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COVID‐19 has infected millions of patients and impacted healthcare workers worldwide. Personal Protective Equipment (PPE) is a key component of protecting frontline clinicians against infection. The benefits of PPE far outweigh the risks, nonetheless, many clinicians are exhibiting skin injury caused by PPE worn incorrectly. These skin injuries, ranging from lesions to open wounds are concerning because they increase the susceptibility of viral infection and transmission to other individuals. Early into the COVID‐19 pandemic (April 2020), the U.S. National Pressure Injury Advisory Panel (NPIAP) developed a series of position statements to improve wear‐ability of PPE and protect healthcare professionals and their patients as safe from harm as possible under the circumstances. The NPIAP positions, which were formed by conducting a systematic review of what was known at the time, include: (1) Prepare skin before and after wearing PPE with skin sealants, barrier creams and moisturizers; (2) Frequent PPE offloading to relieve pressure and shear applied to skin; (3) treat visible skin injuries immediately caused by PPE to minimize future infection; (4) non‐porous dressings may provide additional skin protection, but lack evidence; (5) health systems should take care to educate clinicians about placement and personal hygiene related to handling PPE. Throughout all of these practices, handwashing remains a top priority to handle PPE. These NPIAP positions provided early guidance to reduce the risk of skin injury caused by PPE based on available research regarding PPE injuries, a cautious application of evidence‐based recommendations on prevention of device related pressure injuries in patients and the expert opinion of the NPIAP Board of Directors. Clinicians who adhere to these recommendations reduce the prospects of skin damage and long‐term effects (e.g. scarring). These simple steps to minimize the risk of skin injury and reduce the risk of coronavirus infection from PPE can help.

The American Society for Parenteral and Enteral Nutrition (ASPEN) Position Paper focus is on applying the 4 ethical principles for clinician's decision-making in the use of artificially administered nutrition and hydration (AANH) for adult and pediatric patients. These basic principles are (1) autonomy, respect the patient's healthcare preferences; (2) beneficence, provide healthcare in the best interest of the patient; (3) nonmaleficence, do no harm; and (4) justice, provide all individuals a fair and appropriate distribution of healthcare resources. Preventing and resolving ethical dilemmas is addressed, with an emphasis on a collaborative, interdisciplinary approach. Optimizing early communication and promoting advance care planning, involving completion of an advance directive, including designation of a surrogate decision-maker, are encouraged. Clinicians achieve respect for autonomy when they incorporate the patient, family, community, country, geographical, and presumed cultural values and religious belief considerations into ethical decision-making for adults and children with a shared decision-making process. These discussions should be guided by the 4 ethical principles. Hospital committees and teams, limited-time trials, clinician obligation with conflicts, and forgoing of AANH are addressed. Specific patient conditions are addressed because of the concern for potential ethical issues: coma, decreased consciousness, and dementia; advanced dementia; cancer; eating disorders; and end-stage disease/terminal illness. Incorporated in the Position Paper are ethical decisions during a pandemic and a legal summary involving ethical issues. International authors presented the similarities and differences within their own country or region and compared them with the US perspective.

COVID-19 pandemic raised the issue to guarantee the proper level of care to patients with acute cardiovascular diseases and concomitant suspected or confirmed COVID-19 and, in the meantime safety and protection of healthcare providers. The aim of this position paper is to provide standards to healthcare facilities and healthcare providers on infection prevention and control measures during the management of suspected and confirmed cases of 2019-nCoV infection accessing in cath-lab. The document represents the view of the Italian Society of Interventional Cardiology (GISE), and it is based on recommendations from the main World and European Health Organizations (WHO, and ECDC) as well as from the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI).

Coronavirus Disease 2019 (COVID‐19) has infected more than 3.0 million people worldwide and killed more than 200,000 as of April 27, 2020. In this White Paper, we address the cardiovascular co‐morbidities of COVID‐19 infection; the diagnosis and treatment of standard cardiovascular conditions during the pandemic; and the diagnosis and treatment of the cardiovascular consequences of COVID‐19 infection. In addition, we will also address various issues related to the safety of healthcare workers and the ethical issues related to patient care in this pandemic.

Open Dialogue is a need-adapted approach to mental health care that was originally developed in Finland. Like other need-adapted approaches, Open Dialogue aims to meet consumer’s needs and promote collaborative person-centred dialogue to support recovery. Need-adapted mental health care is distinguished by flexibility and responsiveness. Fidelity, defined from an implementation science perspective as the delivery of distinctive interventions in a high quality and effective fashion is a key consideration in health care. However, flexibility presents challenges for evaluating fidelity, which is much easier to evaluate when manualization and reproducible processes are possible. Hence, it remains unclear whether Open Dialogue and other need-adapted mental health interventions can be meaningfully evaluated for fidelity. The aim of this paper was to critically appraise and advance the evaluation of fidelity in need-adapted mental health care, using Open Dialogue as a case study. The paper opens a discussion about how fidelity should be evaluated in flexible, complex interventions, and identifies key questions that need to be asked by practitioners working in need-adapted mental health care to ensure they deliver these interventions as intended and in an evidence-based fashion.

Aim Using an integrated model of health literacy, we discuss the importance of health literacy among foreign domestic workers in the provision of informal caregiving during outbreaks of communicable diseases. COVID-19 pandemic is used as an example. Background Adequate health literacy in the population is known to be important for the prevention of communicable diseases. Foreign domestic workers, a group of marginalized caregivers in private households, are generally presumed to have limited health literacy because of numerous socio-cultural disadvantages. To date, there is limited evidence that these informal health care providers receive support from community-based nurses. Design A discursive paper. Conclusion Foreign domestic workers, with varying levels of health literacy, may be viewed either as a resource to break the chain of infection or as a potential reservoir of communicable diseases in the community. Meanwhile, restrictions imposed in response to diseases transmissions (e.g., stay-at-home measures for COVID-19) may directly exacerbate the social support received by these foreign domestic works and their ability to access health-related information. There are also concerns about their ability to appraise and evaluate information related to communicable diseases at a time when fake news and misinformation is being disseminated through social media. Language and cultural barriers are important issues that need to be addressed to ensure that foreign domestic workers are in a position to follow public health recommendations. Relevance to clinical practice Nurses hold an important position in empowering foreign domestic workers with adequate health literacy, by engaging groups of foreign domestic workers in the community and their consulates in planning educational programmes and effectively disseminating information. At a time of global pandemic, an assessment of the health literacy levels of foreign domestic workers in places like Hong Kong is urgently required.

