PBDE-47 and PBDE mixture (DE-71) toxicities and liver transcriptomic changes at PND 22 after in utero/postnatal exposure in the rat.

Pentabromodiphenyl ethers (PBDE) are found in human tissue, in household dust, and in the environment, and a particular concern is the potential for the induction of cancer pathways from these fat-soluble persistent organic pollutants. Only one PBDE cancer study has been conducted and that was for a PBDE mixture (DE-71). Because it is not feasible to test all PBDE congeners in the environment for cancer potential, it is important to develop a set of biological endpoints that can be used in short-term toxicity studies to predict disease outcome after long-term exposures. In this study, PBDE-47 was selected as the test PBDE congener to evaluate and compare toxicity to that of the carcinogenic PBDE mixture. The toxicities of PBDE-47 and the PBDE mixture were evaluated at PND 22 in Wistar Han rat (Crl: WI (Han)) pups after in utero/postnatal exposure (0, 0.1, 15, or 50 mg/kg; dams, GD6-21; pups, PND 12-PND 21; oral gavage daily dosing). By PND 22, PBDE-47 caused centrilobular hypertrophy and fatty change in liver, and reduced serum thyroxin (T4) levels; similar effects were also observed after PBDE mixture exposure. Transcriptomic changes in the liver included induction of cytochrome p450 transcripts and up-regulation of Nrf2 antioxidant pathway transcripts and ABC membrane transport transcripts. Decreases in other transport transcripts (ABCG5 & 8) provided a plausible mechanism for lipid accumulation, characterized by a treatment-related liver fatty change after PBDE-47 and PBDE mixture exposure. The benchmark dose calculation based on liver transcriptomic data was generally lower for PBDE-47 than for the PBDE mixture. The up-regulation of the Nrf2 antioxidant pathway and changes in metabolic transcripts after PBDE-47 and PBDE mixture exposure suggest that PBDE-47, like the PBDE mixture (NTP 2016, TR 589), could be a liver toxin/carcinogen after long-term exposure.

Blood gene expression profiling of an early acetaminophen response.

Acetaminophen can adversely affect the liver especially when overdosed. We used whole blood as a surrogate to identify genes as potential early indicators of an acetaminophen-induced response. In a clinical study, healthy human subjects were dosed daily with 4 g of either acetaminophen or placebo pills for 7 days and evaluated over the course of 14 days. Alanine aminotransferase (ALT) levels for responders to acetaminophen increased between days 4 and 9 after dosing, and 12 genes were detected with expression profiles significantly altered within 24 h. The early responsive genes separated the subjects by class and dose period. In addition, the genes clustered patients who overdosed on acetaminophen apart from controls and also predicted the exposure classifications with 100% accuracy. The responsive genes serve as early indicators of an acetaminophen exposure, and their gene expression profiles can potentially be evaluated as molecular indicators for further consideration.

Tetrabromobisphenol A activates the hepatic interferon pathway in rats.

Tetrabromobisphenol A (TBBPA) is a widely used flame retardant in printed circuit boards, paper, and textiles. In a two-year study, TBBPA showed evidence of uterine tumors in female Wistar-Han rats and liver and colon tumors in B6C3F1 mice. In order to gain further insight into early gene and pathway changes leading to cancer, we exposed female Wistar Han rats to TBBPA at 0, 25, 250, or 1000mg/kg (oral gavage in corn oil, 5×/week) for 13 weeks. Because at the end of the TBBPA exposure period, there were no treatment-related effects on body weights, liver or uterus lesions, and liver and uterine organ weights were within 10% of controls, only the high dose animals were analyzed. Analysis of the hepatic and uterine transcriptomes showed TBBPA-induced changes primarily in the liver (1000mg/kg), with 159 transcripts corresponding to 132 genes differentially expressed compared to controls (FDR=0.05). Pathway analysis showed activation of interferon (IFN) and metabolic networks. TBBPA induced few molecular changes in the uterus. Activation of the interferon pathway in the liver occurred after 13-weeks of TBBPA exposure, and with longer term TBBPA exposure this may lead to immunomodulatory changes that contribute to carcinogenic processes.

Blood transcript immune signatures distinguish a subset of people with elevated serum ALT from others given acetaminophen.

