Context: The majority of contemporary enactivist work is influenced by the philosophical biology of Hans Jonas. Jonas credits all living organisms with experience that involves particular “existential” structures: nascent forms of concern for self-preservation and desire for objects and outcomes that promote well-being. We argue that Jonas’s attitude towards living systems involves a problematic anthropomorphism that threatens to place enactivism at odds with cognitive science, and undermine its legitimate aims to become a new paradigm for scientific investigation and understanding of (...) the mind. Problem: Enactivism needs to address the tension between its Jonasian influences and its aspirations to become a new paradigm for cognitive science. By relying on Jonasian phenomenology, contemporary enactivism obscures alternative ways in which phenomenology can be more smoothly integrated with cognitive science. Method: We outline the historical relationship between enactivism and phenomenology, and explain why anthropomorphism is problematic for a research program that aspires to become a new paradigm for cognitive science. We examine the roots of Jonas’s existential interpretation of biological facts, and describe how and why Jonas himself understood his project as founded on an anthropomorphic assumption that is incompatible with a crucial methodological assumption of scientific enquiry: the prohibition of unexplained natural purposes. We describe the way in which phenomenology can be integrated into Maturana’s autopoietic theory, and use this as an example of how an alternative, non-anthropomorphic science of the biological roots of cognition might proceed. Results: Our analysis reveals a crucial tension between Jonas’s influence on enactivism and enactivism’s paradigmatic aspirations. This suggests the possibility of, and need to investigate, other ways of integrating phenomenology with cognitive science that do not succumb to this tension. Implications: In light of this, enactivists should either eliminate the Jonasian inference from properties of our human experience to properties of the experience of all living organisms, or articulate an alternative conception of scientific enquiry that can tolerate the anthropomorphism this inference entails. The Maturanian view we present in the article’s final section constitutes a possible framework within which enactivist tools and concepts can be used to understand cognition and phenomenology, and that does not involve a problematic anthropomorphism. Constructivist content: Any constructivist approach that aims for integration with current scientific practice must either avoid the type of anthropomorphic inference on which Jonas bases his work, or specify a new conception of scientific enquiry that renders anthropomorphism unproblematic. (shrink)

This paper presents methods to visualize the structure of trees that occur in genetic programming. These methods allow for the inspection of structure of entire trees even though several thousands of nodes may be involved. The methods also scale to allow for the inspection of structure for entire populations and for complete trials even though millions of nodes may be involved. Examples are given that demonstrate how this new way of “seeing” can afford a potentially rich way of understanding dynamics (...) that underpin genetic programming. The examples indicate further studies that might be enabled by visualizing structure at these scales. (shrink)

This study examines how heightened expectations of board responsibility and accountability affect the socio-cognitive decision-making of boards and their collective task performance. Using data from the directors of 60 boards who served before and after the enactment of Sarbanes–Oxley, this study provides insight into the potential negative impact that this tightened accountability environment can have on a board’s task performance. Examining several socio-cognitive elements of board decision-making, board authority is found to have a positive main effect on board task performance, (...) while relative CEO power and affective conflict have curvilinear relationships with board task performance. Cohesiveness also moderates the relationship between a board’s perceived uncertainty and affective conflict with board task performance. In sum, the model shows how a new era of director accountability can affect the social cognitions of board decision-making that underlie board task performance. (shrink)

In his ethical writings, Duns Scotus emphasized both divine freedom and natural goodness, and these seem to conflict with each other in various ways. I offer an interpretation of Scotus which takes seriously these twin emphases and shows how they cohere. I argue that, for Scotus, all natural laws obtain just by the natures of actual things. Divine commands, such as the Ten Commandments, contingently track natural laws but do not make natural laws to be natural laws. I present textual (...) evidence for this claim. I also show how this view of Scotus on the natural law is consistent with a number of troubling passages. Scotus’s ethical theory implies that there are genuinely moral reasons for acting which are not absolutely binding (because subject to a divine command or permission otherwise) and also some moral reasons for acting which are absolutely binding (because not thus subject). (shrink)

