Individual Practitioners Research Articles

Abstract P465: Standardizing Hypertension Management In A Primary Care Setting In India Through A Protocol Based Model

Hypertension is a leading cause of death in India. There are numerous barriers to adequate management of hypertension in Indian healthcare settings, including therapeutic inertia and the lack of a systematic approach. Standardizing hypertension management through an evidence based model that sets thresholds for diagnosis, treatment goals, follow up intervals and choice of drugs can lead to improved management of hypertension in an individual hospital or health system. We describe the design of a model that focuses on efficacy, safety and ease of use by healthcare providers with different levels of training. The algorithm endorses a urine albumin first approach in deciding the course of antihypertensive therapy. Providers undergo training in the implementation of this model using a training guide and handout developed for this purpose. The algorithm itself can be utilized as a point of care reference by individual practitioners, hospitals, primary health centers (PHCs) and the Health and Wellness Centers (HWCs) under the Ayushman Bharat initiative. We plan to evaluate the effectiveness of our model at Shree Krishna Hospital, Gujarat, India through a quality improvement framework. The algorithm is designed to allow adaptability to individual institutional requirements in India (and similar low and middle income countries) while standardizing the basic elements of hypertension management.

Unregulated Private Health Sector: India’s Challenges in Realizing Universal Health Coverage

Since India’s independence in 1947, private health sector has witnessed a rapid growth. Today, private sector occupies a major share of health entities, health workforce and medical education institutions in the country. This paper provides an overview of private health sector in India, factors contributing to its growth, and major public policy implications in achieving universal health care based on extensive review of literature and other relevant descriptive information. The findings reveal that private health sector provides 80% of out-patient care and 60% of inpatient care in the country. There are 1.35 million private health entities delivering health services in the country, out of which 0.74 million are own account enterprises run by individual practitioners. About 76% of all private sector entities are allopathic facilities. This sector is largely unregulated with diversity of providers varying in qualifications, physical infrastructure, standards of care, technical knowledge, which are unfavorably affecting costs and quality of care. Strict implementation of regulations to influence private provider behavior in improving quality, reducing cost, appropriate use of medical technology, and accountability along with a huge investment in the public health sector are necessary to guarantee the availability, accessibility, acceptability, and quality of health services for every individual. Keywords: private health sector, public health sector, health workforce, health insurance DOI: 10.7176/PPAR/10-3-07 Publication date: March 31 st 2020

Conscience Dissenters and Disagreement: Professions are Only as Good as Their Practitioners.

In this paper, I consider the role of conscience in medical practice. If the conscientious practice of individual practitioners cannot be defended or is incoherent or unreasonable on its own merits, then there is little reason to support conscience protection and to argue about its place in the current medical landscape. If this is the case, conscience protection should be abandoned. To the contrary, I argue that conscience protection should not be abandoned. My argument takes the form of an analysis of an essential feature of the conscience dissenter's argument, the role of disagreement within "the medical profession." Conscience dissenters make certain assumptions within their arguments about the profession, disagreements within the professions, and how such disagreement should be adjudicated. If it is the case that these assumptions are accurate reflections of the current medical landscape, then the advocate of conscience protection has one less leg to stand on. I aim to show that this is not the case and that the assumptions of the conscience dissenter are not only mistaken but are mistakes of significant magnitude, so significant as to raise serious questions about the merit of their position. If the argument in this paper is sound, then, at the very least, the conversation over conscience protection in medicine, in particular, and health care, in general, must continue.

Rehabilitation for participation in life after spinal cord injury – clinician responses to a preliminary conceptual framework