The diagnosis of drug-induced liver injury is hindered by the limited utility of clinical chemistries. We have shown that hepatotoxicants can produce peripheral blood transcriptome "signatures" (PBTS) in rodents and humans. In this study, 42 adults were treated with acetaminophen (APAP; 1 g every 6 hours) for seven days, followed by three days of placebo. Eleven subjects received only placebo. After five days, 12 subjects (30%) had increases in serum alanine aminotransferase (ALT) levels ("responders"). PBTS of 707 and 760 genes, respectively, could distinguish responders and nonresponders from placebos. Functional analysis of the responder PBTS revealed increased expression of genes involved in TH2-mediated and innate immune responses, whereas the nonresponders demonstrated increased gene expression consistent with a tolerogenic immune response. Taken together, these observations suggest that the clinical subjects with transient increases in serum ALT failed to maintain or intensify a hepatic tolerogenic immune response.

Genomic indicators in the blood predict drug-induced liver injury.

Genomic biomarkers for the detection of drug-induced liver injury (DILI) from blood are urgently needed for monitoring drug safety. We used a unique data set as part of the Food and Drug Administration led MicroArray Quality Control Phase-II (MAQC-II) project consisting of gene expression data from the two tissues (blood and liver) to test cross-tissue predictability of genomic indicators to a form of chemically induced liver injury. We then use the genomic indicators from the blood as biomarkers for prediction of acetaminophen-induced liver injury and show that the cross-tissue predictability of a response to the pharmaceutical agent (accuracy as high as 92.1%) is better than, or at least comparable to, that of non-therapeutic compounds. We provide a database of gene expression for the highly informative predictors, which brings biological context to the possible mechanisms involved in DILI. Pathway-based predictors were associated with inflammation, angiogenesis, Toll-like receptor signaling, apoptosis, and mitochondrial damage. The results show for the first time and support the hypothesis that genomic indicators in the blood can serve as potential diagnostic biomarkers predictive of DILI.

Sharing best practice: developing a Web-based database.

This article reports on the development of a web-based interactive database that was designed to facilitate the dissemination of practice development, research and audit projects across a large NHS trust. A multidisciplinary team worked collaboratively to design the database in order to ensure that it incorporated features which made it easy for the end user. Concise structured information on each project was recorded and search facilities incorporated to facilitate access to information. Hyperlinks to other web pages on the Internet and the Trust intranet were created and full reports/publications of projects were included for those who wanted more information. The subsequent implementation across the organization involved promoting the database, helping practitioners develop skills to access information, setting up quality review procedures for projects and evaluating its use. The development of the database has highlighted that time, the availability of computers in clinical areas and skills development are important considerations when taking forward information technology (IT) initiatives.

Decision-making in teams: issues arising from two UK evaluations.

Interagency and interprofessional working has often been operationalised through the development of integrated, multiprofessional teams in the UK. However, there is considerable ambivalence reported about the success of such teams. This paper reports on two evaluations of different types of inter-agency/intra-agency, interdisciplinary/unidisciplinary teams. One study used a soft systems methodology to evaluate a health and social care team for people with enduring mental health needs and the other used a pluralistic framework to examine integrated nursing teams in primary care. In both studies, the team-working arrangements influenced the decisions made by the team members such that client care became increasingly responsive and proactive. These changes were made possible by two processes. First, information transaction was augmented and was instrumental in supporting effective client-related decision-making. Second, there was enhanced support for decision-making, especially in respect of problem solving. However, the increased autonomy of the team members had the potential to marginalise those outside the team from decision-making. It is suggested that working within a team can impact on the decisions made by team members, which exceeds a collection of individual decisions. The strengths of complex multiprofessional teams for service users may be realised if the processes of decision-making are respected.

The role of hepatic nuclear factor 1 alpha and PDX-1 in transcriptional regulation of the pdx-1 gene.