Ward examines Scotus's arguments for his distinctive version of hylomorphism, the view that at least some material objects are composites of matter and form. It considers Scotus's reasons for adopting hylomorphism, and his accounts of how matter and form compose a substance, how extended parts, such as the organs of an organism, compose a substance, and how other sorts of things, such as the four chemical elements and all the things in the world, fail to compose a substance. It (...) highlights the extent to which Scotus draws on his metaphysics of essential order to explain why some things can compose substance and why others cannot. Throughout the book, contemporary versions of hylomorphism are discussed in ways that both illumine Scotus's own views and suggest ways to advance contemporary debates. (shrink)

This Element defends a version of the classical theory of divine ideas, the containment exemplarist theory of divine ideas. The classical theory holds that God has ideas of all possible creatures, that these ideas partially explain why God's creation of the world is a rational and free personal action, and that God does not depend on anything external to himself for having the ideas he has. The containment exemplarist version of the classical theory holds that God's own nature is the (...) exemplar of all possible creatures, and therefore that God's ideas of possible creatures are in some sense ideas of himself. Containment exemplarism offers a monotheism fit for metaphysics, insofar as it is coherent, simple, and explanatorily powerful; and offers a metaphysics fit for monotheism, insofar as it leaves God truly worthy of the unconditional worship which Christians, along with Jews and Muslims, aspire to offer to God. (shrink)

This paper examines some aspects of Spinoza's metaphysics of the essences of modes.2 I situate Spinoza's use of the notion of essence as a response to traditional, Aristotelian, ways of thinking about essence. I argue that, although Spinoza rejects part of the Aristotelian conception of essence, according to which it is in virtue of its essence that a thing is a member of a kind, he nevertheless retains a different part of such a conception, according to which an essence is (...) some structural feature of a thing which causally explains other, non-essential features. I go on to develop an account of Spinoza's metaphysics of essence, according to which essences, what he sometimes calls formal essences, are produced by the divine essence prior to and independent of the creation of finite modes, and according to which essences are the formal or exemplar causes of finite modes. I then argue that finite modes, in virtue of the formal essences which they actualize, are genuine causal relata. Finally, I offer some speculations about Spinoza's answer to the question, "Why, in a necessitarian cosmos filled with formal essences, should there be temporal finite modes at all?". (shrink)

Upshot: In our target article we claimed that, at least since Weber and Varela, enactivism has incorporated a theoretical commitment to one important aspect of Jonas’s philosophical biology, namely its anthropomorphism, which is at odds with the methodological commitments of modern science. In this general reply we want to clarify what we mean by anthropomorphism, and explain why we think it is incompatible with science. We do this by spelling out what we call the “Jonasian inference,” i.e., the idea that (...) we are entitled, based on our first-person experience of teleology, to take the appearance of teleology in other living beings at face value. (shrink)

I propose that primary conscious awareness arises from synchronized activity in dendrites of neurons in dorsal thalamic nuclei, mediated particularly by inhibitory interactions with thalamic reticular neurons. In support, I offer four evidential pillars: consciousness is restricted to the results of cortical computations; thalamus is the common locus of action of brain injury in vegetative state and of general anesthetics; the anatomy and physiology of the thalamus imply a central role in consciousness; neural synchronization is a neural correlate of consciousness.

Taking Aquinas's metaphysics of human nature as my point of departure and taking inspiration from Dante's concept of transhumanization, I sketch a metaphysics of the afterlife according to which a human person in the interim phase between death and resurrection is not a mere disembodied soul. I offer some theological reasons for thinking that our bodily human nature is essential to what we are and for thinking that we can survive the destruction of our bodies at death. I argue that (...) these claims are consistent, provided we hold that our bodily human nature, while essential to what we are, is not necessary to what we are. I argue for this distinction between essence and necessity. I then raise a mereological puzzle about the relation between a disembodied soul and the person whose soul it is, and argue that, if we are to avoid the Cartesian conclusion that this relation is identity, we must hold that a human person, even in the interim phase, is composed of a soul and something else. Drawing on Dante's concept of transhumanization, I argue that this something else is God himself or some specially created divine grace or energy. (shrink)

This article presents a new interpretation and critique of some aspects of Aquinas’s metaphysics of relations, with special reference to a theological problem—the relation of God to creatures—that catalyzed Aquinas’s and much medieval thought on the ontology of relations. I will show that Aquinas’s ontologically reductive theory of categorical real relations should equip him to identify certain relations as real relations, which he actually identifies as relations of reason, most notably the relation of God to creatures.