Purpose To explore face validity of a preliminary conceptual framework for rehabilitation (the HEAR Framework), which is grounded in the narratives of people with spinal cord injury. Methods Using a quantitative online survey, experienced spinal cord injury rehabilitation practitioners were asked to compare the overall Framework, and its three components and nine elements, against usual practice. Participants rated the helpfulness and ease of implementation of each component. Perceived training needs, to support the implementation of the Framework were also explored. Respondents were given the opportunity to provide qualitative feedback about the Framework. Results Thirty-four participants completed the survey. Median rating of congruence of the Framework with usual practice was 6 (out of 10). The Help component of the Framework was rated as more like usual practice than the Encourage and Accept components. Median rating of the potential helpfulness to practice, of all the elements of the Framework was 5 (out of 5). Participants rated the elements within the Help component of the Framework as easiest to implement. Teaching assertiveness, promoting flexible thinking and fostering responsive communication were the highest rated training topics related to implementation of the Framework. Conclusions Face validity testing suggests the preliminary HEAR Framework is promising as a basis for spinal cord injury rehabilitation theory. Broad-based testing is required to progress the promise of the Framework. IMPLICATIONS FOR REHABILITATION Spinal cord injury rehabilitation lacks conceptual frameworks to guide practice. This validity study suggests moderate alignment between the preliminary HEAR Framework and usual practice (based on the perceptions of professionals in a spinal cord injury service). The Framework may be useful to individual rehabilitation practitioners as a basis for clinical reflection. The Framework may be useful as a practice development tool for teams of rehabilitation practitioners.

From Individual Heroes to National Performers: The Shift in Taekwondo’s Peace Promotion Activities

The writings of early taekwondo pioneers promote peace through the practice of the martial art and, later, the combat sport. These pioneers charged taekwondo practitioners with a duty to contribute to justice, defend the weak, and build a more peaceful world. National and international taekwondo organizations such as the Kukkiwon, World Taekwondo (WT), and the International Taekwon-Do Federation (ITF) have taken up the charge of peace promotion through taekwondo by means of transnational events, such as goodwill tours and joint taekwondo demonstrations by adversarial states (e.g., South and North Korea). These activities are soft diplomacy initiatives and have seen some level of success. While these soft diplomacy activities are in line with the goal of peace promotion that the early pioneers advocated, they are qualitatively different from what the pioneers advocated. Originally, the responsibility of peace promotion was on the individual taekwondo practitioner, who ought to cultivate moral character, courage, and martial art skill in order to uphold justice and defend the weak. With the current use of taekwondo for soft diplomacy, the responsibility of peace promotion has shifted from the individual practitioner to the governing bodies, such as WT and the ITF. Instead of focusing on issues surrounding justice and the protection of the weak, these national and international organizations focus on geopolitical cooperation, which is mediated through cultural exchange activities in the form of taekwondo demonstrations. These events involve activities such as acrobatic performances, dance routines, and board breaking that require little combat skill and may not pose the risk of serious injury to the individual practitioners, mainstays of the individual heroes of old. The charge to safeguard justice and physically defend the weak, which are acts of true courage as was envisioned by the taekwondo pioneers, is mostly ignored.