The 2014 outbreak of Ebola virus disease (EVD) in West Africa has presented a significant public health crisis to the international health community and challenged U.S. emergency departments (EDs) to prepare for patients with a disease of exceeding rarity in developed nations. With the presentation of patients with Ebola to U.S. acute care facilities, ethical questions have been raised in both the press and medical literature as to how U.S. EDs, emergency physicians (EPs), emergency nurses, and other stakeholders in the health care system should approach the current epidemic and its potential for spread in the domestic environment. To address these concerns, the American College of Emergency Physicians, the Emergency Nurses Association, and the Society for Academic Emergency Medicine developed this joint position paper to provide guidance to U.S. EPs, emergency nurses, and other stakeholders in the health care system on how to approach the ethical dilemmas posed by the outbreak of EVD. This paper will address areas of immediate and potential ethical concern to U.S. EDs in how they approach preparation for and management of potential patients with EVD.

This White Paper builds on the publication of the International League Against Epilepsy (ILAE) and International Bureau for Epilepsy (IBE) report "Listening for a change-medical and social needs of people with intellectual disability who have epilepsy" (Listening for a change the medical and social needs of people with epilepsy and intellectual disability, ILAE, 2013). The Paper presents an overview of the recommendations of the report, which aim to improve the health and social care of this important population of people with epilepsy worldwide. Actions in four domains are indicated: (1) the development of standards and initiatives that would enhance diagnosis, pathways to investigation, and treatment; (2) the development of guidelines for treatment, specifically best practice in the management of antiepileptic drugs including rescue medication; (3) the development of standards for primary care, multidisciplinary teamwork, and clinical consultations, with emphasis on the need to enhance communication and improve access to information; and (4) the enhancement of links among different stakeholders including medical services, educational establishments, employment services, organizations providing opportunities for social engagement, and family members. The breadth of needs of this population is a challenge to the epilepsy world, spanning all the professional groupings, care providers, and the research modalities in epilepsy.

Currently, there is a lack of consensus regarding the accepted terminology pertaining to the pressure ulcer healing progression and recidivism. This lack of uniformity can negatively impact initiation of treatment pathways, completion of appropriate interventions, clinical documentation, medical coding, patient education, discharge planning and healthcare revenue through out the healthcare system. The purpose of this paper is to introduce a standard nomenclature as it pertains to pressure ulcer healing progression and any recidivism that may occur. The National Pressure Ulcer Advisory Panel has formulated a framework of terms regarding pressure ulcer progression. We also developed a clearer nomenclature for lack of progress and recidivism of pressure ulcers. This document should serve as a starting point for the discussion of the pressure ulcer care, research, and terminology.

Aim The aim of this paper is to discuss the importance of ethical aspects when implementing eHealth services in healthcare. Background Challenges in healthcare today include a growing older population and, as a consequence, an increased need for healthcare services. One possible solution is the use of eHealth services. Design Discussion paper. Data sources Research literature published from 2000 - 2017 in CINAHL, PubMed and Scopus. Implications for nursing Implementing eHealth services in healthcare involves ethical challenges where different technologies can solve different problems in different ways. eHealth services should therefore be developed and implemented based on the patient's specific needs and conditions for use and in accordance with the healthcare professionals’ presumption to provide high quality care. Conclusion To preserve patients’ integrity, dignity and autonomy, healthcare professionals must include ethical aspects when implementing and using eHealth services in healthcare. Healthcare professionals have to take responsibility for the eHealth services introduced, explaining why and how they are implemented based on a person-centered approach. More knowledge is needed about ethical aspects when implementing eHealth services to improve the quality of care. This article is protected by copyright. All rights reserved.

Aim A discussion of key considerations related to selecting instruments and tools for evaluating healthcare professionals' evidence-based practice (EBP) competencies. Design A discussion paper. Data sources Articles published in international peer-reviewed journals from January 2000 - November 2017 on validated instruments for assessing healthcare professionals' performance-based EBP competencies. Implications for nursing Validated EBP competency instruments based on actual performance to evaluate the EBP competencies of healthcare professionals are currently available in the field of medicine. Although some of these instruments have already been adapted for use in physical and occupational therapy, their modification for use in nursing has begun only in the last few months. Conclusion A concerted effort on modifying and validating objective measures of actual performance for use in nursing should be commenced to evaluate directly measurable EBP competencies, instead of continuing to rely on nurses' self-assessments. Future studies focusing on development and validation of objective instruments to evaluate EBP competencies based on actual performance and exploring the modification of currently available objective instruments from medicine are urgently needed in nursing. Impact Instead of measuring actual EBP competencies, the majority of competency evaluations in nursing are still being conducted via self-assessments, despite growing evidence of their poor accuracy in evaluating directly measurable constructs such as evidence-based practice knowledge and skills. Accurate measurement of nurses' EBP competencies is essential to increasing systematic implementation of EBP in healthcare organizations, thus promoting the attainment of improved care quality and patient outcomes in healthcare delivery.

Healthcare spending in the United States is the highest in the world, yet quality indicators such as life expectancy and infant mortality lag other countries. U.S. reforms are under way to lower costs and raise quality of care, notably the Patient Protection and Affordable Care Act (PPACA). Value-based purchasing (VBP) and programs for reducing the incidence of hospital-acquired conditions (HACs) and hospital readmissions represent initial changes. With these programs, overarching themes are to coordinate care during and beyond hospitalization and to ensure that physicians and hospitals are aligned in their treatment strategies. Hospital malnutrition represents a large, hidden, and costly component of medical care; hospital administrators and caregivers alike must harness the benefits of nutrition as a vital component of healthcare. Medical, nursing, and allied health training programs must find places in their curricula to increase awareness of nutrition and promote knowledge of best-practice nutrition interventions. Hospitals use dietitians and nutrition support teams as critical members of the patient care team, but more work needs to be done to disseminate and enforce best nutrition practices. Such training, nutrition interventions, and practice changes can help prevent and treat malnutrition and thus help avert HACs, reduce hospital readmissions, lower infection and complication rates, and shorten hospital stays. Nutrition care is an effective way to reduce costs and improve patient outcomes. This article calls hospital executives and bedside clinicians to action: recognize the value of nutrition care before, during, and after hospitalization, as well as develop training programs and policies that promote nutrition care.