Gaunilo’s Lost Island Objection to Anselm’s Ontological Argument aims to show that if Anselm’s argument can establish the existence of a greatest conceivable being then a very similar argument can establish the existence of a greatest conceivable island. The challenge for the defender of Anselm is to identify the relevant disanalogy between Anselm’s argument and Gaunilo’s, in order to explain why Anselm’s can succeed while Gaunilo’s fails. In this essay I take up this challenge. Reflection on the differences between the (...) nature of islands and the nature of being yields the relevant disanalogy. (shrink)

The two most important concepts in Duns Scotus's (1265/6‐1308) theology of the Atonement are satisfaction and merit. Just what these amount to and how they function in his theory are heavily conditioned by two more general commitments: Scotus's voluntarism, which includes the claim that nearly all of God's relations with the created order are contingent; and his formulation of the Franciscan Thesis, which holds that fixing the sin problem is not the primary purpose of God's Incarnation in Christ and that (...) if Adam hadn't sinned God would have become incarnate anyway. In this essay I will discuss the theoretical background of Scotus's atonement theology—his voluntarism and his version of the Franciscan Thesis—before moving on to discuss his understanding of merit and satisfaction, how these are related, and how they relate to the theoretical background. I will engage some important recent scholarly attempts to position Scotus's Atonement theology as not quite as anti‐Anselmian as history has characterized it, arguing that one of these attributes to Scotus an understanding of merit which cannot be Scotus's in fact, since it entails a restriction on divine freedom that Scotus certainly would reject. (shrink)

The two most important concepts in Duns Scotus's theology of the Atonement are satisfaction and merit. Just what these amount to and how they function in his theory are heavily conditioned by two more general commitments: Scotus's voluntarism, which includes the claim that nearly all of God's relations with the created order are contingent; and his formulation of the Franciscan Thesis, which holds that fixing the sin problem is not the primary purpose of God's Incarnation in Christ and that if (...) Adam hadn't sinned God would have become incarnate anyway. In this essay I will discuss this theoretical background of Scotus's atonement theology before moving on to discuss his understanding of merit and satisfaction, how these are related, and how they relate to the theoretical background. I will engage some important recent scholarly attempts to position Scotus's Atonement theology as not quite as anti-Anselmian as history has characterized it, arguing that one of these attributes to Scotus an understanding of merit which cannot be Scotus's in fact, since it entails a restriction on divine freedom that Scotus certainly would reject. (shrink)

Several strands of contemporary cognitive science and its philosophy have emerged in recent decades that emphasize the role of action in cognition, resting their explanations on the embodiment of cognitive agents, and their embedding in richly structured environments. Despite their growing influence, many foundational questions remain unresolved or underexplored for this cluster of proposals, especially questions of how they can be extended beyond straightforwardly visuomotor cognitive capacities, and what constraints the commitment of embodiment places on the ontology of explanations. This (...) special issue aims to contribute to these foundational debates by drawing on important precursors to embodied cognition in mid-twentieth century gestalt psychology, its immediate successor ecological psychology, and their dialectical counterpart, phenomenology. Gestalt psychologists and phenomenologists wrestled with many of the same foundational questions that still haunt us today, in a manner that seems refreshing in hindsight, and poised to contribute constructively to contemporary debate. Looking back on this history reveals deep commonalities across competing embodied approaches, exposing fundamental tensions that remain unresolved, but also paving the way to a more ecumenical and conciliatory embodied cognitive science. (shrink)

Could God command us to hate him? Here I offer two arguments that He cannot. I also argue that this restriction on God’s power is consistent with a strong doctrine of omnipotence according to which God can do anything broadly logical possible.