Offstage Intimacy: Best Practices for Navigating the Intimacy of Costuming

Offstage Intimacy:Best Practices for Navigating the Intimacy of Costuming Elaine DiFalco Daugherty (bio), Deborah Hertzberg (bio), and Darrell Wagner (bio) The relatively new specialization of intimacy direction comes out of the desire to maintain physical and emotional safety for all performers. In the era of #MeToo and Time's Up, intimacy direction guidelines are continuing to develop through burgeoning groups, organizations, and individual practitioners. Collectively, as authors we are costume designers, intimacy choreographers, directors, actors, puppeteers, and recent graduates of the MFA program at the University of Idaho. Predominantly, however, we are educators in university theatre departments and see the need to review our processes in light of this work and the importance of these conversations in our daily interactions with students and colleagues. In this note from the field, we discuss the reframing of some foundational ideas behind intimacy choreography and propose ways to apply them practically to the costuming field. While these guidelines may have initially been developed to govern and shape the interactions between actors and directors, they can (and should) be applied in a parallel manner to any interactions that include an aspect of intimate contact—in this case, to assist actors and costumers in creating offstage partnerships in the same manner that they are being created for onstage interactions. We will also offer specific examples of best-practice protocols in the various phases of the costuming process to assist in the transition from a culture of assumed consent to one in which consent is explicitly asked for and received before action is taken. The two main organizations initiating the work to educate, train, and develop best practices have been Intimacy Directors International (IDI) and Theatrical Intimacy Education (TIE). Intimacy work centers on several foundational principles that are common to all practitioners, although the language used to describe those principles may vary. One of the clearest structures of these principles is by IDI, which has established what it refers to as "The Pillars": consent, context, communication, choreography, and closure (Richardson et al.).1 These pillars stand upon the belief in body autonomy, "the right to self-governance over one's own body without external influence or coercion" ("Bodily Autonomy"). This means that you are the only person who has the right to decide how to use your body, for what purpose, and in what manner. As such, a person has the right to give, withhold, or withdraw consent to complete and/or receive a physical action from any other person working on a production. While these principles are designed to guide onstage performance work, they can also be adapted to inform the way actors and costumers interact throughout the inescapably intimate processes of taking measurements, navigating fittings, and choreographing backstage costume changes. Consent is certainly at the very center of this work. As we advocate for body autonomy, we encourage asking for permission to touch and be touched rather than assuming that someone's presence in a situation implies consent. Context refers to understanding the purpose of what we are creating. For example, a stage direction may simply indicate that two characters kiss; however, we are charged with determining the story of the kiss—who initiates, who gives or takes control, how long it lasts and at what intensity, and so on. The discussion of context allows the work to focus on active specific storytelling rather than simply a meeting of lips. Necessity dictates that communication function as an umbrella concept, as it must be present simultaneously with each of the other pillars in order for them to function. If there is no clear, specific [End Page 211] communication, the entire system breaks down. Choreography is developed so that all intimate action is specific and repeatable. Actors are given a series of physical actions done in the same sequence, with an agreed-upon level and type of contact between parties; this specificity allows for greater knowledge, trust, and safety for those involved. Additionally, when the character's actions happen the same way every time, it becomes easier to classify it as "work" and further clarify the dividing line between character and actor. Closure is the final step in the process, and it comes in any...

From the Editor

From the Editor Ricardo D. Trimillos Aloha kākou! For more than a century now, the trope of ethnomusicology has been "the study of music in its cultural context," a phrase that has also been a convenient rejoinder for the inevitable inquiry at cocktail parties: "Oh, ethnic [sic] musicology! What is that?" The focus on the culture (which often defaults to a national culture) as the defining entity is almost canonical, as I recall in such titles as The Music and Musical Instruments of Japan (1893), The Music of Hindostan (1914), Music in the Philippines … (1975), The Music of the Arabs (2003), and Korean Pop Music: Riding the Wave (2006) that span a century. Overarching efforts including Die Musik in Geschichte und Gegenwart (1949), The Garland Encyclopedia of World Music (1998), and the Oxford Press Global Music Series (2004) further reinforce culture as the unit of inquiry and its utility for the scholarly gaze. Of course, throughout that century we have continued to critique and refine the trope. In Asian Music 51(1), authors of the four major articles do so by drawing our attention to individual agency and individual actors within a musical culture. The articles reveal various manifestations of individual agency. Some are obvious, such as the Burmese slide guitar artist, described by Elias, who transmits his skill to his students; others are subtle, as Danielson shows in her accounts of empowerment of the female vocalist within a patriarchal Arab world. For Garvey, the individual practitioner and the specific performance event shape the sounding of Iraqi maqām; in other instances individual agency can be obscured by state rhetoric, as Rizzo posits for gamelan training in postindependence Indonesian conservatories. In the book review section, individual agency figures in the Yıldız study of Armenian music in Turkey and in the attention to a female shaman in Vorreiter's monograph on the Hmong of Thailand and Laos. At the risk of overreaching, I note that each of the two CDs of Japanese music in the media review section features individual performers who represent Japanese music through traditional and contemporary works, quite literally sounding the theme of individual agency for musical continuity and change. In "Listening to Arab Women's Voices," Virginia Danielson rehearses the individual artist, gender, and dynamics of power in Egypt and the Arab Peninsula. Presented as the keynote address at the 2018 meeting of the Society for [End Page 1] Asian Music in Albuquerque, New Mexico, the essay argues that female empowerment has been an issue in various cultures and throughout many historical eras. Thus its presence in the Arab world is not a limited case, but one of many problematizing asymmetrical power relationships. The different engagements of the female performer with male power over centuries of Arab culture offer the provocative possibility that the female singer can subvert a prevailing power structure, empowering the female subject mutatis mutandis in ways that do not register patriarchal notice or contestation. Drawing on her long-term engagement with Arab music, Danielson calls attention to the efficacy of the grass roots—female practitioners, often unrecognized, who perform in diverse private spaces. Whereas Danielson locates continuity and change within Arab society, in Burma, André P. J. Elias regards external musical materiality as critical to cultural exchange and to the process he calls indigenization. His article "Man Yar Pyae U Tin and the Burmese Slide Guitar: Constructing and Deconstructing Narratives of Cultural Exchange" focuses on the accomplishments of a single artist of the Burmese guitar genre derived from the Hawaiian steel guitar, itself putatively domesticated from a Hispanic-Mexican tradition. The Burmese case exemplifies the broader circulation of the guitar throughout Asia, either in its original form, as in Indonesia, or in an adaptive form, as in India. Elias notes top-down factors in the dynamic of indigenization, including British colonial intervention and Burmese court patronage. He further identifies its strategy of accommodation: incorporating the repertory of the court (mahagita) and of commodified westernized hybrids (kalabaw). He invites broader theorizing—government branding constitutes an instance of state intervention, in which the musical genre and its participants are co-opted by the state's quest for cultural capital. The historical narrative...

