagement with healthcare providers indicate that more collaborative and patient-centric pre-dialysis programs may support patient activation and resolve decisional conflict.

Haderech lekaf-tet b'November: Parashat UNSCOP vereshit meoravuto shel ha'um basichsuch ha'Aravi-Israeli (The road to partition: UNSCOP and the beginning of United Nations involvement in the Israel-Arab conflict)

Haderech lekaf-tet b'November: Parashat UNSCOP vereshit meoravuto shel ha'um basichsuch ha'Aravi-Israeli (The road to partition: UNSCOP and the beginning of United Nations involvement in the Israel-Arab conflict)

Centering female agency while investigating contraceptive use: a case study in Agincourt, South Africa

BackgroundRural areas of South Africa face persistently high teenage and premarital childbearing rates, reflecting a lack of or inconsistent use of modern contraception. In attempting to understand this behavior, much of the literature has denied agency to young women, portraying them solely as victims of their environments. This study moved beyond these approaches to understanding adolescent contraceptive use, to reframe the investigation to focus on the tension around exercising agency within specific structural constraints.MethodsFindings are based on a qualitative study in Agincourt, South Africa. Data were collected through six focus group discussions with 63 women aged 18–44. A grounded theory approach utilizing emergent coding was performed focusing on the decision-making processes around family planning. The focus group participants discussed attitudes and norms around: early first births, contraceptive use, unplanned pregnancy, abortion, and HIV testing. When possible, differences that emerged around these topics according to the age groups (18–24, 25–34, and 35–44) and/or nationality of village (South African or Mozambican) are highlighted.ResultsParticipants of all focus groups agreed that early first birth were common and undesirable. Younger participants described pregnancy prevention as a key rationale for contraceptive usage, while older participants were more inclined to cite HIV prevention. Women of all focus groups discussed the importance of women taking the initiative with family planning. Participants expressed a range of opinions about the acceptability of abortion, and all focus groups discussed concerns about the safety of abortion. Finally, all of the focus group participants stressed the importance of HIV testing, both to protect themselves and to protect their families.ConclusionThis study found many locations of agency for young women in rural South Africa. The decision-making surrounding contraceptive use consists of a series of decision junctures at which women must assign values to certain factors and then select their behavior on the basis of those values. Young women weigh the costs and benefits of contraception and of pregnancy, while also taking into account the chances of actually becoming pregnant along with the costs and benefits of abortion. Furthermore, the women explicitly viewed contraception as within their own realm of decision-making and action (as opposed to within the realm of their male partners).

Causes and cures XV: Synthesis and integration

Abstract The past several years have been a landmark moment for violence prevention, with renewed attention on the part of many international agencies, but especially the United Nations, with its adoption of the 2030 Agenda for Sustainable Development . The latter invites the world community to collaborate in an inclusive, long-ranging vision for the future, highlighting our interdependence and collective responsibility for humanity's future. A growing awareness that preventing violence does not just reduce death and disability but promotes creativity, economic growth, and general well-being is at the heart of this “movement”. In the quest for a better understanding of human violence, interest in the issue has swept through multiple fields. An integration of the major disciplines and practical approaches is therefore timely, and for this to occur, we require a broader overview than just the view from within boundaries of existing domains. In this context, this fifteen article series modeled after a Global Health Studies course entitled, “Violence: Causes and Cures,” has reviewed the causes, consequences, and cures of the problem of violence. While knowledge has brought recognition of the magnitude and pervasiveness of violence, it has also generated insight into the much greater power that humanity possesses. At a time when we are reaching a decisive juncture in human history, with military and economic faculties achieving the ability to destroy our world many times over, we also face the urgent and sober task of integrating all our intellect and insight to best confront this enormous challenge called violence.

HISTORY, MEMORY, AND THE ENGLISH REFORMATION

ABSTRACTThis article is a revised and expanded version of my inaugural lecture as Professor of Modern History at the University of Cambridge, delivered on 20 Oct. 2011. It explores how the religious upheavals of the sixteenth and seventeenth centuries reshaped perceptions of the past, stimulated shifts in historical method, and transformed the culture of memory, before turning to the interrelated question of when and why contemporaries began to remember the English Reformation as a decisive juncture and critical turning point in history. Investigating the interaction between personal recollection and social memory, it traces the manner in which remembrance of the events of the 1530s, 1540s, and 1550s evolved and splintered between 1530 and 1700. A further theme is the role of religious and intellectual developments in the early modern period in forging prevailing models of historical periodization and teleological paradigms of interpretation.

(E)pistemological Awareness, Instantiation of Methods, and Uninformed Methodological Ambiguity in Qualitative Research Projects

This article explores epistemological awareness and instantiation of methods, as well as uninformed ambiguity, in qualitative methodological decision making and research reporting. The authors argue that efforts should be made to make the research process, epistemologies, values, methodological decision points, and argumentative logic open, accessible, and visible for audiences. To these ends, they discuss two ways of conceptualizing the role of epistemological awareness and instantiation of methods, including (a) a series of decision junctures and (b) a spatial conceptualization of epistemological decision making. Through an analysis of researchers’ decision junctures drawn from studies published in high-impact education journals in 2006, the authors illustrate current methodological awareness and instantiation of methods in the field of education research.

