Phosphoinositides (PIs) are pivotal lipid molecules with both scaffolding and signalling functions regulating key aspects of cellular physiology. For example, phosphatidylinositol (3,4,5)-trisphosphate, generated by phosphoinositide 3-kinase (PI3K), is an essential mediator of the PI3K/AKT signalling pathway, which is crucial for cell proliferation, survival and apoptosis. Constitutive activation of this signalling cascade has been identified in acute myeloid leukaemia (AML), the most common haematopoietic malignancy in adults, and experimental deletion of the PI3K antagonists PTEN and SHIP cause leukaemia in mice. However, little is known regarding the role of other PI modulator proteins in AML. Thus, in this thesis, a lentivirally delivered small hairpin RNA (shRNA) library targeting 103 genes (345 pLKO knockdown constructs) with presumed or established roles in PI metabolism was utilised to screen for genes required for AML blast cell viability/proliferation and differentiation. First, knockdown constructs were tested for their impact on proliferation/viability in seven human AML cell lines by measuring fold change in fluorescence of the cell viability dye alamarBlue relative to controls (cells transduced with a non-targeting control hairpin) over three days. This identified 13 candidate genes selected with the criterion that two or more knockdown constructs per gene reduce cell viability/proliferation relative to control by greater than or equal to50 % across all cell lines. From these candidate genes, PIP4K2A, INPP5B and IMPAD1 were selected for downstream validation experiments, which reproduced the observation from the primary screen. For INPP5B and IMPAD1, knockdown constructs also reduced clonogenic potential of primary human AML samples but only showed a modest effect on normal CD34+ haematopoietic stem or progenitor cells (HSPCs) in a methylcellulose based assay. This could be recapitulated in a murine setting where knockdown constructs targeting both genes reduced clonogenic potential of murine MLL- AF9 AML cells with little effect on normal KIT+ HSPCs. In line with this, Inpp5b knockout KIT+ BM cells either failed to immortalise or weakly immortalised, following forced expression of the powerful MLL-AF9 oncogene. A further screen was performed to identify regulators of THP-1 blast cell differentiation, by seeding knockdown construct transduced cells into methylcellulose based semisolid media. After ten days of incubation the degree of macrophage differentiation was evaluated by light microscopy and an arbitrary differentiation score was given. With the criterion that greater than or equal to2 knockdown constructs per gene received the highest differentiation score, reflecting terminal macrophage differentiation of all seeded cells, SBF2 was identified as the top-scoring hit. Validation experiments have confirmed macrophage differentiation based on cytospin preparations of SBF2 knockdown THP-1 cells. Moreover, xenograft assays have shown that knockdown constructs targeting PIP4K2A and SBF2 delayed or abrogated in vivo leukaemogenesis. Thus this work has identified novel roles for PI modulator genes in human AML with possible therapeutic potential.

Rearrangements involving the mixed lineage leukaemia (MLL) gene are found in 5-10% of human leukaemias and are likely propagated by a deregulated self renewing pool of leukaemia stem cells (LSCs). Targeting of the LSC pool represents a key novel strategy for the treatment of AML. In recent years epigenetic dysfunction has been identified as a key driving factor in a range of solid tumours and haematological malignancies. Evidence for this includes identification of mutations in the genes coding for critical epigenetic modifiers, characterisation of localised regions of abnormal chromatin at oncogene or tumour suppressor genes and the efficacious use of epigenetic-targeted therapies already present in the clinic. The data submitted in this thesis identify the histone demethylase KDM1A as a critical regulator of LSC potential in MLL-AF9 acute myeloid leukaemia (AML). Of all the histone demethylases, we found that only Kdm1a expression correlated positively and significantly with LSC frequency in murine models of human MLL fusion AML. Genetic knockdown or Cre-mediated excision of Kdm1a resulted in loss of LSC potential, reduced expression of LSC maintenance transcriptional programs and induction of macrophage differentiation in MLL-AF9 cells. These effects were phenocopied by chemical inhibition of KDM1A using the monoamine oxidase inhibitor tranylcypromine (TCP), as well as novel TCP analogues which inhibit KDM1A with greater potency and selectivity. These results were seen in murine, human cell line and primary patient cells harbouring MLL rearrangements. Global transcriptome and epigenome analyses revealed a key role for KDM1A in maintaining the histone three lysine four (H3K4) methylation status at highly expressed MLL-AF9-bound genes. In vivo transplantation of Kdm1a knockdown MLL-AF9 cells conferred a significant survival advantage compared with control littermates. Similarly, TCP analogue treatment of mice transplanted with MLL-AF9 cells revealed a reduction in LSC potential of the donor-derived AML cells but little impact on normal recipient haematopoietic stem and progenitor cells (HSPCs). Critically the clonogenic and repopulating potential of normal HSPCS, of both murine and human origin, was spared following either knockdown or chemical inhibition of KDM1A. Taken together, the data presented establish KDM1A as a potential therapeutic target in MLL fusion leukaemia.