This paper develops a view of worship according to which worship is a certain sort of _life orientation_, and argues that according to the Bible, the worship of God normatively is _non-instrumental, comprehensive, unconditional orientation of one’s life toward God_. It then develops a biblical view about how this sort of worship of God is _possible_. Finally, it argues that it is _good_ to worship God in this way only if God is an Anselmian being—_that than which nothing greater can (...) be conceived_—and suggests that the God of the Bible, the Psalms in particular, is in fact an Anselmian being. (shrink)

Faculty learning communities are collaborative collegial groups of faculty and other teaching staff who are interested in and committed to the improvement of their teaching to accommodate a diverse student population through group discourse, reflection and goal setting. In this article, we describe our FLC experiences that were supported by a federal grant to ensure accessible learning environments on our campus. The project, Ensuring Access through Collaboration and Technology , sought to introduce faculty at a medium‐sized state university to a (...) pedagogical framework to provide universal access to the curriculum for all students and to encourage faculty to adopt accessible technologies. We describe the recruitment process, the FLC meeting structure, our intended outcomes and the challenges we faced in meeting them. (shrink)

Some theories of goodness are descriptively rich: they have much to say about what makes things good. Neo-Aristotelian accounts, for instance, detail the various features that make a human being, a dog, a bee good relative to facts about those forms of life. Famously, such theories of relative goodness tend to be comparatively poor: they have little or nothing to say about what makes one kind of being better than another kind. Other theories of goodness—those that take there to be (...) absolute goodness—are comparatively rich: they offer grounds for judging some types of things better than others because they have more absolute goodness. Moorean accounts, for example, can tell us that humans and human experiences are superior to bees and blades of grass. But such theories tend to be descriptively poor: they struggle to tell us in virtue of what this is so. In this essay we motivate and flesh out a view that splits the difference between accounts of goodness as relative and accounts of goodness as absolute. Such a view holds promise only if the mechanics of this kind of metaphysics of goodness can be worked out. Here we present a view on which the paradigm for absolute goodness is God and the paradigm for each kind of relative goodness is a divine idea. (shrink)

This article focuses on some topics in Jeffrey Brower’s recent and excellent book, Aquinas’s Ontology of the Material World: Change, Hylomorphism, and Material Objects. Part of Brower’s goal for the book is to reconstruct Aquinas’s views. I offer some reflections on Brower’s use of this metaphor of reconstruction, before considering four topics in some detail. These are: 1. Brower’s discussion of the relation between Aristotle’s Ten Categories and the not-obviously-connected four-fold division of being into substance, form, prime matter, and accidental (...) unity. 2. Brower’s interpretation of prime matter as “non-individual stuff.” 3. Brower’s account of numerical sameness without identity along with some discussion of how this is supposed to be useful for solving a particular puzzle about accidental change. 4. I’ll close with some reflections on Brower’s somewhat novel solution to a longstanding problem with Aquinas’s metaphysics of the afterlife. (shrink)

Previous work suggests that threat-related stimuli are stored to a greater degree in working memory compared to neutral stimuli. However, most of this research has focused on stimuli with physically salient threat attributes, failing to account for how a “neutral” stimulus that has acquired threat-related associations through differential aversive conditioning influences working memory. The current study examined how differentially conditioned safe and threat stimuli are stored in working memory relative to a novel, non-associated stimuli. Participants completed a differential fear conditioning (...) task followed by a change detection task consisting of three conditions across two loads. Results revealed individuals successfully learned to distinguishing CS+ from CS– conditions during the differential aversive conditioning task. Our working memory outcomes indicated successful load manipulation effects, but no statistically significant differences in accuracy, response time, or Pashler’s K measures of working memory capacity between CS+, CS–, or N conditions. However, we observed significantly reduced RT difference scores for the CS+ compared to CS– condition, indicating greater RT differences between the CS+ and N condition vs. the CS– and N condition. These findings suggest that differentially conditioned stimuli have little impact on behavioral outcomes of working memory compared to novel stimuli that had not been associated with previous safe of aversive outcomes, at least in healthy populations. (shrink)

This paper examines some of the metaphysical assumptions behind Aquinas’s denials that a human rational soul unites with matter at conception and that a human rational soul is capable of developing and arranging the organic parts of an embryo. The paper argues that Buridan does not share these assumptions and holds that a soul is capable of developing and arranging organic parts. It argues that, given hylomorphism about the nature of organisms, including human beings, Buridan’s view is philosophically superior to (...) Aquinas’s in several respects. Finally, the paper poses an apparent inconsistency between several of Buridan’s texts on this topic and attempts to show that the inconsistency is merely apparent. (shrink)