Theories, models, and frameworks for de-implementation of low-value care: A scoping review of the literature.

The aim of this scoping review was to identify theories, models, and frameworks for understanding the processes and determinants of de-implementing low-value care (LVC). We investigated theories, models, and frameworks developed specifically for de-implementation of LVC (conceptual studies) and those that were originally developed for implementation of evidence-based practices but were applied in studies to analyze de-implementation of LVC (empirical studies). We performed a scoping review to identify theories, models, and frameworks used to describe, guide, or explain de-implementation of LVC, encompassing four stages following the identification of the research question: (1) identifying relevant studies; (2) study selection; (3) charting the data; and (4) collating, summarizing, and reporting the results. The database searches yielded 9,642 citations. After removing duplicates, 6,653 remained for the abstract screening process. After screening the abstracts, 76 citations remained. Of these, 10 studies were included in the review. We identified 10 studies describing theories, models, and frameworks that have been used to understand de-implementation of LVC. Five studies presented theories, models, or frameworks developed specifically for de-implementation of LVC (i.e., conceptual studies) and five studies applied an existing theory, model, or framework concerning implementation of evidence-based practices (i.e., empirical studies). Most of the theories, models, and frameworks that are used to analyze LVC suggest a multi-level understanding of de-implementation of LVC. The role of the patient is inconsistent in these theories, models, and frameworks; patients are accounted for in some but not in others. The findings point to the need for more research to identify the most important processes and determinants for successful de-implementation of LVC and to explore differences between de-implementation and implementation. Achieving an evidence-based practice not only depends on implementation of evidence-based interventions (programs, methods, etc.) but also requires de-implementing interventions that are not evidence-based, that is, low-value care (LVC). Thus, de-implementation is the other side of the coin of an evidence-based practice. However, this is quite a new topic and knowledge is lacking concerning how de-implementation and implementation processes and determinants might differ. It is almost mandatory for implementation researchers to use theories, models, and frameworks (i.e., "theoretical approaches") to describe, guide, or explain implementation processes and determinants. To what extent are such approaches also used with regard to de-implementation of LVC? And what are the characteristics of such approaches when analyzing de-implementation processes? We reviewed the literature to explore issues such as these. We identified only 10 studies describing theoretical approaches that have been used concerning de-implementation of LVC. Five studies presented approaches developed specifically for de-implementation of LVC and five studies applied an already-existing approach usually applied to analyze implementation processes. Most of the theoretical approaches we found suggest a multi-level understanding of de-implementation of LVC, that is, successfully de-implementing LVC may require strategies that target teams, departments, and organizations and merely focus on individual health care practitioners. The findings point to the need for more research to identify the most important processes and determinants for successful de-implementation of LVC, and to explore differences between de-implementation and implementation. In terms of practice and policy implications, the study underscores the relevance of addressing multiple levels when attempting to de-implement LVC.