Acute kidney injury (AKI) is serious and complicates up to 1 in 7 hospital admissions. It is usually diagnosed from rapidly deteriorating blood tests. Much of the focus of clinical research into AKI has been on strategies to improve recognition and timely intervention. However, emerging evidence suggests that even when people survive AKI, they remain at an elevated risk of poor long-term outcomes. The aim of this thesis was to determine which people with AKI have an ongoing increased risk of poor outcomes (mortality, kidney failure, recurrent illness episodes) after hospital discharge. The design was a population-based data-linkage cohort study involving the Grampian Laboratory Outcomes Morbidity and Mortality Study (GLOMMS-II). Data linkages included population biochemistry, hospital episode data, mortality records, intensive care records and renal registry data from 1999-2013. A cohort of 17,630 people hospitalised in 2003 were followed through to 2013. Outcomes were mortality, progression of kidney disease and unplanned hospital readmission episodes. There have been several novel research outputs. I evaluated and adapted international AKI criteria for use in large population biochemistry datasets. I developed a clinical risk prediction model for unplanned readmissions after hospital discharge, for which AKI was a strong independent predictor. I described long-term survival after AKI, showing that people with AKI (vs no AKI) have a substantially higher risk of death in the first year, but diminishing excess risk thereafter. Finally, I conducted a novel analysis of renal prognosis after AKI, showing that mortality and non-recovery are more common than subsequent renal progression after AKI, but that renal progression is nevertheless increased after AKI. Overall, AKI is a serious condition and marker of people who have a long lasting poorer prognosis. The first year after discharge is a period of particularly heightened risk that could potentially be targeted with initiatives to improve care.

The finely tuned regulation of haematopoiesis is crucial in order to maintain life-long haematopoiesis. The disruption of the balance among cell fates, can lead to malignant transformation. It has become increasingly evident that the metabolic regulation haematopoietic stem cells is critical for stem cell fate decisions. Haematopoietic stem cells reside in a hypoxic microenvironment within the bone marrow and are thought to mainly utilize glycolysis rather than oxidative phosphorylation in order to maintain their pool. However recent evidence suggests that oxidative phosphorylation is critical for quiescent HSCs and in several cases, for leukaemic stem cells (LSCs). One of the key parts of mitochondrial respiration is the tricarboxylic cycle (TCA), providing co-factors for its efficient activity. The TCA functions by catalysing the oxidation of pyruvate via key enzymatic activities. A key component of the TCA cycle is fumarate hydratase (Fh1) which catalyses the hydration of fumarate into malate within the mitochondria, but also catalyses the same reaction in the cytoplasm. FH is a tumour suppressor in human lyomeioma and renal kidney cancer (HLRCC). Previous work conducted by our team has shown that Fh1 is essential for foetal and adult haematopoiesis, as Fh1 deletion within the haematopoietic system is embryonic lethal. Furthermore, conditional deletion of Fh1 in donor cells of the Mx1-Cre system that were injected in lethally irradiated recipients, resulted in the complete reduction of their chimerism in the peripheral blood of recipient mice. Mechanistically, these phenotypes were mostly associated with supra-physiological levels of fumarate as a result of Fh1 deletion. Interestingly, by employing mice that ubiquitously express the human cytosolic isoform of FH (FHCyt, which lacks the mitochondrial targeting sequence and therefore is excluded from the mitochondria), we rescued the embryonic lethality that Fh1 causes, and reduced the levels of fumarate. Importantly, although FHCyt expression restored fumarate-associated lethality, it did not restore the mitochondrial defects, allowing us to study the importance of genetically