Does the presence of a unionized nursing workforce retard US hospitals’ transition from paper-based to electronic health records (EHRs)? After tying archival data on hospitals’ structural features and health information technology (IT) investment patterns to self-gathered data on unionism, I find that hospitals that bargain collectively with their registered nurses (RNs) appear to delay or forego the transition away from paper, consistent with existing theory and research in industrial relations and institutional economics. However, this relationship is fully mediated by a hospital's payer mix: those serving a larger share of less lucrative, elderly, disabled and indigent patients are more likely to adopt EHRs if they are unionized than if they are not, a result that holds even at the median payer mix. Indeed, this accords with research on the interplay of labour and technology as the aforementioned dynamics are driven entirely by RN-exclusive bargaining units for whom the new IT serves as a complement rather than as a substitute in production. Given the outsized role that unions play in the US healthcare sector, the overall sluggish performance of the sector, and the expectations that policymakers have for EHRs, evidence that these unions are welfare-enhancing should be welcome news.

J Clin Hypertens (Greenwich). 2010;12:757‐764. © 2010 Wiley Periodicals, Inc. Nonadherence and poor or no persistence in taking antihypertensive medications results in uncontrolled high blood pressure, poor clinical outcomes, and preventable health care costs. Factors associated with nonadherence are multilevel and relate not only to the patient, but also to the provider, health care system, health care organization, and community. National guideline committees have called for more aggressive approaches to implement strategies known to improve adherence and technologies known to enable changes at the systems level, including improved communication among providers and patients. Improvements in adherence and persistence are likely to be achieved by supporting patient self‐management, a team approach to patient care, technology‐supported office practice systems, better methods to measure adherence, and less clinical inertia. Integrating high blood pressure control into health care policies that emphasize and improve prevention and management of chronic illness remains a challenge. Four strategies are proposed: focusing on clinical outcomes; empowering informed, activated patients; developing prepared proactive practice teams; and advocating for health care policy reform. With hypertension remaining the most common reason for office visits, the time is now.

Traditionally, Scandinavian anaesthesiologists have had a very broad scope of practice, involving intensive care, pain and emergency medicine. European changes in the different medical fields and the constant reorganising of health care may alter this. Therefore, the Board of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) decided to produce a Position Paper on the future of the speciality in Scandinavia. The training in the various Scandinavian countries is very similar and provides a stable foundation for the speciality. The Scandinavian practice in anaesthesia and intensive care is based on a team model where the anaesthesiologists work together with highly educated nurses and should remain like this. However, SSAI thinks that the role of the anaesthesiologists as perioperative physicians is not fully developed. There is an obvious need and desire for further training of specialists. The SSAI advanced educational programmes for specialists should be expanded and include formal assessment leading to a particular medical competency as defined by the European Union of Medical Specialists (UEMS). In this way, Scandinavian anaesthesiologists will remain leaders in perioperative, intensive care, pain and critical emergency medicine.

The medical specialty of physical medicine and rehabilitation (PMR) has had a proven impact on persons with disability and on health care systems. Documents such as The White Book on Physical and Rehabilitation Medicine in Europe have been important in defining the scope of practice within various regions. However, on some continents, the practice has not been well defined.To explore the practice of PMR in subSaharan Africa and Antarctica.Medline searches, membership data searches, fax survey of medical schools, Internet searches, and interviews with experts.The continents are dissimilar in terms of climate and government. However both Antarctica and subSaharan Africa have no PMR training programs, no professional organizations, no specialty board requirements, and no practicing physicians in the field. Because there are no known disabled children on Antarctica and adults are airlifted to world-class health care, the consequences of this deficit are minimal there. However, the 788,000,000 permanent residents of subSaharan Africa, including approximately 78 million persons with disability, are left unserved.Antarctica is doing fine. Africa is in a crisis. Local medical schools, hospitals doctors, and persons with disability; along with foreign volunteers, aid groups, and policymakers can impact the crisis. However government-specifically national ministries of health-is ultimately responsible for the health and wellbeing of citizens.

Introduction\ud \ud Dental educators are important people who contribute to the development of every aspect of dental education. In part due to the lack of understanding of their roles and competences, dental educator development has so far received little consideration. With the aim of enhancing the dental profession's contribution to the development of undergraduate dental education, this article explores common roles of educators of undergraduate dental students and the competences needed to be effective educators. \ud \ud \ud Methods\ud \ud This is a discussion paper based on a wide reading of the literature on the education of health professionals with a specific focus on roles and competences of educators. \ud \ud \ud Results and discussion\ud \ud Roles of educators of undergraduate dental students typically encompass four areas: teaching, research, administration and providing healthcare. Educators may not be involved in every role; they normally perform the roles relevant to their work contexts. Competences for dental educators based on the four main roles comprise 12 domains: educational theories and principles; modes of education; learner issues; educational materials and instructional design; assessment and feedback; curriculum matters; evaluation; educational research; educational management; quality assurance; patient care and healthcare system and professionalism. Not all competences are required by all educators although educators need to be competent in the areas related to their roles and duties. \ud \ud \ud Conclusion\ud \ud Understanding the roles and competences for educators of undergraduate dental students can help individual educators to improve their personal effectiveness and institutions to tailor staff development programmes appropriate to the needs of their staff. Faculty development contributes to sustained enhancement of undergraduate dental education.

Aims A discussion of partnership in the context of family centered care in the acute paediatric setting, through a critical analysis of partnership models. Background Paediatric healthcare practitioners understand the importance of family centered care, but struggle with how to translate the core tenets into action and are confused by several rival terms. Partnering relationships are included in definitions of family centered care, yet less is known about strategies to fully engage or support parents in these partnerships. A rigorous examination of concepts embedded in family centered care such as partnership may provide a better understanding of how to implement the broader concept and support exemplary care in today's clinical practice environment. Design Discussion paper. Data Sources Electronic search (January 2000 - December 2014) performed on CINAHL, Medline, EMBASE, Sociological Abstracts and PsychINFO using keywords partnership, family centered care and conceptual framework. Eligible references were drawn from the databases, reference lists and expert sources. Eight models met inclusion criteria and had currency and relevance to the acute paediatric setting. Implications for Nursing Nurses should continue exploring partnership in various paediatric contexts given the wide-ranging definitions, lack of operational indicators and need for stronger relational statements in current models. An examination of key strategies, barriers and facilitators of partnership is recommended. Conclusion One partnership model had both high overall maturity and best fit with family centered care principles. All models originate from Western and developed countries, indicating that future partnership models should be more geographically, culturally and economically diverse. This article is protected by copyright. All rights reserved.

The authors thank Swnalund Chair Professor of University of Illinois at Urbana-Champaign Prof. John Rogers for useful discussion about this paper. This publication is based upon work supported by the King Abdullah University of Science and Technology (KAUST) Office of Sponsored Research (OSR) under Award No. Sensor Innovation Initiative OSR-2015-Sensors-2707 and KAUST-KFUPM Special Initiative OSR-2016-KKI-2880. M.M.H. conceptualized and directed the study. J.M.N. led the study. K.M. developed the electronic circuit. K.L. assisted with human subject testing. A.A.A. helped with design. J.M.N. and M.M.H. coauthored the paper. Every author reviewed the final draft.