This paper presents an original interpretation of John Duns Scotus’s theory of hylomorphism. I argue that Scotus thinks, contrary to Aristotle and Thomas Aquinas, that at least some of the extended parts of a substance—paradigmatically the organs of an animal—are themselves substances. Moreover, Scotus thinks that the form of corporeity is nothing more than the substantial forms of these organic parts. I offer an account of how Scotus thinks that the various extended parts of an animal are substantially unified. First, (...) a plurality of substances can become parts of a complex substance if they are essentially ordered to one another in the order of final causality. Second, a plurality of substances do become parts of a complex substance if they are together informed by a soul. The paper closes with some reflections on some of the ramifications of the substancehood of organic parts on the function of soul. (shrink)

I motivate and develop a view, found in John Duns Scotus, concerning God's explanatory role in the possibility of possible natures. A possible nature is a nature which can be instanced. The view is that possible natures have their possibility due to the coherence of their simple parts, but the simples which make up natures are themselves ex nihilo productions of divine intellect.

The primary purpose of Hosea's ministry was to provide a testimony that would effect reconciliation between Yahweh and Israel—during and beyond judgment.

This book is a succinct introduction to the orienting of attention.

Recently, there has been increased interest in the involvement of family members in treating psychiatric patients who are involuntarily admitted into mental hospitals (Goodwin and Happel 2006; Wilkinson and McAndrew 2008). Family is, for instance, expected to be of use in preventing escalations and aggression on the wards by giving information about patient needs and providing support to the patient. Yet, in practice, family is not routinely involved in the treatment process, and is not even regularly informed about situations (Marshall (...) and Solomon 2003). Professionals mention privacy and confidentiality as issues that constrain collaboration with family (Goodwin and Happel 2006; Wynaden and Orb 2005). .. (shrink)

We discuss in this essay the alternative techniques proposed for the isolation of human embryonic stem cells (hESCs) that attempt to satisfy moral issues surrounding killing embryos but show that these techniques are either redundant or do not achieve their intended aim. We discuss the difficulties associated with defining a human embryo and how the lack of clarity on this issue antagonises the ethical debate and impedes hESC research. We present scientific evidence showing that isolation of hESCs does not necessarily (...) "kill" human embryos. In addition, we argue that even those who accord inviolable moral status to the embryo should agree that hESC research is morally obligatory, as it is beneficial to the developmental potential of the embryo and society as a whole. (shrink)

This paper presents a preliminary analysis of the first participatory budgeting experiment in the United States, in Chicago's 49th Ward. There are two avenues of inquiry: First, does participatory budgeting result in different budgetary priorities than standard practices? Second, do projects meet normative social justice outcomes? It is clear that allowing citizens to determine municipal budget projects results in very different outcomes than standard procedures. Importantly, citizens in the 49th Ward consistently choose projects that the research literature classifies (...) as low priority. The results are mixed, however, when it comes to social justice outcomes. While there is no clear pattern in which projects are located only in affluent sections of the ward, there is evidence of geographic clustering. Select areas are awarded projects like community gardens, dog parks, and playgrounds, while others are limited to street resurfacing, sidewalk repairs, bike racks, and bike lanes. Based on our findings, we offer suggestions for future programmatic changes. (shrink)

© 2017. The American Astronomical Society. All rights reserved.We present new observations of the low-mass companion to HD 984 taken with the Gemini Planet Imager as a part of the GPI Exoplanet Survey campaign. Images of HD 984 B were obtained in the J and H bands. Combined with archival epochs from 2012 and 2014, we fit the first orbit to the companion to find an 18 au orbit with a 68% confidence interval between 14 and 28 au, an eccentricity (...) of 0.18 with a 68% confidence interval between 0.05 and 0.47, and an inclination of 119°with a 68% confidence interval between 114°and 125°. To address the considerable spectral covariance in both spectra, we present a method of splitting the spectra into low and high frequencies to analyze the spectral structure at different spatial frequencies with the proper spectral noise correlation. Using the split spectra, we compare them to known spectral types using field brown dwarf and low-mass star spectra and find a best-fit match of a field gravity M6.5 ±1.5 spectral type with a corresponding temperature of K. Photometry of the companion yields a luminosity of log=2.88 ± 0.07 dex with DUSTY models. Mass estimates, again from DUSTY models, find an age-dependent mass of 34 ±1 to 95 ±4 M Jup. These results are consistent with previous measurements of the object. (shrink)