The PDX-1 homeodomain transcription factor regulates pancreatic development and adult islet beta cell function. Expression of the pdx-1 gene is almost exclusively localized to beta cells within the adult endocrine pancreas. Islet beta cell-selective transcription is controlled by evolutionarily conserved subdomain sequences (termed Areas I (-2839 to -2520 base pairs (bp)), II (-2252 to -2023 bp), and III (-1939 to -1664 bp)) found within the 5'-flanking region of the pdx-1 gene. Areas I and II are independently capable of directing beta cell-selective reporter gene activity in transfection assays, with Area I-mediated stimulation dependent upon binding of hepatic nuclear factor 3 beta (HNF3 beta), a key regulator of islet beta cell function. To identify other transactivators of Area I, highly conserved sequence segments within this subdomain were mutagenized, and their effect on activation was determined. Several of the sensitive sites were found by transcription factor data base analysis to potentially bind endodermally expressed transcription factors, including HNF1 alpha (-2758 to -2746 bp, Segment 2), HNF4 (-2742 to -2730 bp, Segment 4; -2683 to -2671 bp, Segment 7-8), and HNF6 (-2727 to -2715 bp, Segment 5). HNF1 alpha, but not HNF4 and HNF6, binds specifically to Area I sequences in vitro. HNF1 alpha was also shown to specifically activate Area I-driven transcription through Segment 2. In addition, PDX-1 itself was found to stimulate Area I activation. The chromatin immunoprecipitation assay performed with PDX-1 antisera also demonstrated that this factor bound to Area I within the endogenous pdx-1 gene in beta cells. Our results indicate that regulatory factors binding to Area I conserved sequences contribute to the selective transcription pattern of the pdx-1 gene and that control is mediated by endodermal regulators like HNF1 alpha, HNF3 beta, and PDX-1.

Whither nursing? Discourses underlying the attribution of master's level performance in nursing.

AIM: Drawing upon the selected findings from a multidisciplinary study that sought to explore the meaning of master's level performance in health professional practice, the characteristics which nurse educators attributed to the practice of master's level nursing graduates are analysed to reveal underlying discourses. BACKGROUND: Although master's level programmes for nurses have been available in the United Kingdom (UK) for the past three decades and current heath policy directives link master's level qualifications with senior clinical nursing roles, the contribution that master's level education might make to the future direction of nursing is unclear. RESEARCH DESIGN AND METHODS: In-depth interviews were undertaken with a purposive sample of 18 nurse lecturers drawn from eight universities in the UK who were responsible for master's level programmes in nursing. The interview agenda explored participants' perspectives of the characteristics of master's level performance. Drawing upon the methodology of discourse analysis, interview transcripts were interpreted in such a way as to show the implicit discourses underlying the participants' claims regarding their graduate's attributes of professional practice. FINDINGS: The characteristics attributed to master's graduates were categorized under (a) cognitive competencies, (b) practice-related competencies, (c) research orientation and (d) personal dynamism. However, these attributions are not empirical generalizations, developed inductively. Rather, they draw on socially available discourses regarding the future direction of the profession. CONCLUSION: The nurse educators drew on the following socially available discourses: (a) a discourse in which nursing is construed as involving great competence in practice, but without radicality of thought. Associated with this is a pervasive rhetoric of pragmatism; (b) a discourse of interprofessional practice in which nursing has a role of leadership. This is associated with a view of the location and power of nursing within the structure of the National Health Service and (c) notably lacking were discourses of care-giving, and of academic/intellectual aspiration. The implications of these discourses for the future direction of nursing are considered.

The nature and effect of communication difficulties arising from interactions between district nurses and South Asian patients and their carers.

AIM: The overall aim of the study was to examine how policy directives concerning the provision of individualized care were modified in their transformation into practice and the implications this carried for the care provided to patients from different ethnic backgrounds. This paper is concerned with one aspect, namely, examining the nature and effects of communication difficulties between the nurses and South Asian patients and their carers. METHODS: An ethnographic approach was used. The study was undertaken in an English community National Health Service (NHS) Trust serving an ethnically diverse population. It comprised two stages. First, an organizational profile of the trust was undertaken in order to analyse the local policy context. Data were collected by means of in-depth interviews with managers and a review of policy documentation and caseload profiles. Second, a participant observational study was undertaken focusing on six district nursing teams. Purposive sampling was used to identify four teams with high ethnic minority caseloads and two teams with predominantly white ethnic majority caseloads. Interview transcripts and fieldnotes were analysed by drawing upon the principles of dimensional analysis. FINDINGS: Over half of South Asian patients had little or no understanding of spoken English with women and older people the least likely to speak English. The limited use of professional interpreters and the concomitant heavy reliance on family members to translate highlighted how ethnic minority patients and carers who were not fluent in English were disadvantaged. The observed language barriers suggested that the content of advice on matters such as compliance with treatment regimes might not be fully understood. Psychological support of patients and carers was severely restricted. Moreover, the fact that follow-up visits were on occasions made to patients for whom there was no one available to interpret constrained on-going assessment of patients' needs. CONCLUSIONS: The findings raise concerns regarding the quality of care provided to patients and carers who are nonusers of English and provide evidence of inequalities in service provision. However, not speaking English should not be a barrier to appropriate and effective nursing care. District nurses need to appreciate their responsibility to provide equitable services irrespective of a patient's linguistic background and seek to overcome the disadvantage experienced by ethnic minority patients.

