Oral rehydration therapy: is anyone drinking?

OBJECTIVES

To examine attitudes toward the use of oral rehydration therapy (ORT) by pediatric emergency medicine physicians before and after being given recent data that might affect their practice and to see if there is a difference in responses based upon year of graduation from medical school.

METHODS

A national survey of all members of the American Academy of Pediatrics' Section on Emergency Medicine was conducted. Respondents were asked about their use of ORT for mild, moderate, and severe dehydration, and then presented with data refuting the concern for longer emergency department length of stay with ORT. Participants were then asked about their knowledge of, agreement with, and reaction to these data. Demographic information, such as board eligibility and year of graduation from medical school, was also obtained. The graduates were plotted on a distribution curve by year of graduation, and the group was split into thirds.

RESULTS

The response rate was 59%. Before being presented with new data, earlier medical school graduates used ORT 86% for mild and 33% for moderate dehydration, whereas recent graduates used ORT 95% for mild dehydration and 55% for moderate dehydration. Overall, only 23% of physicians were familiar with the new data, but 80% agreed with the new data, and 83% would now incorporate ORT into their practice. Although the earliest graduates were as familiar with the new data as recent graduates (24% vs. 19%), they were less likely to agree with the new data (74% vs. 90%) and to incorporate ORT into practice (75% vs. 92%).

CONCLUSIONS

When pediatric emergency medicine physicians are presented with data refuting the perceived barrier of prolonged time for the use of ORT, more practitioners reported that they would use ORT for mild to moderate dehydration. However, a substantial number, especially those who graduated medical school earliest, would maintain their current practice. Additional barriers need to be explored.

Western Australian dental graduates' perception of preparedness to practice: a five-year follow-up

The School of Dentistry in Western Australia developed a pregraduation intern year in which final-year students, having completed their didactic education, undertook a focused clinical experiential program (CEP) over an extended year. This program was implemented for the first time in 2002. The aim of this study was to identify the strengths and weaknesses of the curriculum as perceived by graduates and to compare the perceptions of those graduates who did the CEP to those who did not. A survey with questions based on the graduate outcomes of the dental school was mailed to all graduates from 2000, 2001 (did not complete CEP), and 2004 (completed CEP). The response rate was 66 percent (n=57) and included twenty-nine respondents who graduated before implementation of the CEP and twenty-eight who completed the CEP. Most respondents (80 percent) were in the twenty to twenty-nine age group, and there were slightly more males (53 percent). Learning outcome items with the highest mean scores were practicing universal precautions (4.2), behaving ethically (4.2), and demonstrating a satisfactory level of core dental knowledge (4.2). Practical skills outcomes with the highest scores were amalgam restorations (4.3), anterior endodontics (4.3), and single crowns (3.9). When comparing the respondents who did CEP (51 percent) with those who did not (49 percent), there were few significant differences. The general findings from this survey were that most graduates, whether completing the CEP or not, perceived themselves to be prepared, competent, and confident to practice as dentists and were most confident in managing problems that they most frequently encountered during training.

Assessment of clinical nurse specialists in rheumatology using an OSCE

OBJECTIVE

To introduce a new method of assessment; an observed structured clinical examination (OSCE) into a postgraduate course for rheumatology clinical nurse specialists.

METHOD

The OSCE was introduced into a physical assessment module, which focused on the nurses' ability to perform an examination of patients' shoulders, knees and hands. A modified blueprinting exercise was used to ensure adequate sampling of the different components of the syllabus. This resulted in five active stations and one rest station. The active stations included history-taking, physical examination of the shoulder, knee and hand complexes and multidisciplinary management plans. To enhance authenticity real, rather than simulated, patients were used where practical.

RESULTS

All 11 students passed all stations, the lowest score related to history-taking and the highest score related to devising a management plan. All 11 students rated the OSCE a worthwhile experience reflecting the learning outcomes of the module and recommended that the OSCE should be used to assess the next cohort of students. Eight students found the OSCE too 'anxiety-provoking' and did not want this method of assessment to be used in other modules. All examiners felt this mode of assessment was more valid than the previous assessment format of a viva on a single patient.

CONCLUSION

This was the first time an OSCE was used in a postgraduate course to assess the physical examination skills of rheumatology nurse specialists. The course faculty, examiners and students found it was a reliable and valid means of assessment.

Nurses’ reasoning process during care planning taking pressure ulcer prevention as an example. A think-aloud study

BACKGROUND

Nurses' clinical reasoning is of great importance for the delivery of safe and efficient care. Pressure ulcer prevention allows a variety of aspects within nursing to be viewed.