Aim A discussion of the concepts of leadership and emotional intelligence in nursing and midwifery education and practice. Background The need for emotionally intelligent leadership in the health professions is acknowledged internationally throughout the nursing and midwifery literature. The concepts of emotional intelligence and emotional-social intelligence have emerged as important factors for effective leadership in the healthcare professions and require further exploration and discussion. This paper will explore these concepts and discuss their importance in the healthcare setting with reference to current practices in the UK, Ireland and internationally. Design Discussion paper. Data sources A search of published evidence from 1990–2015 using key words (as outlined below) was undertaken from which relevant sources were selected to build an informed discussion. Implications for nursing/midwifery Fostering emotionally intelligent leadership in nursing and midwifery supports the provision of high quality and compassionate care. Globally, leadership has important implications for all stakeholders in the healthcare professions with responsibility for maintaining high standards of care. This includes all grades of nurses and midwives, students entering the professions, managerial staff, academics and policy makers. Conclusion This paper discusses the conceptual models of leadership and emotional intelligence and demonstrates an important link between the two. Further robust studies are required for ongoing evaluation of the different models of emotional intelligence and their link with effective leadership behaviour in the healthcare field internationally. This is of particular significance for professional undergraduate education to promote ongoing compassionate, safe and high quality standards of care.

The oral health education system is in need of major reform! This is especially apparent in university-based education for the health professions. So-called preclinical as well as clinical education simply has not kept pace with or been responsive enough to shifting patient demographics and patient/population desires and expectations, changing health system expectations, evolving interdisciplinary expertise and practice requirements, new scientific discoveries and scientific information, focus on quality improvement, and/or integration of emerging technologies. Moreover, university-based "dental education" is the most costly professional degree education within the entire university portfolio, and dental student accumulated debt is increasing each year well beyond national inflation estimates. Today, we have an enormous opportunity to explore major reforms in health professional education. Through the Santa Fe "process" of open and candid engagements and discussions (see www.santafegroup.org), we advance an argument as well as a national strategy that can enable major reforms in the oral health education system. We further suggest that major revisions can result in an outcome-based education system that prepares oral health professionals to meet both the needs of patients/families/communities and the requirements of a changing health system.

Open Dialogue is a resource-oriented approach to mental health care that originated in Finland. As Open Dialogue has been adopted across diverse international healthcare settings, it has been adapted according to contextual factors. One important development in Open Dialogue has been the incorporation of paid, formal peer work. Peer work draws on the knowledge and wisdom gained through lived experience of distress and hardship to establish mutual, reciprocal, and supportive relationships with service users. As Open Dialogue is now being implemented across mental health services in Australia, stakeholders are beginning to consider the role that peer workers might have in this model of care. Open Dialogue was not, initially, conceived to include a specific role for peers, and there is little available literature, and even less empirical research, in this area. This discussion paper aims to surface some of the current debates and ideas about peer work in Open Dialogue. Examples and models of peer work in Open Dialogue are examined, and the potential benefits and challenges of adopting this approach in health services are discussed. Peer work in Open Dialogue could potentially foster democracy and disrupt clinical hierarchies, but could also move peer work from reciprocal to a less symmetrical relationship of 'giver' and 'receiver' of care. Other models of care, such as lived experience practitioners in Open Dialogue, can be conceived. However, it remains uncertain whether the hierarchical structures in healthcare and current models of funding would support any such models.

Aim and Objective To assess and compare the quality of paper-based and electronic-based health records. The comparison examined three criteria: content, documentation process, and structure. Background Nursing documentation is a significant indicator of the quality of patient care delivery. It can be either paper-based or organized within the system known as the Electronic Health Records (EHRs). Nursing documentation must be completed at the highest standards, in order to ensure the safety and quality of health care services. However, the evidence is not clear on which one of the two forms of documentation (paper-based versus EHRs) is more qualified. Methods A retrospective, descriptive, comparative design was utilized to address the study's purposes. A convenient number of patients’ records, from two public hospitals, were audited using the Cat-ch-Ing Audit Instrument. The sample size consisted of 434 records for both paper-based health records and EHRs from medical and surgical wards. Results EHRs were better than paper-based health records in terms of process and structure. In terms of quantity and quality content, paper-based records were better than EHRs. The study affirmed the poor quality of nursing documentation and lack of nurses’ knowledge and skills in the nursing process and its application in both paper-based and electronic-based systems. Conclusion Both forms of documentation revealed drawbacks in terms of content, process, and structure. This study provided important information, which can guide policymakers and administrators in identifying effective strategies aimed at enhancing the quality of nursing documentation. Relevance to Clinical Practice Policies and actions to ensure quality nursing documentation at the national level should focus on improving nursing knowledge, competencies, practice in nursing process, enhancing the work environment and nursing workload, as well as strengthening the capacity building of nurses practice to improve the quality of nursing care and patients’ outcomes. This article is protected by copyright. All rights reserved.

Summary The production of paper is a key economic activity accounting in value terms for about 2.5% of the world's industrial production and 2% of world trade. Paper products make a vital contribution to education, communications, packaging, and health care. In recent years the paper cycle has become the focus of environmental concerns about the impacts of forestry pollution from manufacturing, and waste. To address these concerns, the World Business Council for Sustainable Development commissioned the International Institute for Environment and Development (IIED) to examine the sustainability of the paper cycle. The first phase ofthe study involved a review of literature related to the paper cycle to identify the main debates and gaps in knowledge. This was followed by a journal of Industrial Ecology wide-ranging program of research and consultation on various aspects of the paper cycle. This article summarizes the key findings of the study for different stages of the cycle covering issues such as the impacts of forestry, the outlook for fiber supply, the role of nonwood fiber; the environmental and social impacts of pulp and paper manufacturing, the choice of options for wastepaper and the contribution of the paper cycle to greenhouse gas emissions. The study makes a number of recommendations for the pulp and paper industry, governments, international agencies, consumers, and nongovernmental organizations

Individuals increasingly are taking a more active role in their health care, and herbal products have emerged as a common choice among self-care therapies. Pharmacists are active participants in the care of patients who are taking herbal products. Currently, most pharmacists are not educated adequately about herbal products and other types of alternative medicine. Furthermore, good information about many of these products is not available. These combined factors present a challenge for pharmacists as they seek to provide optimal care and counseling to patients who use herbs or supplements. We recommend the following actions to place pharmacists in better positions as effective agents protecting public safety: Regulations should be implemented at a federal level to require basic levels of standardization and quality control in the manufacture of herbal products. Indexing terms in medical bibliographic systems should be expanded to target herbal products. Funding should be increased for scientific research evaluating herbal products. Pharmacy schools should include a competency statement in their curricula regarding herbal medicines. Continuing education in herbal products should be available and encouraged for all pharmacists. Pharmacists should approach the use of all therapeutic interventions with scientific rigor, whether they are traditional or complementary in nature. Patients will benefit as more information is known and widely disseminated. By actively embracing the responsibility for counseling individuals on the appropriate use of herbal products, pharmacists will become a recognized source of expert information in this rapidly growing area, yielding important improvements in the quality of care.