A pluralistic evaluation of nursing/practice development units.

Nursing/practice development units (N/PDU) are perceived as centres for pioneering, evaluating and disseminating innovative practice development and facilitating the professional development of practitioners. This paper reports on a pluralistic evaluation research study of the nursing/ practice development unit accreditation programme provided by the University of Leeds, UK. Individual and focus group interviews were undertaken with key stakeholders involved in six nursing/practice development units. These included: clinical leaders, team members, executive nurses, trust board members, general medical practitioners, nursing/practice development unit steering group members, and accreditation panel members. Stakeholder perceptions of what constituted a successful nursing/practice development unit were elicited and then used to judge the success of the programme. Seven criteria for judging the success of nursing/practice development units were identified. These were: achieving optimum practice; providing a patient-orientated service; disseminating innovative practice; team working; enabling practitioners to develop their full potential; adopting a strategic approach to change and autonomous functioning. The findings highlighted differences between the rhetoric of a successful nursing/practice development unit and the reality in which they function. Whereas all the units were actively involved in innovative practice development, evaluation, dissemination and networking activities, several factors influenced the success of the units, in particular, the role of the clinical leader, the motivation and commitment of nursing/practice development unit members, financial resources, and the nature of support from managers, medical staff and education institutions. Although the nursing/practice development units had made significant progress in developing both healthcare practice and practitioners, there is still a need to consider how the claim that nursing/practice development units benefit patients can be substantiated.

Cardiac rehabilitation: the needs of South Asian cardiac patients.

There is an indication that South Asian people in the UK experience greater delays than white British populations in obtaining appropriate treatment and intervention despite experiencing higher levels of coronary heart disease (Chaturvedi et al, 1997). Evidence suggests that access to and uptake of UK cardiac rehabilitation services is disproportionately low in South Asian populations (NHS Centre for Reviews and Dissemination, 1998). This article examines the results of an audit of cardiac rehabilitation among cardiac patients of South Asian origin who were admitted to a large city teaching hospital in Sheffield. The results are discussed in the light of current concerns about the adequacy of communication with non-English speaking NHS patients. The implications for access to services and clinical practice are considered.

Some dilemmas of master's level nurse education.

Despite an increase in the growth of master's level provision for qualified nurses in the United Kingdom uncertainty exists regarding the characteristics of master's level performance in respect of professional practice. This paper presents selected findings from a multidisciplinary study that sought to examine the characteristics of master's level performance in health professional courses that had an expressed practice orientation. It focuses specifically on dilemmas nurse educators encountered in relation to British master's level nurse education. Following an initial pilot stage involving focus group interviews with separate groups of nurses, occupational therapists and physiotherapists, an interview agenda was developed to explore participants' perspectives of the characteristics of master's level performance. Individual in-depth interviews were undertaken with a purposive sample of 18 nurse educators drawn from eight universities in England. Interview transcripts were coded and thematically analysed. Six kinds of dilemma emerged from the interviews. These were breadth vs. depth in the conceptualization of master's level for nursing, relevance to practice vs. academic detachment, facilitating creative thinking vs. reinforcing rigidity, encouraging or suppressing different modes of critical thinking, postgraduate nurses as loyal change agents vs. the problem of well-qualified mavericks, and professional experience as facilitating or hindering master's level performance. These dilemmas raise important questions about course design and the role of stakeholders in determining curriculum content. Moreover, a pervasive tension between a utilitarian emphasis on the application and utility of knowledge on one hand, and aspirations to promote creativity and critical thinking which look to alternative possibilities on the other hand, suggests that nurse educators exercise a degree of conservatism in relation to master's level. It is concluded that this apparent quest to maintain a safe variant of the status quo as the best way of promoting the wellbeing of patients should be subject to profound questioning.

Still fumbling along? A comparative study of the newly qualified nurse's perception of the transition from student to qualified nurse.