OBJECTIVE

The aim of this study was to describe both the process and the content of nurses' reasoning during care planning at different nursing homes, using pressure ulcer prevention as an example.

DESIGN

A qualitative research design was chosen.

SETTINGS

Seven different nursing homes within one community were included.

PARTICIPANTS

Eleven registered nurses were interviewed.

METHOD

The methods used were think-aloud technique, protocol analysis and qualitative content analysis. Client simulation illustrating transition was used. The case used for care planning was in three parts covering the transition from hospital until 3 weeks in the nursing home.

RESULT

Most nurses in this study conducted direct and indirect reasoning in a wide range of areas in connection with pressure ulcer prevention. The reasoning focused different parts of the nursing process depending on part of the case. Complex assertations as well as strategies aiming to reduce cognitive strain were rare. Nurses involved in direct nursing care held a broader reasoning than consultant nurses. Both explanations and actions based on older ideas and traditions occurred.

CONCLUSIONS

Reasoning concerning pressure ulcer prevention while care planning was dominated by routine thinking. Knowing the person over a period of time made a more complex reasoning possible. The nurses' experience, knowledge together with how close to the elderly the nurses work seem to be important factors that affect the content of reasoning.

Self-reported confidence, attitudes and skills in practical procedures among medical students: questionnaire study

The aim of our study was to investigate the influence of gender, loss of academic year(s), confidence and attitudes of students on the clinical experience gained by undergraduate education. The survey was conducted during 2004 and 2005 in a sample of 182 students of the 5th and the 6th year at J.J. Strossmayer University School of Medicine in Osijek. The participants were grouped and matched according to their gender, regular studying, the number of time(s) student has performed certain practical medical procedure and the self-confidence arisen by performing one. Furthermore, participants were grouped and compared due to their own assessment of their own practical and theoretical medical knowledge, courses which provide them the least and oppositely--the most practical medical knowledge and their attitude toward current medical faculty curriculum on clinical courses as well as the possibilities of improving them. Fisher's exact test and chi2-test were used to estimate statistical differences between the groups and the parameters in research, while coefficient of contingency was introduced with the aim of defining their correlation. The results showed statistically significant differences between male students who performed more practical medical procedures than female (p < 0.001), non-repeaters performed medical procedures more often than repeaters (p < 0.001, C = 0.658) while repeaters thought higher of their theoretical knowledge than non-repeaters (p < 0.005). Data analysis showed statistically significant correlation between clinical experience and the level of confidence (C = 0.944). This study confirmed influence of male gender, regular studying, better opinion about one's own practical skills and higher confidence in one's own work on greater number of clinical skills performed during undergraduate education.

Student teachers can be as good as associate professors in teaching clinical skills

AIM

The aim of this study is to compare student teachers and clinical associate professors regarding the quality of procedural skills teaching in terms of participants' technical skills, knowledge and satisfaction with the teaching.

METHODS

This is an experimental, randomized, controlled study comparing the teaching of student teachers and associate professors regarding participants' learning outcome and satisfaction with the teaching. Two skills are chosen for the experiment, i.v.-access and bladder catheterization. Learning outcome is assessed by a pre- and post testing of the participants' knowledge and skills. Participants evaluate satisfaction with teaching on nine statements immediately after the teaching.

RESULTS

In total 59 first year medical students are included as participants in the experiment. The students taught by student teachers perform just as well as the students taught by associate professors and in one skill--catheterization--they perform even better, mean post- minus pre-test scores 65.5 (SD 12.9) vs. 35.0 (SD 23.3), One-way ANOVA, p < 0.0001, effect size 1.62. Student teachers receive significantly more positive evaluations than associate professors on several statements.

CONCLUSION

Trained student teachers can be as good as associate professors in teaching clinical skills.

Cross-referencing the Scottish Doctor and Tomorrow's Doctors learning outcome frameworks

Learning outcomes, organised into systems or frameworks which describe and define the output of an educational programme, are being created and used in healthcare education with increasing frequency (Harden 2001, 2002). Medical schools may be required to conform to more than one such outcome framework. For example, both the UK General Medical Council (GMC) and the Scottish Deans' Medical Curriculum Group (SDMCG) have created and published a systematic learning outcome framework for medical graduates. Although both of these publications are concerned with undergraduate medical education, they differ in their aims, and structure. In order to use, evaluate and validate them, a cross-referencing system which relates each learning outcome statement, term or groups of terms is required. This paper describes the cross-referencing exercise undertaken by the SDMCG, the philosophy behind it, the practical steps taken, the findings, the lessons learnt and reflections upon how this work may be taken forward. It will be of interest to all those who are involved in curriculum development using outcomes, and especially those who use the GMC's Tomorrow's Doctors or the SDMCG's Scottish Doctor frameworks and those who are interested in education informatics in general.