Much of the discussion surrounding the publication of the NHS White Paper ‘Working for Patients’ has centred on proposals for an ‘Internal Market’. However, the term ‘Internal Market’ embraces two quite distinct concepts, both of which are found within the White Paper. These two types of Internal Market have very different implications for cost, equity, priorities and the planning and delivery of health care. The pattern of health and health care will be strongly influenced by the relative strengths of the two types of Internal Market in the future NHS.

OLEDWorks has started production operations for manufacturing OLED lighting panels. Compared to OLED displays, affordability is much more important for market adoption of OLED lighting. To this end, we have developed a unique approach in both product design and manufacturing processes. These elements are embodied in our first product, amber lighting for the health care market.

Background Heart failure (HF) care takes place in multiple settings, with a variety of providers, and generally involves patients who have multiple comorbidities. This situation is a “perfect storm” of factors that predispose patients to medication errors. Methods and Results The goals of this paper are to outline potential roles for clinical pharmacists in a multidisciplinary HF team, to document outcomes associated with interventions by clinical pharmacists, to recommend minimum training for clinical pharmacists engaged in HF care, and to suggest financial strategies to support clinical pharmacy services within a multidisciplinary team. As patients transition from inpatient to outpatient settings and between multiple caregivers, pharmacists can positively affect medication reconciliation and education, assure consistency in management that results in improvements in patient satisfaction and medication adherence, and reduce medication errors. For mechanical circulatory support and heart transplant teams, the Centers for Medicare and Medicaid Services considers the participation of a transplant pharmacology expert (e.g., clinical pharmacist) to be a requirement for accreditation, given the highly specialized and complex drug regimens used. Although reports of outcomes from pharmacist interventions have been mixed owing to differences in study design, benefits such as increased use of evidence-based therapies, decreases in HF hospitalizations and emergency department visits, and decreases in all-cause readmissions have been demonstrated. Clinical pharmacists participating in HF or heart transplant teams should have completed specialized postdoctoral training in the form of residencies and/or fellowships in cardiovascular and/or transplant pharmacotherapy, and board certification is recommended. Financial mechanisms to support pharmacist participation in the HF teams are variable. Conclusions Positive outcomes associated with clinical pharmacist activities support the value of making this resource available to HF teams.

This paper is a discussion of the possible ethical dilemmas that may arise in both qualitative and quantitative research despite stringent methodological protocols. Three categories of ethical issues will be elaborated on, namely, researcher–participant relations, informed consent and confidentiality and privacy. These are of note because ethical dilemmas most often arise in these areas. Both qualitative and quantitative research types may thus present with problems associated with any, or a combination, of these categories. Methodological rigour will also be discussed as a vital component of any research study. Critics of the qualitative approach have often suggested that the innate lack of methodological rigour has resulted in the preponderance of ethical issues in qualitative studies. Qualitative studies, similar to quantitative studies, have mechanisms that guarantee rigour, quality and trustworthiness. These checks are at par with those of quantitative research but based on different criteria. Both types of research, then, can be considered equal in terms of methodological rigour, regardless of the nature. As no research approach can be perfectly free from threats of ethical issues, it is the researcher's responsibility to address these in ways that will be less harmful to the participants, bearing in mind ethical problems can arise at any time during the research endeavour.

The Association of Community Health Nursing Educators (ACHNE) has developed a number of documents designed to delineate the scope and function of community/public health nursing (C/PHN) educators, researchers, and practitioners. Consistent with the mission of ACHNE, this position paper entitled Academic Faculty Qualifications for Community/Public Health Nursing has been developed by the Faculty Qualifications Task Force. The shortage of qualified nursing faculty has been well documented. In particular, this shortage has increased the difficulty in having sufficient numbers of faculty who are educationally and experientially qualified to teach in the C/PHN specialty. ACHNE is addressing this concern by setting forth preferred qualifications for faculty to teach C/PHN at both the graduate and undergraduate level. While we recognize that the current faculty shortage may require schools to use faculty to teach in areas in which they do not have appropriate formal preparation, the paper outlines best practices for teaching C/PHN, a goal we urge all schools of nursing to work toward. Task Force members developed an earlier draft of the document in fall 2008, and input was solicited and received from ACHNE members and considered in the final document, which was approved by the ACHNE Executive Board in July 2009.

This summary paper for the symposium provides a brief overview of the papers by Craig Veitch, John Beard and Max Kamien that deal with the environmental, socioeconomic and political descriptors of 'rurality'. Those three papers deal with a number of fundamental truths about rural and remote health, including the fact that internal migration is an important and poorly understood factor in determining community and health outcomes. A brief treatment of the issue suggests that selective internal migration is likely to mean that the burden of illness in rural and remote areas is even higher than that suggested by the published figures. The paper then asserts that thinking in the rural and remote health sector in Australia focuses largely on the negative aspects of the current characteristics of rural areas. A self-evident definition of 'rurality' is offered that has it defined by the set of factors that currently characterise places, communities and individuals outside the major cities. The paper suggests that each of these characteristics has an upside or benefit, as well as a downside or risk, and that giving greater attention to the former will provide a better basis for informing rural health policy and practice than the deficit view alone.