intact TCA in the context of haematopoiesis. Here I investigated the impact that a genetic truncation of the TCA cycle (as a result of the lack of the mitochondrial isoform of Fh1) has on leukaemic transformation and on aged haematopoiesis. Fh1fl/fl; FHCyt; Vav-iCre mice of approximately 60 weeks old displayed and expansion in the pool of early stem and progenitor compartment (Lin- Sca-1+ c-Kit+), as well as in the early progenitors HPC-1 (LSK CD48+ CD150-) and HPC-2 (LSK CD48+ CD150+). Furthermore, the mice exhibited a drastic depletion of B cells (CD19+ B220+) and an expansion in the frequency of the myeloid compartment (Mac-1+ Gr1+). In order to assess the importance of the TCA cycle in malignant transformation, I isolated stem and progenitor cells from Fh1fl/fl; FHCyt; Vav-iCre (and control (Fh1fl/fl; FHCyt Vav-iCre negative or Fh1fl/fl Vav-iCre negative)) E 14.5 day old embryos and infected them with retroviruses expressing Meis1 and Hoxa9, and generated pre-leukaemic cells (pre-LCs). Genetically intact TCA was required for the efficient generation of leukaemia-initiating cells (LICs), as injection of pre-LCs lacking mitochondrial Fh1 into sub-lethally irradiated recipient mice, resulted in 76 % of leukaemia-free mice while injection of control pre-LCs resulted in 25 % of leukaemia-free mice. However, the genetic perturbation of the TCA did not exert and effect on the long-term self-renewal capacity of LICs. Inducible deletion of mitochondrial Fh1 in established LICs of the Mx1-Cre background using poly (I:C) did not affect their ability to generate AML in primary and secondary recipient mice. These data indicate that genetically intact TCA is required for the efficient generation of LICs in vivo but is dispensable for their long-term self-renewal capacity, highlighting the metabolic rewiring that occurs at different stages of leukaemic transformation. In an effort to understand whether, similarly to HLRCC, Fh1 plays a tumour-suppressive role in malignant haematopoiesis, I isolated LSK cells from the foetal liver of E 14.5 old embryos lacking both isoforms of Fh1. Fh1fl/fl; Vav-iCre cells transduced with Meis1/Hoxa9 or MLL-AF9, MLL-ENL, AML-ETO (chromosomal translocations involved in AML development) -expressing retroviruses, failed to generate colonies in methylcellulose, indicating that stem and progenitor cells require Fh1 to undergo in vitro transformation by these oncogenes. Furthermore, acute deletion of Fh1 (via the use of lentivirally-expressed Cre) in pre-LCs generated using the Meis1/Hoxa9 retroviruses, rendered them unable to generate colonies in methylcellulose, indicating that Fh1 is required for the self-renewal capacity of pre- LCs in vitro. Similarly, when LICs (Fh1fl/fl; Vav-iCre negative) isolated from primary recipient mice were infected with Cre to induce deletion of Fh1, they were unable to generate colonies indicating that Fh1 is required for the self-renewal capacity of LICs in vitro. Finally, in order to identify whether Fh1 is important for LIC self-renewal in vivo I generated Fh1fl/fl; Mx1-Cre pre-LCs by infecting stem and progenitor cells of E 14.5 embryos with Meis1/Hoxa9 retroviruses, and injected them into sub-lethally irradiated mice. After the mice developed AML, I induced the deletion of Fh1, by injecting the mice with poly (I:C). Interestingly, the percentage of LICs in the peripheral blood of recipient mice was drastically decreased, leaving recipient mice leukaemia-free for the remaining time they were monitored. Surprisingly however, approximately 50 % of the recipient mice exhibited a drastic increase in LIC chimerism after two weeks post poly (I:C). Assessment of LICs isolated from recipient mice indicated that Fh1 was fully deleted. These data indicate that while in some cases Fh1 is required for LIC self-renewal in vivo, in other cases it is dispensable. Therefore, the tumour-suppressive roles of Fh1 are likely tissue-specific and do not extend to haematopoietic cells. Overall, this study agrees with published work supporting the notion that intact mitochondrial respiration is important (in varying degrees), in both the contexts of normal and malignant haematopoiesis.