Since its founding in 1943, Medievalia et Humanistica has won worldwide recognition as the first scholarly publication in America to devote itself entirely to medieval and Renaissance studies. Since 1970, a new series, sponsored by the Modern Language Association of America and edited by an international board of distinguished scholars and critics, has published interdisciplinary articles. In yearly hardbound volumes, the new series publishes significant scholarship, criticism, and reviews treating all facets of medieval and Renaissance culture: history, art, literature, music, (...) science, law, economics, and philosophy. (shrink)

Consent plays a vital role in every aspect of medicine and surgery, facilitating the patient in making informed decisions about their treatment. The recently published Reference Guide to Consent, by the Department of Health (DH), notes that, although not a legal requirement, the completion of consent forms is good practice, particularly in interventions such as surgery. In addition, the Parliamentary and Health Service Ombudsman noted that a significant number of complaints about consent involved the complainant feeling that they did not (...) fully understand what was going to happen. It was often found that there was no documentation to clarify what the patient was told, when and by whom. We have performed an audit of 71 randomly selected consent forms, elective and trauma cases within our district general hospital orthopaedics department. Our data demonstrate that a significant number of consent forms were incorrectly or insufficiently completed. This could not only leave the patient confused about their procedure but also leaves the doctor open to litigation, with little in the way of documentation support. Minor changes in consenting methods and more precise documentation could significantly improve patient experience and satisfaction. (shrink)

One of the difficulties nurses experience in clinical practice in relation to ethical issues in connection with young oncology patients is moral distress. In this descriptive correlational study, the Moral Distress Scale-Paediatric Version (MDS-PV) was translated from the original language and tested on a conventional sample of nurses working in paediatric oncology and haematology wards, in six north paediatric hospitals of Italy. 13.7% of the total respondents claimed that they had changed unit or hospital due to moral distress. The items (...) with the highest mean intensity in the sample were almost all connected with medical and nursing competence and have considerably higher values than frequency. The instrument was found to be reliable. The results confirmed the validity of the MDS-PV (Cronbach’s alpha = 0.959). This study represents the first small-scale attempt to validate MDS-PV for use in paediatric oncology-ematology nurses in Italy. (shrink)

Abstract: Potatoes are edible tubers, available worldwide and all year long. They are relatively cheap to grow, rich in nutrients, and they can make a delicious treat. The humble potato has fallen in popularity in recent years, due to the interest in low-carb foods. However, the fiber, vitamins, minerals, and phytochemicals it provides can help ward off disease and benefit human health. They are an important staple food in many countries around the world. There are an estimated 200 varieties (...) of potatoes, which can be classified into a number of categories based on the cooked texture and ingredient functionality. Using a public dataset of 2400 images of potatoes, we trained a deep convolutional neural network to identify 4 types (Red, Red Washed, Sweet, and White).The trained model achieved an accuracy of 99.5% of test set, demonstrating the feasibility of this approach. (shrink)

Originally published in 1937, this book presents the philosophy of James Ward, the Professor of Mental Philosophy and Logic at the University of Cambridge. Ward was primarily concerned with the perceived antagonism between science and philosophy or religion, and Murray supplies a psychological background to Ward's thinking that helps to explain his interest in this topic. This book will be of value to anyone with an interest in Ward or the duality of faith and reason.