Beyond The Competency Model of Therapist Trainings - Developing Expertise Through Deliberate Practice

The purpose of the present paper is to describe how Deliberate Practice (DP) can be used to assist individual therapists develop expertise and improve their ability to effect change in their clients' psychotherapy outcomes. The author provides a targeted review of this literature and articulates a method of training therapists based on this relatively new and exciting concept. The initial training of psychotherapists represents an important milestone in an often lifelong career and one that is marked with a continuous professional development trajectory. While it is particularly important to achieve competency in many foundational skills and techniques during training, this method of training and continuous development of therapists does relatively little to engage individual practitioners based on their individual needs, which are said to be vast. Individual therapist effects account for a large proportion of the variance of client outcomes. However, historically, the individual therapist has been given little consideration. DP seeks to move beyond the standardized competency framework and provide a highly individualized training regime to therapists based on their individual deficits identified through data mining and linked to factors of therapy practice that have demonstrated to impact client outcomes; and as such, they can be leveraged by therapists. The findings of this review are used to inform seven recommendations for practitioners, training institutes, and regulatory bodies to consider for the initial and continuous development of therapists.

General practitioners’ consultation counts and associated factors in Swiss primary care – A retrospective observational study

Research on individual general practitioner (GP) workload, e.g. in terms of consultation counts, is scarce. Accurate measures are desirable because GPs' consultation counts might be related to their work satisfaction and arguably, there is a limit to the number of consultations a GP can hold per day without jeopardizing quality of care. Moreover, understanding the association of consultation counts with GP characteristics is crucial given current trends in general practice, such as the increasing proportion of female GPs, part-time work and group practices. The aim of this study was to describe GPs' consultation counts and efficiency and to assess associations with GP and practice variables. In this retrospective observational study we used routine data in electronic medical records obtained from 245 Swiss GPs in 2018. We described GPs' daily consultation counts as well as their efficiencies (i.e. total consultation counts adjusted for part-time work) and used hierarchical linear models to find associations of the GPs' total consultation counts in 2018 with GP- and practice-level variables. The median daily consultation count was 28 over all GPs and 33 for full-time working GPs. Total consultation counts increased non-linearly with part-time status, with high part-time working GPs (60%-90% of full-time) being equally or more efficient than full-time workers. Excluding part-time status in the regression resulted in higher consultation counts for male GPs working in single practices and with older patients, whereas part-time adjusted consultation counts were unaffected by GP gender and practice type. Female gender, part-time work in the range of 60%-90% of full-time, and working in group practices do not decrease GP efficiency. However, the challenge of recruiting sufficient numbers of GPs remains.

Linking Occupational Concentration to Hourly Wages for Non-College Going Individuals

One of the stated goals of career and technical education (CTE) is to improve the labor market outcomes of participants. One population of students for which concentration CTE may be particularly beneficial is those who determine they will not pursue postsecondary education. By exploring how occupational concentration—defined as earning three or more credits in a specific CTE cluster—relates to labor market outcomes for non-college participants, this study adds to a growing body of research on the benefits of CTE participation. In an effort to gain a more nuanced understanding of these labor market benefits, the current study further disaggregates these potential benefits across different CTE categories. Using a nationally representative dataset to explore the CTE concentration association with eventual earnings, results indicated that occupational concentration in general links to increased wages. However, these benefits are limited to a few specific CTE categories: health sciences, trades, and agriculture and natural resources. Implications for individual students, practitioners, and policymakers are discussed.