OBJECTIVE: To review the scientific validity of published papers on the efficacy of acupuncture in dentistry based on predefined methodological criteria. MATERIALS: A literature search performed by the Royal Society of Medicine and the University Library, Copenhagen, Denmark was able to identify 74 papers written in English, German, Danish, Swedish, Norwegian, Italian, French and Russian published between 1966 and 1996. The search words were: acupuncture and electro-acupuncture, randomised controlled trials (RCT), dental pain, postoperative dental pain, painrelieving in dentistry, and dental analgesia. Among the 74 listed papers, 48 papers were reviewed in the following languages: English, Danish, Swedish, Norwegian and German. Fifteen papers were excluded because they were written in French, Italian or Russian; 11 papers were excluded because the abstract clearly indicated the paper was not a RCT or the paper was of a general nature without relevance to acupuncture. METHODS: To assess the methodological quality of the included papers, all papers were scored on the basis of predefined criteria. A total of 92 points could be achieved and on the basis of this scale papers were rated as: Excellent (85–100%), Good (70–84%), Fair (60–69%) and Bad (

Health Services Research (HSR) is pleased to announce a new feature called “The Theme Series.” The journal will from to time issue a call for papers on a specific “theme” considered to be of particular significance to the field and importance for current health care policy. Manuscripts submitted for the Theme Issue will undergo the usual HSR peer review process. Articles that meet HSR's high standards for publication will be further evaluated for relevance and significance, and the best 8–10 articles will be gathered into an issue devoted entirely to the announced theme. Accepted manuscripts that are not selected for the Theme Issue will be automatically accepted for publication in a regular issue. The first theme selected is “Improving Efficiency and Value in Health Care” in which we seek to publish research that will help improve the value and efficiency of the American Healthcare System. This Theme Issue is sponsored by the Agency for Healthcare Research and Quality (AHRQ), which will assist HSR in publicizing the call and disseminating the findings of the selected studies. (See the Call for Papers at http://www.hsr.org.) This theme is particularly fitting to initiate this new feature because it presents a conundrum for researchers and policy makers alike. HSR aims to attract the best research on this theme in time to contribute to the national debate and collective interest about health care that attends election years. We all recognize that high and rising healthcare costs—especially when accompanied by gaps in quality, safety, equity, and access—are unsustainable. Federal and state policy makers, along with private payers and systems leaders, are seeking new ways to reduce waste, increase efficiency of health care delivery, and allocate resources in order to improve value in health care. Consumers also seek guidance about how to maximize the value of their own health care dollar, particularly as some payer innovations have increased consumers' financial exposure. We invite you to respond to our call with your research to add value and efficiency to our system. The processes used for Theme Issues in the new Theme Series will differ from those HSR uses for its regular and special issues in several ways. Manuscripts submitted for regular issues, of course, are unsolicited. The Co-Editors-in-Chief (EIC) make an initial judgment of the suitability of each submitted manuscript for our audience and the quality of the work. Manuscripts surviving this cut are then assigned to one of the eight Senior Associate Editors (SAE) for additional review before deciding to send it out for external peer review (see Luft and Flood 2003; Flood 2004; Luft 2004 for more details). The most appropriate SAE is chosen for each manuscript based on the topic of the research and the SAE's experience and academic discipline. Special issues, on the other hand, are of two basic types (see Luft 2003 for details). Most special issues consist of a series of papers presented at a conference. A few special issues have resulted from a special call for papers. In both cases, however, the special issues are proposed and sponsored by organizations or groups external to HSR that approach the Journal with a particular topic in mind. A guest editor from the organization or group proposing the topic, working with an assigned SAE, plays a role in reviewing and selecting articles for publication based on their suitability for the special issue. In contrast, for the Theme Series, the editors and publisher of HSR will select the themes and subsequently seek sponsorship for publishing and disseminating the resulting issue. HSR will then issue a targeted call for papers. Papers submitted to HSR in response to the call will first undergo the process for regular manuscripts, i.e., the EICs will make the initial cut based on fit and quality and then assign remaining manuscripts to the most appropriate SAE for another internal review and decision to send for external peer review. Subsequently, as with regular manuscripts, SAEs will make a recommendation to the EIC on acceptance, revision, or rejection. All manuscripts accepted through this process will be scheduled for electronic publication in Online Early; these articles are fully published and may be cited. It usually takes a few weeks from the date the accepted manuscript and required forms are received by our Managing Editor until they are published online. It is during the “final” step—scheduling for print publication—that the Theme Issue manuscripts will be handled differently. At this point, one SAE (and Guest Editor, if any) will be assigned to review all accepted manuscripts responding to our call, taking into account both external reviewer and SAE assessments of manuscripts' originality and significance as well as their fit to the theme. The SAE and Guest Editor will select specific papers to be published in the Theme Issue, and recommend them to the EICs, who will make the final decisions on selection. Accepted manuscripts that are not selected for the Theme Issue will be published in regular issues. Why would authors be interested in submitting their best work for publication in a Theme Issue? There are several important advantages from an author's perspective: First, and most important, extra attention is likely to be focused on the manuscripts that are printed in the Theme Issue for several reasons. Theme Issues are more likely to draw attention to the topic and therefore to the manuscripts in the issue, which will also feature an editorial on the importance and timeliness of the theme and the contributions made by each manuscript. The Theme Issue is likely to get additional attention from the planned extra dissemination that will accompany publication of Theme Issues. Second, there is potential for speeding up the review cycle since we will be monitoring the process for these manuscripts more closely in order to keep them on track for the intended publication date. Third, once manuscripts are accepted, they will be published promptly in Online Early. Moreover, selection for the Theme Issue is likely to result in “jumping the queue” for print publication in HSR since the Theme Issue is likely to come to print earlier than regular manuscripts accepted at the same point in time. Finally, we plan to introduce another new electronic feature related to the Theme Issue to allow readers to comment on the papers and themes. What are the potential benefits for HSR? While we remain strongly committed to our principal mission to publish high quality, original and significant research in the field of health services research, we also want to help build the field and bolster its ability to make an impact in changing the health care system through building the underlying science and evidence base. High-quality Theme Issues will offer a visible and effective mechanism for accomplishing these goals. With these aims in mind, we have also initiated: The From the Editors series, where the editors analyze HSR with the goal of making our intent and objectives and the process of publishing more transparent (see http://www.hsr.org). We have (with permission) provided an example of peer review at http://www.hsr.org using a real manuscript at HSR going through the documents as initially submitted to receiving reviews and letters from us to responding to reviewers until finally being accepted. We initiated a new policy in 2007 to make more transparent to readers of each manuscript the authors' potential conflicts of interests, the sponsor's roles in the conduct of research and publishing the work, and authorship and contributorship based on explicit definitions of these terms; these disclosures now be a published part of each article at HSR (Luft, Flood, and Escarce 2006). In collaboration with AcademyHealth, we publish the President's address and selected Roundtable discussions featuring translations of research to policy and clinical settings from the Annual Research Meetings. In honor of John M. Eisenberg, we initiated an annual award for the best article published in HSR that addresses one of Dr. Eisenberg's principal areas of research or leadership (Flood and Luft 2004) see current and past recipients at http://www.hsr.org. We feature occasional manuscripts, which we call “Building the Field,” that are designed to improve the training and development of the field of health services research (see HSR 42(1, part I) for two examples). We invite you to help us in this latest new feature by contributing your best work to the Theme Series as we all seek to add value to the field and to our health care system.