The finely tuned regulation of haematopoietic stem and progenitor cells (HSPCs) is crucial to sustain normal haematopoiesis. The disruption of the balance between the quiescence state of haematopoietic stem cells (HSCs) and the proliferation/differentiation programs that are necessary to meet daily haematopoietic demands and respond to external insults, can lead to malignant transformation, such as acute myeloid leukaemia (AML). Therefore, it is essential to investigate the players that are responsible to maintain haematopoietic homeostasis, so that novel therapeutic targets can be identified. HSCs reside in a hypoxic environment that is crucial for their maintenance, as it protects them from over-proliferation and exhaustion. The response to a limited availability of oxygen is critically mediated by a transcription factor - hypoxia inducible factor (HIF). HIF is predominantly regulated by prolyl hydroxylases (PHDs) that are 2-oxoglutarate (2OG) dependent oxygenases. This superfamily of oxygen-sensing enzymes has been assigned important roles ranging from hypoxia signaling, DNA repair, chromatin modifications and oncogenesis Following the data published by our group attesting that HIF is dispensable for HSC survival and maintenance, we focused our investigation on HIF-independent pathways. This manuscript describes the study of the role of an oxygen-sensor enzyme, member of the 2OG oxygenases and HIF negative regulator, jumonji domain-containing protein 6 (Jmjd6), in normal and malignant haematopoiesis. Our knockout studies deleting Jmjd6 specifically within the haematopoietic system (Jmjd6fl/fl;Vav-iCre) demonstrate that the homeostasis of HSPC pool was compromised and lymphopoiesis was attenuated in Jmjd6-deficient cohorts. Upon transplantation, HSCs lacking Jmjd6 exhibited a defective chimerism and impaired capacity to fully reconstitute haematopoiesis of recipient mice. Thus, Jmjd6 is essential for HSC self-renewal and maintenance. Our assessment of the impact of Jmjd6 deletion in the context of inflammatory response and recovery from treatment with a myelotoxic agent treatment revealed that Jmjd6 is a positive regulator of HSC homeostasis and recovery from cytotoxic stress. There are accumulating data on the importance of epigenetics in the development of haematological malignancies. Being an epigenetic regulator, clearly involved in RNA splicing, we investigated Jmjd6 as possible player in leukaemogenesis. The results from our leukaemic studies unravelled a new biological function for Jmjd6 as a tumour suppressor in Meis1/Hoxa9 murine model. Altogether, our findings offer important novel insights into the biological functions of Jmjd6 and pave the way for further studies to discover on the mechanism of action of this complex enzyme. Our observations add value to the idea that Jmjd6 might constitute a good candidate for cancer diagnosis, that can be use to ameliorate patient’s prognosis and that it can be used to help patient prognosis in the future.

Abstrakt Bakgrund: Hjärtinfarkt kan vara livshotande och kräver omedelbar sjukhusvård. För att reducera skada på hjärtat är det viktig att patienten kommer till omedelbar reperfusionsbehandling. Om symtom inte känns eller relateras till hjärtat, kan det göra att personen avvaktar med att söka vård och därmed försenas diagnos och behandling vilket kan leda en till ökad risk för att dö. För att öka kunskapen inom detta område vill vi med vår analys undersöka patienters upplevelse av symtom vid en akut hjärtinfarkt. Syfte: Att undersöka patientens upplevelse av symtom vid en akut hjärtinfarkt. Metod: En integrativ litteraturöversikt genomfördes vilken baserades på sökningar i Cinahl och Pubmed. Nio vetenskapliga artiklar med både kvalitativ och kvantitativ ansats valdes ut. Resultat: Studierna visade stor variation av patienternas upplevda symtom och symtomdebutens karaktär. Det fanns även skillnader mellan förväntade och upplevda symtom och resultatet visade att det råder en generell kunskapsbrist om AMI symtom bland allmänheten. Detta sammantaget leder till fördröjning i patienternas beslutsprocess för att uppsöka vård och behandling. Slutsats: Om tiden till behandling kortas, kan det leda till stora förbättringar vad gäller personens hälsa, välmående och livskvalitet. Det borde därmed finnas ett stort intresse att investera i strategier för att öka kunskapen om de olika och varierande symtom vid akut hjärtinfarkt hos allmänheten och även hos yrkesverksamma inom vård- och omsorg.