Reflective practice groups in a children’s social work setting - what are the outcomes, how do they work and under what circumstances? A new theoretical model based on empirical findings

ABSTRACT Despite widespread acceptance of the importance of reflection and reflective practice groups (RPGs) in children’s social work, almost no evidence exists as to the outcomes of RPGs in this context. This is a serious limitation because such evidence is crucial for funders and policy-makers and to establish RPGs as an evidence-based practice. There is also an absence of theoretical models to inform thinking about how RPGs might ‘work’ as an intervention to support workers and improve practice. Contributing new evidence to bridge these gaps, this paper reports a mixed-methods, longitudinal evaluation of RPGs within one local authority children’s social work services department. The study advances the methods that have been used to investigate RPGs in the social work context and considers outcomes beyond that of the individual practitioner. The paper also presents a new theoretical model, based on these empirical findings, of how RPGs ‘worked’ and under what circumstances.

Clinical reflective practice

Clinical reflective practice

Imperfect by design: the problematic ethics of surgical training

There exists in academic medicine a core ethical issue that is seldom pursued: trainees are frequently not the best person in the operating room at a given intervention being performed,...

The Oncology and Sexuality, Intimacy, and Survivorship Program Model: An Integrated, Multi-disciplinary Model of Sexual Health Care within Oncology.

Cancer-related sexual dysfunction is documented as one of the most distressing and long-lasting survivorship concerns of cancer patients. Canadian cancer patients routinely report sexuality concerns and difficulty getting help. In response to this gap in care, clinical practice guidelines were recently published in the Journal of Clinical Oncology. A sweeping trend is the creation of specialized clinics for patients' sexual health concerns. However, this much-needed attempt to address this service gap can be difficult to sustain without addressing the cancer care system from a broader perspective. Herein, we describe the implementation of a tiered systemic model of cancer-related sexual health programming in a tertiary cancer center. This program follows the Permission, Limited Information, Specific Suggestions, Intensive Therapy (PLISSIT) model, used previously for guiding individual practitioners. Visually, the model resembles a pyramid. The top 2 levels, corresponding to Intensive Therapy and Specific Suggestions, are comprised of group-based interventions for common cancer-related sexual concerns and a multi-disciplinary clinic for patients with complex concerns. The bottom 2 levels, corresponding to Permission and Limited Information, consist of patient education and provider education and consultation services. We describe lessons learned during the development and implementation of this program, including the necessity for group-based services to prevent inundation of referrals to the specialized clinic, and the observation that creating specialized resources also increased the likelihood that providers would inquire about patients' sexual concerns. Such lessons suggest that successful sexual health programming requires services from a systemic approach to increase sustainability.

Psychotherapists in danger: The ethics of responding to client threats, stalking, and harassment.

The ethics issues involved when clients threaten, stalk, or harass their psychotherapists have generally been neglected in the literature, leaving few psychologists prepared to manage such challenging situations. This article presents 3 clinical vignettes and recommendations resulting from a recent conference in Colorado on this important topic. In essence, the article seeks to address ways psychotherapists can balance the ethical challenges of simultaneously protecting clients and themselves. Each vignette is considered from ethical, clinical, and legal perspectives. Suggestions for the individual practitioner include reference to the principles and standards in the American Psychological Association's Ethics Code, professional consultation, and an increased emphasis on self-care. Recommendations for the profession involve ideas for the American Psychological Association's Ethics Code Task Force as well as a call for further research. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Growth hacking as an approach to producing growth amongst UK technology start-ups: an evaluation

Purpose“Growth hacking” is a “data-informed” marketing approach that uses digital marketing tools and tactics as well as traditional marketing channels to help technology companies show “proof-of-concept” and sustainability before gaining funding. The purpose of this study was to identify and understand the relevance and importance of growth hacking and identify what growth hacking tools and techniques are used by such organisations.Design/methodology/approachThe main research method for the collection of primary data was in-depth interviews with both industry experts (senior professionals working for growth hacking agencies) and individual growth hacking practitioners who work for technology start-ups based in the UK. Interviews included the use of dimension cards with key growth hacking terms to act as visual cues to facilitate focus and prompt reflection.FindingsIn addition to a data analysis element, growth hacking also requires people to spot emerging opportunities before anyone else does. This makes it very difficult to find people with the right skill-set. It is also important to use traditional marketing methods to bridge the gap between the physical and digital world.Originality/valueThis study shows that growth hacking is a mind-set and process that can help technology start-ups grow quickly with a limited marketing budget. The research offers guidelines and frameworks for start-ups to understand the growth hacking process. The concept has direct synergy with agile marketing and this might be a term/ methodology with which people in the UK may feel more comfortable given the negative connotations of the word “hacking”.