The CanMEDS initiative: implementing an outcomes-based framework of physician competencies

BACKGROUND

Outcomes-based education in the health professions has emerged as a priority for curriculum planners striving to align with societal needs. However, many struggle with effective methods of implementing such an approach. In this narrative, we describe the lessons learned from the implementation of a national, needs-based, outcome-oriented, competency framework called the CanMEDS initiative of The Royal College of Physicians and Surgeons of Canada.

METHODS

We developed a framework of physician competencies organized around seven physician "Roles": Medical Expert, Communicator, Collaborator, Manager, Health Advocate, Scholar, and Professional. A systematic implementation plan involved: the development of standards for curriculum and assessment, faculty development, educational research and resources, and outreach.

LESSONS LEARNED

Implementing this competency framework has resulted in successes, challenges, resistance to change, and a list of essential ingredients for outcomes-based medical education.

CONCLUSIONS

A multifaceted implementation strategy has enabled this large-scale curriculum change for outcomes-based education.

Promoting Clinical Competence: Using Scaffolded Instruction for Practice-Based Learning

Competency-based education is essential for bridging the gap between education and practice. The attributes of competency-based education include an outcomes focus, allowance for increasing levels of competency, learner accountability, practice-based learning, self-assessment, and individualized learning experiences. One solution to this challenge is scaffolded instruction, where collaboration and knowledge facilitate learning. Collaboration refers to the role of clinical faculty who model desired clinical skills then gradually shift responsibility for nursing activity to the student. This article describes scaffolded instruction as applied in a Web-based second-degree bachelor of science in nursing (BSN) program. This second-degree BSN program uses innovative approaches to education, including a clinical component that relies on clinical coaches. Students in the program remain in their home community and complete their clinical hours with an assigned coach. The method will be described first, followed by a description of how the method was applied.

[The teamconcept: Liberty Hall?]

Dutch legislation allows paramedics to perform certain dental treatments. At least an important part of the dentists and paramedics in this study does not meet the legal conditions for bringing in paramedics into daily dental practice. As the relevant Dutch law on this subject makes it possible to prosecute both the dentist and the paramedic who goes beyond their professional competence, it is advised to consult the law before exploring the possibilities of the team concept.

Public Health Perspectives on the Rising Incidence of Pertussis

OBJECTIVES

Pertussis is one of the few vaccine-preventable diseases on the rise in the United States, particularly among adolescents. We analyzed the epidemiology of pertussis, focusing on disease burden in public health, and examined methods for controlling pertussis and reducing its incidence. DESIGN, SAMPLE, AND MEASUREMENTS: We evaluated current knowledge about pertussis, reported cases of pertussis in the United States, and the changing recognition, diagnosis, and management of the disease. The development of a pertussis vaccine, now licensed and recommended for use in adolescents and adults, was reviewed.

RESULTS

Of reported cases in 2004, 38% occurred in adolescents. The increased incidence of pertussis may be the result of better diagnosis, better reporting, and increased awareness of the disease. The burden of adolescent and adult pertussis is significant and includes medical visits, laboratory tests, treatment for cases and contacts, time lost from school and work, disruption of schools experiencing outbreaks, and public health and media turmoil. At current disease rates, the financial cost of adolescent pertussis in this decade is projected at $3.2 billion.

CONCLUSIONS

Efforts are needed to increase health care providers' knowledge of pertussis disease and vaccines, improve on-time infant immunization rates, promote immunization registries and public health surveillance, and ensure adequate compensation for vaccine purchase and administration. Universal recommendations for and widespread use of acellular pertussis vaccines in adolescents are the most effective measures in controlling the disease.

Tobacco cessation counseling training with standardized patients

A pilot study was conducted to assess clinician receptivity to tobacco cessation counseling training methods using standardized patients. Additionally, the study assessed changes in clinician knowledge and behavioral intentions following the training. Medical and dental residents and dental hygiene students from the University of Louisville attended a one- to two-hour lecture addressing the counseling strategies (the Five As/the Five Rs) and pharmacotherapy recommended in the U.S. Public Health Service Clinical Practice Guideline: Treating Tobacco Use and Dependence. Participants subsequently had three training encounters with standardized patients representing various stages of change including a patient ready to quit, a patient contemplating quitting, and a patient resistant to quitting. Thirty-six participants completed a preprogram survey prior to the lecture and a postprogram evaluation that included questions about their attitudes and beliefs about tobacco, their comfort level with various aspects of tobacco intervention, and eight knowledge questions. Participants demonstrated a statistically significant increase in objective knowledge about the practices recommended in the Clinical Practice Guideline following intervention. Results also indicate a significant increase in subjective measures of participant receptivity, self-reported comfort, and perceived skill with various aspects of tobacco intervention. Overall, participants were found to be very receptive to training sessions on tobacco cessation counseling with standardized patients. In light of the educational gains and positive response from participants, the use of standardized patients is a promising strategy for training on tobacco cessation counseling.

