North Wales Hospital

The aims of this study were to describe differences in nurse leaders' ethical decision-making confidence and their professional values based on identified characteristics and to explore the relationship between ethical decision making and professional values. Nurse leaders have multiple duties and obligations toward their patients, other staff, and the organizations where they work. However, ethical decisions can be complex, requiring the guidance of professional values and critical appraisal of the situation. This study was conducted using a correlational design. Convenience sampling was used, resulting in a sample of 56 nurse leaders in various positions. Ethical decision making and professional values were found to be strongly correlated. Ethical decision making and professional values are highly correlated in this sample. Understanding the importance of the effects of certain factors on ethical decision making can assist in forming an environment supportive of ethical practices for nurses.

In response to Stephen Ornes’ feature “Turning water into watts” (March pp31–34) in which he explores the research and business ventures looking into wave energy, and harnessing the vast power of the world’s oceans.

The Tree Bumble Bee, Bombus hypnorum, is a native of forest environments but has now successfully colonised urban areas. To better understand its success in an anthropogenic context, this review considers aspects of its natural history and nesting habits using a combination of published literature, anecdotal field observations by entomologists from a number of countries, and information from the BWARS database. Where man’s influence is minimal, B. hypnorum appears to nest almost exclusively in tree cavities. Modern woodlands tend to be managed and nest-cavity poor. Urban areas with gardens provide foraging opportunities together with a large supply of well-insulated and well-protected aboveground nest sites. B. hypnorum currently appears to do better in urban areas than managed woodlands, and quite possibly better than it ever did in primeval forest. In Britain, where it was first found in 2001, its notable success appears to reflect the absolute quantity of suitable anthropogenic, and specifically urban, nesting habitat. Conspicuous nest placement has resulted in more nest records for this recent arrival than exist for any native British bumble bee species. In “helping itself” to an anthropogenic nesting niche, B. hypnorum highlights how important appropriate nesting sites are in determining which bumble bee species can live in any given area. Detailed information on nest site preferences and availability needs to inform conservation measures for threatened native species.

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Background: NICE guidelines recommend that patients with severe active RA be treated with a biologic disease-modifying anti-rheumatic drug as monotherapy (bDMARD mono) if they respond inadequately to 2 traditional DMARDs and are intolerant to MTX.Registry and healthcare utilization data have shown that around one-third of RA patients receive their biologic treatment as monotherapy.Methods: This UK wide chart review was undertaken to better understand the current management of RA patients with biologics in monotherapy, in particular, why patients receive monotherapy and how effective this is in daily practice.The chart review was conducted across 26 rheumatology departments between September 2012 and May 2013 and data from 309 RA patients, who had been prescribed a bDMARD mono, were collected retrospectively.Data are presented from an interim analysis of 150 patients.Results: The mean patient age was 62.4 years and mean duration of disease was 16.3 years.The majority of patients were female (109).102 (74.4%) patients were RF positive (n ¼ 137) and 34 (36.6%)anticyclic citrullinated peptide (anti-CCP) antibody positive (n ¼ 93).With regards to past RA treatment (prior to switch to monotherapy, n ¼ 61), the most frequently used bDMARDs monotherapies (at any time prior to switch) were etanercept (ETN; 19.3%), adalimumab (ADA; 14%), certolizumab pegol (CZP, 7.3%), rituximab (RTX, 4.7%) and tocilizumab (TCZ, 2.7%).55 (36.7%) patients had used two or more bDMARD monotherapies.The most frequently used traditional DMARDs (n ¼ 146) were MTX (92%), SSZ (74.7%) and HCQ (42.7%).With regards to current RA treatment (all patients receiving bDMARD mono), the most frequently used bDMARDs were ETN (42.7%),ADA (26%), TCZ (10.7%),RTX (9.3%) and CZP (8%).The main reason for prescribing bDMARD monotherapy (n ¼ 150) was unknown (88%, assumed clinician decision), with other stated reasons including patient preference (6.7%) and contra-indications (7.3%).Nearly a quarter of patients were taking a non-NICE approved monotherapy drug and only 24.2% were in DAS28 ESR remission.Conclusion: Registry and healthcare utilization data have shown that around one-third of RA patients receive their biologic treatment as monotherapy.The results of this audit highlight a patient population where treatment outcomes with bDMARD monotherapy are still not optimal (only 24.2% were in DAS28 ESR remission).76.7% of the patients were treated with NICE approved TNF inhibitors, and 55 (36.7%) patients had used two or more bDMARD monotherapies, indicating that there are a significant number of patients where combination therapy with traditional DMARDs is not an option.As remission is the treatment goal and only 24.2% of patients were in remission, there appears to be an unmet medical need.Alternative treatment options should be explored to ensure better treatment outcomes for patients with this debilitating disease.Disclosure statement: E.G.C. has