Risk Attitudes within ‘Complex Youth’ Assessment and Decision Making: Professional Perspectives

ABSTRACTRisk has become a driving force within the provision of welfare services in post-modern society (Kemshall [2002]. Conflicting knowledge’s on risk: The case of risk knowledge in the probation service. Health, Risk and Society, 2(2), 153–158). There is a dearth of research exploring how “risk” influences multi-agency professionals’ attitudes and responses to young people with complex needs - “complex youth” in the Republic of Ireland. This is the focus of this article. It draws from a wider doctoral study that explores attitudes, decision-making and service responses of professionals across statutory and non-statutory services towards “complex youth” in the North East region of the Republic of Ireland. The data presented is based on interviews and vignettes carried out with 27 professionals from the disciplines of child protection and welfare services; addiction services; youth justice services; mental health services; educational welfare services and community and voluntary services. The findings suggest that the discourse of risk dominates across all areas. The focus of multi-agency professionals’ work is about managing “risk”, rather than on addressing “need”. This leads to “complex youth” either not receiving a service, or receiving a service that is unsuitable and is focused on managing risk rather than addressing individual need. A further consequence is that young people are rendered invisible and absent as active agents from services and professionals are silenced. Recommendations for future practice are explored that focus on developing mechanisms to facilitate reflexivity within the individual practitioner, within the workplace and within multi-agency settings and to develop rights-based approaches within practice. It is hoped these recommendations will enable professionals to identify and better manage the influence of risk discourses in practice and in doing so enable the visibility of complex youth within services.

Call Me Bob:: A Safety Culture Initiative to Improve Interprofessional Teamwork

Patient safety is the highest goal in any health care environment. However, individual practitioner efforts are not enough; high-functioning, collaborative teams are required to achieve desired results. Traditional physician culture has emphasized physician authority and individual responsibility, leading to power gradients and often disrupting effective communication. To address this, an initiative to help remove communication barriers and promote all team members' comfort with proactively speaking up about concerns was created in a major Midwest regional children's hospital. This process is now part of the organization's working culture and has the potential to enhance communication, collaboration, and safety in other health care organizations.

Understanding disasters: managing and accommodating different worldviews in humanitarian response

Over the past decade, humanitarian events affected on average 120 million people annually. Whilst many of these events are human-induced, a large number of the 400 or so complex humanitarian emergencies that require international response each year are natural. Such events result in loss of life, injure and maim survivors, destroy infrastructure and give rise to psycho-social trauma. Aid agencies working alongside affected communities must address all these consequences as part of their responses. What is also required though is an appreciation that worldviews will inform how affected communities both understand the cause of the event, their role in the event and how they will subsequently participate in rebuilding or reconstruction programs. Disasters can be affected by religious beliefs. With more than 85% of the global population self-professing religious belief, these worldviews are often shaped in whole or in part by sacred texts, religious teachings and sectarian practices. In this regard, it is not uncommon for those affected by disasters (particularly natural disasters) to genuinely describe these events as ‘acts of God’. Effective responses require the local context to be central in assessing needs and determining capacities. This must include an understanding of and authentic engagement with religious beliefs and how this may affect how the humanitarian event interacts with these beliefs. There is though little evidence as to how professional humanitarian workers accommodate the religious beliefs of local populations in their planning, implementation and evaluation of humanitarian responses. This paper draws on the experiences of humanitarian workers based in the USA and Australia from both faith-based and secular international non-governmental organizations to consider both how these workers themselves accommodate the religious views of affected communities in their responses and also their experience as to how such views affect the effectiveness of responses. This paper will consider why aid agencies must incorporate (and appreciate) different worldviews around disasters in order to more effectively respond to the needs of communities affected by humanitarian events. It will also identify difficulties and opportunities experienced by individual humanitarian practitioners as well as agencies when working in such environments.