Background Appreciating the need to better translate biomedical research into improved clinical care and health, the NIH Roadmap was initiated in 2003 to focus on this by strengthening NIH’s central role in clinical research and clinical research training. As part of the needed re-engineering, in 2006 NIH began the CTSA program. At this writing (Summer 2009), there are 39 CTSAs at leading universities across the United States, each having a clinical research graduate program and extensive resources for promoting clinical and translational research. Each of these, and the CTSA Consortium as a whole, are committed to transforming clinical and translational research to maximize impact on health. The CTSAs bring to this challenge an array of capacities, extensive research infrastructure, formal training and career development programs, community engagement of the public and of clinical practice communities, and informatics related to research and clinical practice. Various CTSAs have different areas of emphasis, including along the spectrum of translational research from bench to patient bedside (the first translational step, “T1”), from the bedside to general use in clinical practice (“T2”), and from clinical practice to public benefit and policy (“T3”). This broad array of activities has allowed the national consortium to be responsive to needs all along this path of translation of biomedical research into practice and public benefit. Although the activities of CER can be seen as primarily involving T2 and T3 research, they also can be seen as focusing on the optimal translation of T1 research into effective treatment, and thus the very epitome of work in which CTSAs should be deeply involved. This appreciation was reinforced by CER’s selection as a key Strategic Goal focus of the CTSA Consortium. In this context, the CER Strategic Goal of the CTSA Consortium is to promote the translation of the results of clinical and translational research into practice and public policy. In service of this, in two sections below, we review the span of CER resources across the CTSA Consortium and propose potential roles for CTSAs in supporting CER. As a point of reference for this White Paper, below are two important definitions of CER from reports released at the end of June 2009, from the IOM and from the FCC-CER: Definition from the IOM Report on Priorities for CER The generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care. The purpose of CER is to assist patients, clinicians, purchasers, and policy makers, and the public to make informed decisions that will improve healthcare at both the individual and population levels.

In 2000, the Society of Critical Care Medicine (SCCM) and the American College of Clinical Pharmacy (ACCP) published a position paper that defined critical care pharmacy services as fundamental, desirable, and optimal. A task force was developed that included individuals who are members of the ACCP Critical Care Practice and Research Network, the SCCM clinical pharmacy and pharmacology section, and the American Society of Health-System Pharmacists to develop an opinion paper with three primary objectives: to provide recommendations for the level of preparation and training of pharmacists to practice in critical care, to develop recommendations for the credentialing of pharmacists providing critical care services, and to develop mechanisms for documenting and justifying intensive care unit (ICU) pharmacy services. Each objective was addressed to accommodate the levels of services defined as fundamental, desirable, or optimal, and are targeted at all pharmacists providing or wanting to provide pharmacy services to critically ill patients. The training and preparing of the pharmacist caring for critically ill patients is discussed in the context of the knowledge and skills required to provide pharmacy services in the ICU. Credentialing of the critical care pharmacist and the documentation of services take into account the various scopes of practice, and recommendations are based on current and idealistic mechanisms. A detailed outline is provided for the process of services justification. This paper provides a foundation that is focused on delivering direct and proactive patient care services, particularly at the desirable and optimal levels, with the ultimate goal of enhancing the level of pharmacy services provided to the care of critically ill patients. This commentary should be of interest to numerous stakeholders including pharmacists, other pharmacy department staff, other ICU health care professionals, hospital and academic administrators, accrediting agencies, government officials, and payers. The task force encourages the profession of pharmacy in general to incorporate key recommendations provided in this document with respect to specialized training, credentialing, and service justification.

Summary. A recently published randomized controlled trial (RCT) showed that adherence to infusion diary record keeping was improved by the use of handheld computers. In this study, attitudes to record keeping were explored and patient preferences regarding the method of recording determined for the patients who participated in the trial. Qualitative study consisting of individual semi-structured interviews with 20 severely affected patients with haemophilia who participated in an RCT. Individuals were purposefully sampled based on their recent method of record keeping and whether child or adult. Analysis employed a constant comparative method to identify key themes from the data. Most individuals (19 of 20, 95%) considered record keeping to be important. They readily identified reasons to keep records: to benefit themselves, their families, clinical staff, product distributors and manufacturers. Keeping records helps them: feel a part of the health care team; have confidence they would be notified of product recalls; review their past history; improve their ability to advocate for themselves and improve communication among all parties. Record keeping, particularly when using paper diaries, can be burdensome and a challenge to maintain consistently. All 10 individuals (100%) who had used both paper diaries and handheld computers preferred the latter. Most patients understand that record keeping can be of benefit to them. Clinics can use this knowledge to inspire other patients by developing educational programmes that de-emphasize authority. In addition, given the evidence of both patients’ preference for handheld computers, and the effectiveness of this approach documented in an RCT, switching to handheld computers is likely to improve record keeping.

Aims. To discuss the intricacies of the decision‐making process about initiating end‐of‐life care pathways. Background. Internationally, enhancing the quality of end‐of‐life care has become a central concern in governments’ health policies. Despite limited empirical evaluation, end‐of‐ life care pathways have been championed and widely adopted as complex interventions to enhance end‐of‐life care worldwide. Data sources. A literature search of established electronic databases was conducted for published articles in English addressing decision‐making and end‐of‐life care pathways between 1997–2010. Manual searches of relevant journals and internet sites were also undertaken. Discussion. The initiation of an end‐of‐life care pathway marks the transition to the terminal phase of care. Although guidance for commencing these pathways exists, this may not overcome the complexities of the decision‐making process, which must be viewed in context, namely: marking the transition to terminal care, dealing with ambiguity, reaching professional consensus and engaging patients and families. Implications for nursing. Nurses in all care settings have an important role in easing the transition to end‐of‐ life care. Accordingly, nurses need not only an appreciation of end‐of‐life care pathways, but the complexities surrounding the decision to commence a pathway and their role within. Conclusion. The initiation of an end‐of‐life care pathway is contingent on the outcome of a complex decision‐making process which is rarely explored and poorly understood.

The HITECH Act, passed in 2009 by the federal government, deepens the concerns for patient privacy faced by healthcare organizations subject to HIPAA. This article examines the law and demonstrates that healthcare entities are facing greater duties to safeguard patients' protected health information, as well as severe civil and criminal penalties should they fail to do so. In recognition of this heightened liability, healthcare entities must reassess their methods for handling patient data and take action in key areas to ensure that risk is contained.