An earlier study conducted in the United Kingdom, examining the newly qualified nurse's perception of the transition from student to qualified nurse, highlighted the limitations of pre-registration nurse education in respect of failing to provide adequate preparation for the qualified nurse's role. In the intervening years, major reforms in pre-registration nurse education and continuing professional education have occurred. Concomitant with these reforms have been major policy changes in health care delivery that have impacted upon the role of the nurse. Questions now arise as to whether the education reforms have served to equip newly qualified nurses more appropriately with the necessary knowledge, skills and confidence to function in contemporary health care settings. This paper presents the findings of a follow-up study that entailed a secondary analysis of exiting data obtained from in-depth interviews with 10 newly qualified nurses in 1985 and collecting additional data from 25 newly qualified nurses in 1998 in order to ascertain their perceptions of the transition from student to qualified nurse. Interview transcripts from both sources of data were coded and thematically analysed and comparisons made between the two sets of data. The paper focuses on one theme emanating from the original study. Entitled 'fumbling along', it described the haphazard manner whereby the nurses learned to perform their role in the light of what they perceived to be inadequate preparation and lack of support. Similarities and differences in the experiences and perceptions of the two cohorts of nurses are examined in respect of stressful aspects of the role, pre-registration preparation and post-registration development. Data from the follow-up study suggest that although newly qualified nurses still feel inadequately prepared for their role, they have developed a more active style of learning and when supported through a preceptorship scheme appear to find the transition less stressful than nurses in 1985. However, further attention needs to be paid to the development of clinical, organizational and management skills in pre-registration courses and the bridging period between the latter part of the course and the first 6 months post-qualification, in order to enable the neophyte nurse to acclimatize gradually to becoming an accountable practitioner.

Individualized care: its conceptualization and practice within a multiethnic society.

This paper reports on the selected findings from a larger ethnographic study of the provision of individualized care by district nurses to patients from different ethnic backgrounds. Undertaken in an English community National Health Service (NHS) Trust serving an ethnically diverse population, the study comprised two stages. First, an organizational profile of the Trust was undertaken in order to analyse the local policy context. Data were collected by means of in-depth interviews with managers and a review of policy documentation and caseload profiles. Second, a participant observational study was undertaken focusing on six district nursing teams. Purposive sampling was used to identify four teams with high minority ethnic caseloads and two teams with predominantly white ethnic majority caseloads. Interview transcripts and field notes were analysed by drawing upon the principles of dimensional analysis. This paper focuses upon aspects of the second stage, namely how the nurses' conceptualized and practised individualized care. Six principles underpinning the philosophy of individualized care expounded by the nurses were identified: respecting individuality; holistic care; focusing on nursing needs; promoting independence; partnership and negotiation of care; and equity and fairness. Each is examined in turn and consideration given to how they were modified in their transformation into practice. Some implications for patients from minority ethnic backgrounds of the nurses' conceptualization and practice of individualized care are discussed. The lack of internal consistency within the nurses' discourse, the impact of policy directives on care delivery and the influence of factors outside the nurses' control, served to illuminate the complexity whereby the ideals of individualized care were adjusted and reworked in the realities of everyday nursing practice. This in turn raised questions about the appropriateness of the current interpretation and practice of individualized care in a multi-ethnic society.

Researching ethnic diversity in the British NHS: methodological and practical concerns.

The collection of data on ethnic groupings has become an increasingly pervasive feature of contemporary health policy and research in the United Kingdom, with attention concentrating primarily on monitoring access to and utilization of services by different ethnic groups, together with epidemiological data on morbidity and mortality. At the same time, the collection of data on ethnic populations by census and health agencies has been the subject of a wide-ranging and contentious debate and there is a growing critique that challenges the collection and use of such data on political, methodological and practical grounds. This paper explores the nature of these debates as they apply to health research. Issues of validity and reliability arising from the application of pre-defined ethnic categories, such as those used within the National Health Service derived from the 1991 census, are considered and alternative approaches which utilize a range of variables such as language, religion and length of residency in a country suggested. Experiences derived from an ethnographic study of the provision of district nursing care to patients from different ethnic backgrounds are used to illustrate some of the practical issues of researching ethnic diversity. Strategies for addressing some of the methodological and practical concerns are proposed.

Pancreatic beta cell-specific transcription of the pdx-1 gene. The role of conserved upstream control regions and their hepatic nuclear factor 3beta sites.