This thesis reports the outcomes of research into the use of restraint in the care of patients in an acute teaching hospital in Australia. The literature review undertaken for the study revealed much research into restraints showing evidence of the harm they cause, and their ineffectiveness as a safety measure. The literature indicates that the prevalence of restraint use is high - about a third of all hospital patients over the age of eighty-five years may be restrained at some time during the period of their admission.The main emphasis in my investigation was to uncover an understanding of how the use of restraints has remained possible, despite negative reports on their efficacy and questions about their possible abuse of human rights. Primarily, 1 set out to provide vide an understanding of restraint practice, and of how it is maintained and legitimised in a metropolitan teaching hospital.The study was guided by a Foucauldian approach to discourse analysis. The study reports on in depth studies of three patients. The case studies extend beyond observations of the patients to include interviews with members of the multidisciplinary team: nurses, doctors, occupational therapists and physiotherapists. Medical and nursing notes were another source of data.A discursive formation was identified by which restraint use is justified, and legitimised by the health professionals who use it. Five discourses were established, constituting: inability to 'self govern'; an appropriate environment; treatment; duty of care; and marginalisation.The study concludes that restraint use can be understood as a complex discursive practice. Through this discursive practice we can understand how staff maintain a monopoly over the truth and perpetuate claims about the inevitability of restraint use. Knowledge of these discursive practices enables an understanding of how the current ++ / educational approaches to restraint reduction are likely to have little immediate or sustained impact. With these understandings, we are hopefully better placed to change practice in a way that does not substitute one undesirable approach for another. If this is so, the value of this thesis will lie in its influence on practice as much as in its contribution to scholarship.

Athletes who participate in sports where performance relies on repeated high-intensity efforts could benefit from creatine (Cr) ingestion due to an increased ability to perform and recover from high-intensity exercise bouts either during training or competition. However, few studies exist which have investigated the effects of acute short-term Cr supplementation on appropriately simulated soccer-specific performance.Aims. To determine the reproducibility of a 90 minute soccer-specific performance test and to subsequently examine the effects of acute short-term Cr ingestion (1 week) on soccer-specific physical performance. Study design. Two experimental designs were adopted for this thesis. For study one, a test-retest design was used to determine the reliability and validity of the Ball-sport Endurance And Sprint Test (BEAST). Two trials of the BEAST were performed, separated by five to seven days. For study two, a randomised, triple-blind, placebo-controlled experimental design was adopted to determine the efficacy of acute short-term Cr supplementation (seven days) on soccer-specific performance, using the BEAST protocol.Methods. Twenty male amateur soccer players volunteered to participate in the study. For study one, the test-retest reliability of several soccer-specific performance measures obtained during a modified version of the BEAST was quantified using the standard error of measurement (Van Cutsem, Duchateau, & Hainaut) (or typical error) (Hopkins, 2000), coefficient of variation (CV), and Intraclass Correlation Coefficient (ICC). For study two, the cohort was split and subjects randomly allocated to one of two groups (Cr supplementation and Placebo) on a matched-pair basis. The Cr group (mean age 25.4 ± 4.5 years, mean body-mass 79.3 ± 10.5 kg) ingested 20 g of Cr and 8 g of glucose powder per day for seven days, whereas the placebo (mean age 26.7 ± 4.6 years, mean body-mass 80.8 ± 8.6 kg) group ingested 20 g of corn-flour and 8 g of glucose per day for seven days. The effects of acute short-term Cr supplementation were analysed by repeated measures ANOVA. In addition, effect sizes (ES) were calculated and entered with the associated p-value into Hopkins' spreadsheet for determination of the ES confidence limits (95%) and the chances that the true effect was substantial (i.e. ES ≥ 0.2). Clinical/practical inferences were made accordingly.Results. Study 1: The BEAST protocol had good reliability (high ICC values, relatively low coefficients of variation, low noise to signal ratios) and face validity (HR, VO2, distances covered, duration, and movements performed in the BEAST were all similar to those reported in actual soccer matches). Study 2: Performance of the four major physical measures (12 m sprint, 20 m sprint, circuit time and vertical jump) during the BEAST deteriorated during the second half relative to the first half for both Cr and placebo groups, indicating a fatigue effect associated with the protocol. HR and body-mass values also decreased for both groups during the 90 minute protocol. However, there was no statistically significant differences between the groups for these four measures or for body-mass, HR or VO2max values, suggesting Cr had no substantial effect (relative to placebo) on improving physical performance (or reducing fatigue). When the effects were assessed for the whole 90 minute BEAST protocol, all effects showed a negative trend and, correspondingly, the chances of a detrimental effect were greater than the chances of a beneficial effect.Conclusions: The 90 minute BEAST protocol had good reliability and face validity making it a suitable soccer simulation and performance protocol with which to investigate the effects of Cr supplementation on soccer performance. However, no significant (statistical or clinical) effects of acute short-term Cr supplementation on soccer performance were observed suggesting its potential use as an ergogenic aid for soccer players is questionable.