The methodology of randomized clinical trials is essential for the critical assessment and registration of therapeutic interventions. The CONSORT (Consolidated Standards of Reporting Trials) statement was developed to alleviate the problems arising from the inadequate reporting of randomized controlled trials. The present article reflects on the items that we believe should be included in the CONSORT checklist in the context of conducting and reporting trials in allergen-specific immunotherapy. Only randomized, blinded (in particular blinding of patients, health care providers, and outcome assessors), placebo-controlled Phase III studies in this article. Our analysis focuses on the definition of patients' inclusion and exclusion criteria, allergen standardization, primary, secondary and exploratory outcomes, reporting of adverse events and analysis.

Aim and objectives. To provide an overview of tinnitus, current management and its psychosocial impact offering strategies for managing acute and chronic tinnitus in practice. Background. Tinnitus, characterised by the perception of sound in the absence of external stimuli, is experienced by about 10% of the population at some time in their lives. It may be temporary/longstanding; approximately 5% adults experience severe, persistent tinnitus affecting their lifestyle. Although many adjust successfully, others are disabled by the condition. Though often unrecognised, tinnitus affects many patients regardless of their presenting illness. Design. A literature review including descriptive, theoretical and empirical material. Databases were searched using the keyword ‘tinnitus’ providing diverse information which was used to address the research questions. Results. Tinnitus represents more than ‘simple’ ringing in the ears and may be accompanied by many distressing changes. It may be acute or chronic. It is difficult to treat, care may be directed towards management rather than cure. Many patients are, however, told that ‘nothing can be done’. Relevance to clinical practice. Despite the high prevalence of tinnitus, there is a paucity of relevant nursing literature suggesting that there is an information deficit amongst nurses. The information provided shows that understanding the full impact of the condition and identification of patients’ needs are essential to effective care. Strategies to help affected patients are given. Conclusions. Tinnitus, a widespread, often intractable condition, affects millions of people; there is considerable debate about its causes. Tinnitus is distressing and may be severe enough to affect lifestyle and quality of life. Affected patients need considerable support and advice on healthcare options, encouragement to try different treatments and recognition that help and hope are available. Though patients may have to learn to live with tinnitus, the most important thing is that they recognise that help is available.

The UK's Department of Health Independent Sector Programme to procure healthcare for National Health Service (NHS) patients from the independent sector revealed many of the challenges of commissioning, particularly assessing governance arrangements and identifying the organisational attributes of high quality healthcare providers. These issues were first discussed in a workshop at the British Association of Medical Managers (BAMM) Medical Directors Conference in Dublin in November 2007 (Dale, et al., 2009). The more difficult challenges of achieving effective clinical engagement, including motivational factors, organisational environment and systems and partnership working, in the complex field of commissioning healthcare in the UK are also explored here with particular reference to systems in other countries. Copyright © 2009 John Wiley & Sons, Ltd.

This is the protocol for a review and there is no abstract. The objectives are as follows: To determine the effectiveness of manual paper reminders in changing professional practice and improving patient outcomes To explore whether a number of potential effect modifiers influence the effectiveness of manual paper reminders

Physicists have and continue to play a major role in the creation and introduction of novel technology into medical care. This review covers some of the highlights of contributions of medical physicists to the field of radiation oncology during the history of the AAPM. While not comprehensive, the broad scope of developments and their impact hints at the importance of the medical physicist in advancing the field in the past, present, and future.

Over the past 100 years, both diagnostic radiology and radiation therapy have grown from infancy to maturity. Accompanying this growth, the discipline of medical physics has evolved and advanced accordingly. New diagnostic and therapeutic procedures continue to be developed, for example, multidetector computed tomography, multileaf collimation, magnetic resonance imaging, dual-source computed tomography, and intensity-modulated radiation therapy. These are now incorporated in health care facilities throughout the world. Modern technologies such as these provide information on underlying pathology at increasingly higher resolutions, generating more information; thus requiring complex methods of image recording and storage. The management of the storage and retrieval of accumulated information is a domain of informatics. In this short review, we describe the different roles of medical physicists and the effective contribution of the American Association of Physicists in Medicine in the evolution of informatics. Medical physicists have contributed to the development of informatics in numerous ways, such as designing hospital information systems and infrastructures that better serve radiologists and other physicians. In addition, the positive exploitation of knowledge gathered in medical settings and effective interdisciplinary collaborations between scientists of different backgrounds have increased. These developments provide future medical physicists the opportunity to develop strategic roles in information technology and thus better contribute to health care.

Objective\ud To understand why skilled birth attendance—an acknowledged strategy for reducing maternal deaths—has been effective in some settings but is failing in Pakistan and to demonstrate the value of a theory-driven approach to evaluating implementation of maternal healthcare interventions.\ud \ud Design\ud Implementation research was conducted using an institutional ethnographic approach.\ud \ud Setting and population\ud National programme and local community levels in Pakistan.\ud \ud Methods\ud Observations, focus group discussions, and in-depth interviews were conducted with 38 Community Midwives (CMWs), 20 policymakers, 45 healthcare providers and 136 community members. A critical policy document review was conducted. National and local level data were brought together.\ud \ud Main outcomes\ud Alignment of programme theory with real-world practice.\ud \ud Results\ud Data revealed gaps between programme theory, assumptions and reality on the ground. The design of the programme failed to take into account: (1) the incongruity between the role of a midwife and dominant class and gendered norms that devalue such a role; (2) market and consumer behaviour that prevented CMWs from establishing private practices; (3) the complexity of public–private sector cooperation. Uniform deployment policies failed to consider existing provider density and geography.\ud \ud Conclusions\ud Greater attention to programme theory and the ‘real-world’ setting during design of maternal health strategies is needed to achieve consistent results in different contexts.

In the Fourth Quarter 2003 issue I asked readers to send contributions for the international nurses list of grand challenges in improving global health. Although responses were few the list below is informative and revealing both in its content and in comparison to the list of grand challenges identified in an extensive effort sponsored by the Bill and Melinda Gates Foundation and the National Cancer Institute (available at http://www.grandchallengesgh.org/). Differences in these lists do not constitute contradictions nor do they imply that any items are wrong. Instead the two sets of grand challenges indicate the vast and complex needs in improving global health and the necessity of focusing efforts on a multitude of conditions underlying health and illness. This list is focused only on health and health care needs not on challenges pertaining to nurses other personnel or resources. Global challenges for nursing were identified in an extensive effort sponsored by Sigma Theta Tau International (Dickenson-Hazard 2004). The list below includes additional information that can be used in conjunction with other reports to focus energies toward improving health. (excerpt)