Lifting the Lid on Chaplaincy: A First Look at Findings from Chaplains' Case Study Research.

Since the publication of Chaplain Rhonda Cooper's case study in 2011, chaplain case studies have become part of the chaplaincy research agenda. Chaplains from North America, Europe and Australia have published almost 30, and this article offers a first look at the findings that are emerging from these cases. Locating chaplains' case studies at the juxtaposition of 'outcome oriented chaplaincy' and so-called 'process-oriented chaplaincy', the article argues chaplains' case studies dissolve what is a false dichotomy. Utilizing an analytical framework provided by ongoing debate among psychotherapists, the article argues that the emerging data suggests chaplaincy manifests features that are common to psychotherapy but also that there are significant factors specific to chaplaincy. From this analysis, the article observes the case studies paint a picture of chaplaincy care as a religious intervention. However, contemporary chaplaincy exists within a rapidly changing context, where increasing numbers of people are religiously unaffiliated. The article concludes by suggesting that chaplains' case study research poses significant theological, ethical and existential questions to chaplaincy about how to respond to its changing context. The article ends with a call for chaplaincy care to be radically and explicitly remodeled as care for the human spirit regardless of religious affiliation.

"He Needs to Talk!": A Chaplain's Case Study of Nonreligious Spiritual Care.

Chaplains have always worked with nonreligious people, but it is not always clear what is distinctive about their contribution. This case describes an episode of nonreligious spiritual care in order to explore the value of chaplaincy work with people who regard themselves as nonreligious. This case reports on work with a dying man and his family-wife, daughter, sister, and son-in-law-whose religion is secularized, but whose secularism is touched by the sacred.

Hope beyond (redundant) hope: how chaplains work with dying patients.

Using Grounded Theory, this study examines the experience of 19 palliative care chaplains in counselling dying people. Taking a broad-based definition of counselling, and using unstructured individual interviews and group work, the study aimed to understand how palliative care chaplains work with patients at the point when it has been decided to cease active treatment, the point where they risk losing hope and falling into despair. Analysing the data using code-based theory building software, the author identified four organic moments in the chaplain-patient relationship, each moment being a discernable development in the chaplain's being-with the patient: 'evocative presence'; 'accompanying presence'; 'comforting presence'; and 'hopeful presence'. The author represents the four moments as a theory of 'chaplain as hopeful presence', and offers a description of the way in which the quality of presence can facilitate patients to develop 'a hopeful manner' in which hope is reconfigured into an attribute of being. The author concludes (with Levinas) that chaplains and other palliative care staff should be aware that simply being-with an other can, in itself, be hope fostering.

In defence of the indefensible: an alternative to John Paley's reductionist, atheistic, psychological alternative to spirituality.

John Paley has rightly observed that, while spirituality is widely discussed in the nursing literature, the discussions are uncritical and unproblematic. In an effort 'to reconfigure the spirituality-in-nursing debate, and to position it where it belongs: in the literature on health psychology and social psychology, and not in a disciplinary cul-de-sac labelled "unfathomable mystery" ', Paley has proposed an alternative, reductionist approach to spirituality. In this paper, I identify two critiques developed by Paley: one political, the other 'logical'. Paley's political critique claims the concept of 'spirituality' has been appropriated by nursing theorists as part of an attempt to accrue professional power and jurisdiction over occupational territory. I suggest that Paley's analysis masks his own exclusivist, secularizing jurisdictional claim made at the expense of spirituality. Paley's so-called 'logical' critique is motivated by an intention to 'determine what the "spirituality" terrain looks like from the naturalistic point of view'. However, noting a number of inconsistencies, I challenge his 'logical move' as a naïve attack on a straw man. In place of Paley's reductionism, I propose my own alternative and argue (after Foucault) that 'spirituality' is a discourse, a non-reductionist attempt, in a post-religious society, to speak about the human condition open to the unknown. I conclude with a definition and a description of empirically congruent spirituality.

Medicare Part D-a roundtable discussion of current issues and trends.

BACKGROUND: Medicare Part D was introduced with a goal of providing access to prescription drug coverage for all Medicare beneficiaries. Regulatory mandates and the changing landscape of health care require continued evaluation of the state of the Part D benefit. OBJECTIVE: To review the current state of plan offerings and highlight key issues regarding the administration of the Part D benefit. SUMMARY: The Part D drug benefit continues to evolve. The benefit value appears to be diluted compared to the benefit value of large employer plans. Regulatory restrictions mandated by the Centers for Medicare and Medicaid Services (CMS) are reported to inhibit the ability of plans to create an effective, competitive drug benefit for Medicare beneficiaries. Management in this restrictive environment impedes competitive price negotiations and formulary coverage issues continue to create confusion especially for patients with chronic diseases. The doughnut hole coverage gap represents a significant cost-shifting issue for beneficiaries that may impact medication adherence and persistence. To address these and other challenges, CMS is working to improve the quality of care for Part D beneficiaries by designing and supporting demonstration projects. Although these projects are in different stages, all stakeholders are hopeful that they will lead to the development of best practices by plans to help manage their beneficiaries more efficiently. CONCLUSIONS: A significant number of Medicare beneficiaries are currently receiving prescription drug benefits through Part D. The true value of this benefit has been called into question as a result of plan design parameters that lead to cost-shifting, an increasing burden for enrollees. Concerns regarding the ability to provide a competitive plan given the stringent rules and regulations have been voiced by plan administrators. In an effort to drive toward evidence-based solutions, CMS is working to improve the overall quality of care through numerous demonstration projects.