I assume that we find it hard to understand, for example, how a person could harm another person in cold blood. I then set out Kant's reason's for thinking that, strictly speaking, evil behavior is impossible: people may act on wicked desires but deliberate wrong-doing is not a genuine phenomenon. However, Kant's view is at odds with our common sense intuitions about morally evil behavior, namely, that such behavior is possible, albeit difficult to understand. I then suggest how Kant's analysis (...) of the problem of evil behavior can help us to understand under what conditions evil behavior would be possible. Next, I introduce Peck's theory of how evil behavior can manifest itselfwhen a person suffers from malignant narcissism—a complaint that involves acting on principles which are not consciously acknowledged. I conclude that Kant's views on evil can be understood with reference to Peck's theory (and vice versa). (shrink)

This volume addresses a wide variety of moral concerns regarding slavery as an institutionalized social practice. By considering the slave's critical appropriation of the natural rights doctrine, the ambiguous implications of various notions of consent and liberty are examined. The authors assume that, although slavery is undoubtedly an evil social practice, its moral assessment stands in need of a more nuanced treatment. They address the question of what is wrong with slavery by critically examining, and in some cases endorsing, certain (...) principles derived from communitarianism, paternalism, utilitarianism, and jurisprudence. (shrink)

Objectives To conduct an independent evaluation of the first phase of the Health Foundation’s Safer Patients Initiative (SPI), and to identify the net additional effect of SPI and any differences in changes in participating and non-participating NHS hospitals. Design Mixed method evaluation involving five substudies, before and after design. Setting NHS hospitals in the United Kingdom. Participants Four hospitals (one in each country in the UK) participating in the first phase of the SPI (SPI1); 18 control hospitals. Intervention The SPI1 (...) was a compound (multi-component) organisational intervention delivered over 18 months that focused on improving the reliability of specific frontline care processes in designated clinical specialties and promoting organisational and cultural change. Results Senior staff members were knowledgeable and enthusiastic about SPI1. There was a small (0.08 points on a 5 point scale) but significant (P<0.01) effect in favour of the SPI1 hospitals in one of 11 dimensions of the staff questionnaire (organisational climate). Qualitative evidence showed only modest penetration of SPI1 at medical ward level. Although SPI1 was designed to engage staff from the bottom up, it did not usually feel like this to those working on the wards, and questions about legitimacy of some aspects of SPI1 were raised. Of the five components to identify patients at risk of deterioration—monitoring of vital signs (14 items); routine tests (three items); evidence based standards specific to certain diseases (three items); prescribing errors (multiple items from the British National Formulary); and medical history taking (11 items)—there was little net difference between control and SPI1 hospitals, except in relation to quality of monitoring of acute medical patients, which improved on average over time across all hospitals. Recording of respiratory rate increased to a greater degree in SPI1 than in control hospitals; in the second six hours after admission recording increased from 40% (93) to 69% (165) in control hospitals and from 37% (141) to 78% (296) in SPI1 hospitals (odds ratio for “difference in difference” 2.1, 99% confidence interval 1.0 to 4.3; P=0.008). Use of a formal scoring system for patients with pneumonia also increased over time (from 2% (102) to 23% (111) in control hospitals and from 2% (170) to 9% (189) in SPI1 hospitals), which favoured controls and was not significant (0.3, 0.02 to 3.4; P=0.173). There were no improvements in the proportion of prescription errors and no effects that could be attributed to SPI1 in non-targeted generic areas (such as enhanced safety culture). On some measures, the lack of effect could be because compliance was already high at baseline (such as use of steroids in over 85% of cases where indicated), but even when there was more room for improvement (such as in quality of medical history taking), there was no significant additional net effect of SPI1. There were no changes over time or between control and SPI1 hospitals in errors or rates of adverse events in patients in medical wards. Mortality increased from 11% (27) to 16% (39) among controls and decreased from 17% (63) to 13% (49) among SPI1 hospitals, but the risk adjusted difference was not significant (0.5, 0.2 to 1.4; P=0.085). Poor care was a contributing factor in four of the 178 deaths identified by review of case notes. The survey of patients showed no significant differences apart from an increase in perception of cleanliness in favour of SPI1 hospitals. Conclusions The introduction of SPI1 was associated with improvements in one of the types of clinical process studied (monitoring of vital signs) and one measure of staff perceptions of organisational climate. There was no additional effect of SPI1 on other targeted issues nor on other measures of generic organisational strengthening. (shrink)