Miracles in Enlightenment England (review)

Reviewed by: Miracles in Enlightenment England Alexandra Walsham Miracles in Enlightenment England. By Jane Shaw. (New Haven: Yale University Press. 2006. Pp. x, 244. $45.00.) The tendency to regard the eighteenth century as a critical period in the eventual triumph of scientific rationalism over "superstition" has lingered long in English historiography. Jane Shaw's lucid and elegantly constructed book contributes to a growing body of research which is questioning settled assumptions about the intellectual contours of the "age of reason" and complicating our understanding of the nature of "Enlightenment culture." Exploring the speculation, debate, and critical investigation prompted by events that seemed miraculous to their observers, it offers a new perspective on claims that the period marked a decisive juncture in the narrative of progress and secularization that, until very recently, dominated historiographical assessments of it. Shaw identifies and traces three strands of thought about miracles: the Protestant doctrine that they had ceased after apostolic times; the renewed claims about supernatural healing and intercession made by the members of independent churches and sects from the mid-seventeenth century; and the attempt by Anglicans and natural philosophers to negotiate a middle way between the extremes of "atheistical" skepticism and nonconformist "enthusiasm." Her book demonstrates the extent to which the idea that the deity might intervene supernaturally in human affairs retained its vitality in the long eighteenth century, and indeed intensified in the century or so following 1650. As well as providing an overview of the theological and philosophical arguments that swirled about miracles, her chapters introduce us to a series of celebrated figures and episodes:from the thaumaturgic claims of the Baptists and Quakers and the Irish "stroker" Valentine Greatrakes, to the royal practice of touching for the king's evil, the prodigious abstinence of fasting girls, and the "perfectly Protestant miracles" of pious women cured while reading the Bible. Rejecting paradigms that presuppose a split between the elite and the common people, Shaw emphasizes instead the interaction between different social groups, and between theology and "lived religion." Highlighting the [End Page 385] extent to which interest in miracles became implicated in the burgeoning public sphere, she seeks to draw attention to the extent to which ordinary men and women participated in creating and shaping the Enlightenment, and how practical experiences of the miraculous fed into the heated abstract discussions that took place within the circles of the learned. Two further key lessons emerge from this monograph: the manner in which the techniques of experimentation at the heart of the new natural philosophy were harnessed to test and authenticate as much as to discredit supernatural phenomena, and the attractive suggestion that it may be helpful to think (with the sociologist David Martin) less of a steady advance toward a more "secular" society than of "successive Christianizations followed or accompanied by recoils." The broad thrust of Shaw's argument is enormously persuasive, but there are areas where the analysis might have been strengthened and deepened. Even while emphasizing the complexity and diversity of early Protestant thinking on this topic, her opening chapter may oversimplify the source of this ambivalence in presenting it as essentially a measure of the gap between clerical and lay theology. The polemical slogan that miracles had ceased must be assessed alongside works of systematic divinity that continued to carve out a place for miracles within a Reformed universe.To this extent, the implied contrast between the sixteenth and later seventeenth and eighteenth centuries may be a touch overstated. So too the claim that several of the particular episodes on which Shaw focuses her attention constituted key "turning points." To say that the activities of Valentine Greatrakes "sparked an epistemological shift" may be to attribute too much agency to them. It may also overlook the degree to which miracles had always been implicated in "the domain of the natural philosophy," from Augustine and Aquinas onwards (pp. 73, 74): To suggest that they had hitherto been confined largely to the realm of the doctrinal is to posit too dramatic a change in the register of the age-old debate about the ontological status of the supernatural. What altered was rather the criteria and method of determining whether an event...

The Empire Strikes Back: The People of Washington State Revisit the Death With Dignity Act

INTRODUCTION The passing of the 10th anniversary of Oregon’s unique Death with Dignity Act occurred unremarkably, with one notable exception: soon it may no longer stand alone. After several failed attempts, right-to-die advocates in the state of Washington are once again attempting to vault into the dispute; taking on religious groups, right-to-life organizations, and even the federal government to advance the right-to-die movement. Such legislation places medical providers unequivocally in the center of one of the most impassioned debates this nation has engaged in since Roe v Wade, and compels physician assistants (PAs) to evaluate their own attitudes and ethics when confronted with a terminally ill patient making the ultimate request. To place this in perspective, most PAs will be confronted during their careers with patients who are diagnosed with a terminal illness. Continuing involvement with that patient until the end is an obligation, especially where a pre-existing established relationship exists between the PA and the patient. Although providing it can sometimes be discomforting and unpleasant, patients need competent and informed care at this decisive juncture, and being competent entails comprehending all treatment alternatives, even those that cause moral distress. This is especially true in jurisdictions where a patient may query the PA on the rules of self-termination. However, solid foundation in this arena must begin with the fundamentals: at the PA program level. Then as states evolve legislation is this setting (and arguably they will), the PA profession will be a respected leader. Like Oregon’s, Washington’s proposal was advanced through the “public initiative” process, as opposed to through state congressional legislation. Washington, like approximately half the states in the nation, enjoys the option of pursuing legislation through public initiative. This method requires that signatures on petitions be obtained from representative portions of the state. In July 2008, Washingtonians garnered more than 300,000 signatures, far exceedThe Just Ethics feature is a forum for sharing insights, experiences, and literature on how we do and should teach ethics to our students. All who teach the subject of professional behavior and bioethics are invited to share their personal insights, experiences, and approaches to teaching this foundational and essential topic. Authors desiring to contribute to Just Ethics should forward submissions to:

Chronic Lymphocytic Leukemia

Chronic lymphocytic leukemia (CLL) is one of the most commonly diagnosed leukemias managed by practicing hematologists. For many years patients with CLL have been viewed as similar, with a long natural history and only marginally effective therapies that rarely yielded complete responses. Recently, several important observations related to the biologic significance of V(H) mutational status and associated ZAP-70 overexpression, disrupted p53 function, and chromosomal aberrations have led to the ability to identify patients at high risk for early disease progression and inferior survival. Concurrent with these investigations, several treatments including the nucleoside analogues, monoclonal antibodies rituximab and alemtuzumab have been introduced. Combination of these therapies in clinical trials has led to high complete and overall response rates when applied as initial therapy for symptomatic CLL. Thus, the complexity of initial risk stratification of CLL and treatment has increased significantly. Furthermore, when these initial therapies do not work, approach of the CLL patient with fludarabine-refractory disease can be quite challenging. This session will describe the natural history of a CLL patient with emphasis on important decision junctures at different time points in the disease. In Section I, Dr. Stephan Stilgenbauer focuses on the discussion that occurs with CLL patients at their initial evaluation. This includes a review of the diagnostic criteria for CLL and prognostic factors utilized to predict the natural history of the disease. The later discussion of risk stratification focuses on molecular and genomic aberrations that predict rapid progression, poor response to therapy, and inferior survival. Ongoing and future efforts examining early intervention strategies in high risk CLL are reviewed. In Section II, Drs. Ian Flinn and Jesus G. Berdeja focus on the discussion of CLL patients when symptomatic disease has developed. This includes an updated review of monotherapy trials with nucleoside analogs and recent trials that have combined these with monoclonal antibodies and/or alternative chemotherapy agents. Appropriate application of more aggressive therapies such as autologous and allogeneic immunotherapy and less aggressive treatments for appropriate CLL patient candidates are discussed. In Section III, Dr. John Byrd focuses on the discussion that occurs with CLL patients whose disease is refractory to fludarabine. The application of genetic risk stratification in choosing therapy for this subset of patients is reviewed. Available data with conventional combination based therapies and monoclonal antibodies are discussed. Finally, alternative promising investigational therapies including new antibodies, kinase inhibitors (CDK, PDK1/AKT, PKC) and alternative targeted therapies (DNA methyltransferase inhibitors, histone deacetylase inhibitors, etc.) are reviewed with an emphasis on the most promising agents for this patient population.

A la charnière ?

France at a Turning Point, by Jean Dufourcq Rediscovering the strategie advantages of its traditional pivotal position, France is at a decisive juncture: the convergence between a still preserved uniqueness and a European commitment which had become more and more demanding. This dilemma is the strategie reincarnation of an old geopolitical position that placed France at the junction of Europe's major Unes and from which it has always taken advantage. From now on, questions for France's leaders are: should a choice be made for a new framework, if yes, what choice to make -and how to choose?

History, Historicism, and the Social Logic of the Text in the Middle Ages

The study of literary texts appears at the moment to stand at a decisive juncture. Trends in critical thinking over the last decades have questioned the possibility of recovering a text's historical meaning. At the same time, there is a newly insistent plea for a return to "history" in the interpretation of literature. Before a rapprochement can occur, however, we need to have a clearer understanding of how both historians and critics understand "history" and of the ways in which postmodernist thought positions history and the role of the historian with respect to issues of literary interpretation at the forefront of contemporary critical debate. One thing is clear: the paradigms that have governed historical and literary study since the nineteenth century no longer hold unquestioned sway. The confident, humanist belief that a rational, "objective" investigation of the past permits us to recover "authentic" meanings in historical texts has come under severe attack in postmodernist critical debate. At stake in this debate are a number of concepts traditionally deployed by historians in their attempts to understand the past: causality, change, authorial intent, stability of meaning, human agency and social determination. What place, then, does history have in a postmodern theoretical climate? What, if anything, can the historian contribute to the reconfiguration of both theoretical concerns and interpretive practices signaled by the very notion of postmodernism? My purpose here is to explore some of the issues in question from the historian's point of view, paying particular attention to trends in literary criticism that suggest a reawakened interest in history.