The aims of this thesis were to examine: (1) plasma and cellular pharmacokinetics of daunorubicin and its major metabolite daunorubicinol in patients with acute leukaemia, and the relationships between pharmacokinetics, patient response and the presence of P glycoprotein; (2) actions of the multidrug resistance reversing agents cyclosporin A and trifluoperazine, at clinically achievable concentrations, on daunorubicin accumulation and retention in human leukaemia cell lines and patients with acute leukaemia; and (3) effect of daunorubicin on the cell membrane of both sensitive and resistant cell lines, with and without the multidrug resistance reversing agents. Twenty-seven patients with acute leukaemia received daunorubicin as part of induction therapy. The plasma and cellular levels of daunorubicin and its metabolite daunorubicinol were determined using HPLC. There were no significant differences between patients who went into complete remission (12 out of 23) compared to those who did not respond for any of the plasma pharmacokinetic parameters. There was a significant difference in the cellular daunorubicin and daunorubicinol area under the concentration-time curve between responders and non responders (p less than 0.02), as well as in cellular Cmax, cellular clearance and cellular volume of distribution. Eleven patients were P glycoprotein positive and 10 P glycoprotein negative (no sample available for 2 patients). There was no correlation between patient response and the presence of P glycoprotein; nor a correlation between the cellular concentration of daunorubicin or daunorubicinol and P glycoprotein. Patients responding to chemotherapy had higher cellular daunorubicin and daunorubicinol compared to non responders. In contrast to in vitro studies, overexpression of P glycoprotein was not the reason for the lower cellular daunorubicin levels. Cyclosporin A was capable of increasing both cellular accumulation and retention in the drug resistant CEM/VLB and HL 60/ADR cell lines, but not in the drug sensitive CEM and HL 60 cell lines. Trifluoperazine had no effect in any of the four cell lines. In contrast to the cell line findings, only the combination of cyclosporin A and trifluoperazine were able to increase both accumulation and retention in the blast cells of patients at initial presentation. The multidrug resistant reversing agents alone had no effect in increasing accumulation or retention in the blast cells of P glycoprotein positive patients, nor patients in relapse. The cell line studies show that at clinically relevant concentrations only cyclosporin A is capable of increasing daunorubicin accumulation in both the drug resistant P glycoprotein positive (VLB) and P glycoprotein negative (ADR) cell lines. Thus, cyclosporin A does not work only by inhibiting the actions of P glycoprotein. Trifluoperazine was unable to reverse drug resistance at clinically relevant concentrations in either cell lines or patient blast cells. However, the combination of cyclosporin A and trifluoperazine increased accumulation in patient blast cells at initial presentation, suggesting that these agents may be more useful in patients at initial presentation than relapse. Daunorubicin was immobilised by linking it to poly vinyl alcohol and the effect of immobilised-daunorubicin was studied on the four cell lines above. The immobilised-daunorubicin was able to decrease cell growth in the drug sensitive HL 60 cell line but not in the drug resistant VLB or ADR cell lines. Poly vinyl alcohol itself was cytotoxic to the CEM cell line. The multidrug resistance reversing agents cyclosporin A and trifluoperazine were only capable of increasing cytotoxicity in the HL 60 cell line, with no effect in the drug resistant VLB or ADR cell lines.

This workplace study examined the every day ethical dilemmas of a multidisciplinary team in one acute psychiatric setting and the social factors affecting their moral domain of practice. The research design was a case study involving both qualitative and quantitative data. The context that shaped the team's process of ethical dilemma identification was conceptualised for the purpose of this research within a systems theory framework of interrelated factors at a societal, organisational and clinical level with ethics theory pervading the entire scene. The findings indicated that dilemmas arose in situations concerning patient care, team strain, and limited resources with the most common dilemma across disciplines arising from lack of community resources. Further findings suggested that clinicians were aware of various forces shaping practice but these ideas were not well connected conceptually. Staff felt wary of identifying ethical dilemmas because they were unsure of the process and sensed a reticence in the unit's social processes around negotiation and problem solving. Important social factors that were perceived to affect their abilities around ethical dilemma identification included rational economics, professional socialisation, medical-legal monopoly with a concomitant use of the ethic of justice, and managerial strategies. The concept of transference and countertransference issues within the staffing group was explored. These results are useful for the team to understand the nature of their own particular dilemmas and what factors constrain and enhance their abilities to identify dilemmas. Other health care settings may find that replication of the research results in a similar way may raise awareness of their moral situation. Generalisability at a theoretical level contributes to the current research agenda in applied ethics about the effect of context in the ethical domain of clinical practice.