The future of Medicare Part D drug plans--results from a roundtable discussion.

BACKGROUND: The Medicare Prescription Drug, Improvement, and Modernization Act, signed into law in 2003, provided access to prescription drugs for elderly Americans. The Part D benefit continues to evolve. Changes in plan designs, the impact of the doughnut hole on beneficiaries, and increased cost shifting have the potential to hamper the future of the Part D benefit. OBJECTIVE: To discuss factors that will likely have the most impact on the future of Medicare Part D from a patient and payer perspective. SUMMARY: The continued growth of the elderly population is expected to place an increasing burden on the services provided through Medicare. Given the current financial situation, it has been predicted that Medicare's Hospital Insurance Trust Fund will be depleted by 2019. To provide quality benefits and remain competitive, health plans are continually evaluating and redesigning their Part D benefits. However, the current regulatory environment is preventing plans from offering innovative products and designs that could lower costs to beneficiaries. The growing number of beneficiaries hitting the doughnut hole is also becoming a concern for both beneficiaries and health plans. More beneficiaries are reaching the doughnut hole, and this has resulted in changes in beneficiary behaviors, including stopping medications, switching to alternative drug classes, and reducing medication use. Because of the increasing concerns about Medicare's sustainability, it is anticipated that the government may become more involved. CONCLUSION: As the health care landscape continues to change, payers will be challenged to offer benefit designs that are affordable to elderly beneficiaries. For its part, the government must allow plans to design benefits that will improve the overall quality of care. Additionally, closer attention must be given to the growing number of beneficiaries hitting the doughnut hole and its potential adverse clinical and economic consequences.

Health information technology--results from a roundtable discussion.

BACKGROUND: Health information technology (HIT), notably e-prescribing and electronic health records (EHR), have the potential to improve the quality of care, reduce medication errors and adverse events, and decrease overall health care utilization and costs. However, the United States continues to lag behind other countries in the adoption and use of HIT. OBJECTIVE: To review the various issues surrounding the implementation of HIT in the United States and potential drivers that will influence the use of e-prescribing and EHR. SUMMARY: The United States has been slow to embrace HIT. However, various factors, including increasing government involvement, are speeding the implementation and use of HIT. E-prescribing and EHR are both electronic means to provide better coordination of care by enabling various health care professionals to access patient medical records. Widespread adoption of HIT can be especially helpful for the elderly, since this population tends to have more chronic conditions requiring polypharmacy. Adoption of e-prescribing can reduce medication errors due to poor handwriting, while EHR can promote better clinical outcomes, improve medication adherence and refill rates, improve member satisfaction, and lower overall health care expenditures. Unfortunately, barriers to the adoption of e-prescribing and EHR still exist, including resistance to learning new technology, initial start-up costs, delay in seeing a return on investment, lack of a standardized platform, increased administrative burden, and misaligned incentives. In an effort to promote greater adoption of e-prescribing and EHR, the Centers for Medicare & Medicaid has designed several initiatives, and other private organizations are now becoming more involved to close the HIT gap. CONCLUSION: Although the United States has been slow to implement HIT, there is reason to be hopeful. Increasing involvement by the government and other organizations will facilitate the greater adoption and use of e-prescribing and EHR in the near future. Ongoing data are needed, however, to demonstrate improvements in overall patient care and reductions in health care utilization and costs. These data are necessary to remove existing barriers that may prevent widespread implementation.

Alkyne-azide click chemistry mediated carbanucleosides synthesis.

Hitherto unknown 1,4-disubstituted-[1,2,3]-triazolo-4',4'-dihydroxymethyl-3'-deoxy carbanucleosides were synthesized based on a "click approach." Various alkynes were introduced on a key azido intermediate by the "click" 1,3-dipolar Huisgen cycloaddition. Their antiviral activities and cellular toxicities were evaluated on vaccinia virus. None of the synthesized compounds exhibited a significant antiviral activity.

Study of different copper (I) catalysts for the "click chemistry" approach to carbanucleosides.

We compare herein the scope of three copper (I) catalysts on the synthesis of various 1,4-disubstitued-1,2,3-triazolo-carbanucleosides through a microwave (and thermic) assisted Huisgen 1,3-dipolar cycloaddition. The tetrakis(acetonitrile)copper hexafluorophosphate ([Cu(CH3CN)4]PF6), the imidazoline(mesythyl)copper bromide (Imes)CuBr, and the copper/copper sulfate Cu(0)/CuSO4 (II) mixture have been chosen for this study. Their influence in a catalytic amount will be analyzed according to the substituent of the alkyne, the solvent, or the heating method.