To identify potential transactivators of pdx-1, we sequenced approximately 4.5 kilobases of the 5' promoter region of the human and chicken homologs, assuming that sequences conserved with the mouse gene would contain critical cis-regulatory elements. The sequences associated with hypersensitive site 1 (HSS1) represented the principal area of homology within which three conserved subdomains were apparent: area I (-2694 to -2561 base pairs (bp)), area II (-2139 to -1958 bp), and area III (-1879 to -1799 bp). The identities between the mouse and chicken/human genes are very high, ranging from 78 to 89%, although only areas I and III are present within this region in chicken. Pancreatic beta cell-selective expression was shown to be controlled by mouse and human area I or area II, but not area III, from an analysis of pdx-1-driven reporter activity in transfected beta- and non-beta cells. Mutational and functional analyses of conserved hepatic nuclear factor 3 (HNF3)-like sites located within area I and area II demonstrated that activation by these regions was mediated by HNF3beta. To determine if a similar regulatory relationship might exist within the context of the endogenous gene, pdx-1 expression was measured in embryonic stem cells in which one or both alleles of HNF3beta were inactivated. pdx-1 mRNA levels induced upon differentiation to embryoid bodies were down-regulated in homozygous null HNF3beta cells. Together, these results suggest that the conserved sequences represented by areas I and II define the binding sites for factors such as HNF3beta, which control islet beta cell-selective expression of the pdx-1 gene.

Nursing development units: factors influencing their progress.

Nursing development units (NDUs) have long been advocated as 'test-beds' for pioneering leading-edge practice development. This article reports on the findings of a study examining factors influencing the development of NDUs, and, more recently, established multidisciplinary practice development units (PDUs). Individual and focus group interviews were undertaken with key stakeholders involved in six NDUs/PDUs accredited by the University of Leeds. The findings from the study highlight a number of internal and external factors that have impacted upon the progress made by these units. Importantly, the role of the clinical leader, the staffing establishment, organizational infrastructures to facilitate dissemination and the nature of the support from managers and medical staff have all influenced the success of the NDUs/PDUs. In order to ensure the long-term viability of an NDU/PDU it is essential that practice development is planned and managed in a systematic and coordinated way with a full appraisal undertaken of the human, physical and financial resources necessary to implement and disseminate change and that the work of the NDU/PDU is incorporated in the trust's strategic plans in order to ensure organizational support.

Inequalities in service provision: an examination of institutional influences on the provision of district nursing care to minority ethnic communities.

This paper reports on the selected findings from a larger ethnographic study of the provision of district nursing care to patients from different ethnic backgrounds. The two-stage study was undertaken in an English community National Health Service (NHS) trust serving an ethnically diverse population. The first stage comprised an organizational profile in order to analyse the local policy context, including specific responses to ethnic diversity. Data were collected by means of in-depth interviews with managers. The second stage entailed a participant observational study focusing on six district nursing teams. Purposive sampling was used to identify four teams with high minority ethnic caseloads and two teams with predominately white ethnic majority caseloads. Interview transcripts and field-notes were analysed by drawing upon the principles of dimensional analysis. The paper focuses upon institutional influences on the provision of care to minority ethnic communities. An analysis of the allocation of district nursing resource to different general practitioner (GP) practices identified marked inequalities in the district nursing provision which impacted upon the services provided to minority ethnic patients. Single-handed, inner city GP practices with a large minority ethnic practice population received a much smaller allocation of nursing staff than single group practices serving a smaller and predominately white practice population. The reasons why this situation existed are explored and an explanation offered as to why it had not been rectified. Observation of caseload management indicated that despite differences in the size of the practice populations served by the respective teams, all patients referred for nursing care received it. However, several covert processes appeared to limit the caseload size of those teams with large practice populations so that it remained manageable within the limited nursing resource available. It is concluded that although nurses at an individual level did not appear overtly to disadvantage minority ethnic patients, institutional forces conspired to perpetuate the disadvantage experienced by minority ethnic communities.

'Levels' of attainment in nursing practice: reality or illusion?

In earlier research based on an analysis of course documentation, it had been found that there was little consensus among nurse educators concerning the parameters which distinguish levels of practice skills, particularly those which differentiate diploma and degree qualifications in the United Kingdom. This result was confirmed and strengthened in the current study. Lecturers in nursing, when presented with a sorting task using 40 statements derived from course documentation selected from the earlier study, were unable to distinguish statements describing diploma level from those describing degree level practice. Possible reasons for the difficulty are discussed. It is concluded that the attempt to represent practice skill in a hierarchy of assessment for degree or diploma qualifications is premature since the parameters of practice remain unreliably specified.