A two-tiered quality management program: Morbidity and Mortality conference data applied to resident education

The ACGME mandates a competency-based resident education curriculum. The Joint Commission (TJC) requires a quality improvement (QI) program in all hospitals with residency training programs. Our QI program, based on M&M conference data, provided the operational framework for peer review and resolution of adverse events. However, the conference focused on only three of the six ACGME core competencies (patient care, medical knowledge, practice-based learning and improvement) but not specifically on interpersonal and communication skills, professionalism or systems-based practice. To address this issue, we devised a two-tiered QI process that meets the reporting mandate of TJC and addresses all six ACGME core competencies. Adverse events are reported and discussed in the Department of Surgery's divisional M&M conferences. If an issue involving the ACGME core competencies is identified that requires nonconference discussion, ie, communication, professionalism or systems-based practice, the case is referred to the Department of Surgery Subcommittee for Quality Improvement (SCQI). A report is then returned to the divisional M&M for discussion and possible incorporation into the Resident Core Curriculum. Resident and attending surgeon surveys demonstrated the new format to be effective in addressing all six ACGME competencies.

Anogenital Warts Knowledge and Counseling Practices of US Clinicians: Results From a National Survey

OBJECTIVES

To examine messages US clinicians use when counseling patients diagnosed with anogenital warts.

STUDY DESIGN

In mid-2004, we conducted a confidential mail survey of nationally representative samples of physicians practicing internal and adolescent medicine, family/general practice, obstetrics/gynecology, urology, or dermatology; nurse midwives; physician assistants; and nurse practitioners. The survey assessed knowledge and counseling practices of clinicians who had diagnosed anogenital warts.

RESULTS

After adjusting for survey eligibility, 81% responded. Most (89%) were aware that human papillomavirus (HPV) causes anogenital warts, but only 48% were aware that oncogenic and wart-related HPV genotypes usually differ. Most (>95%) clinicians reported telling patients with warts that warts are an STD, are caused by a virus, or that their sex partners may have or may acquire warts. Many clinicians (>/=85%) also reported discussing STD prevention or assessing STD risk with such patients. Most reported addressing ways to prevent HPV (89%), including using condoms; limiting sex partners or practicing monogamy; or abstinence. Many also reported recommending prompt (82%) or more frequent (52%) Pap testing to female patients with anogenital warts. Potential barriers to counseling included providing definitive answers on how HPV infection was acquired, dealing with patients' psychosocial issues, and inadequate reimbursement.

CONCLUSIONS

Most surveyed clinicians appropriately counseled patients about the cause and prevention of anogenital warts. However, many clinicians were unaware that oncogenic and wart-related HPV types usually differ, and this may explain why many reported recommending more aggressive cervical cancer screening for female patients with warts.

Social marketing meets health literacy: Innovative improvement of health care providers' comfort with patient interaction

OBJECTIVE

It is essential to train health care providers to deliver care sensitive to the needs of diverse individuals with varying degrees of health literacy. We aimed to evaluate an innovative, theory-based, educational intervention involving social marketing and health literacy.

METHODS

In 2006 at a large medical school, all first-year students were exposed to the intervention. They completed pre- and post-test anonymous surveys including demographic data, covariates, and key outcome variables. Paired t-tests and multiple linear regression were used to evaluate the intervention and to determine independent associations among the key outcome variables.

RESULTS

Post-intervention scores were significantly higher than pre-intervention scores for social marketing (3.31 versus 1.90, p<0.001), health literacy (3.41 versus 2.98, p<0.001), and comfort in brochure development (3.11 versus 2.52, p<0.001) (N=83). After controlling for demographic and covariate data, health literacy and comfort in brochure development were independent predictors of comfort interacting with diverse populations.

CONCLUSION

A brief intervention involving social marketing and health literacy can improve skills that improve medical students' comfort with patients of diverse backgrounds.

PRACTICE IMPLICATIONS

Health care providers can be taught educational principles and skills involved in developing effective patient education materials. These skills may improve providers' comfort with direct patient interaction.

Proposed ACGME Change in Length of Radiology Residency Training Before Independent Call

PURPOSE

To assess radiology residency program directors' and chief residents' views regarding the Radiology Residency Review Committee's proposed revision of program requirements which would delay independent call until a resident has had 12 months of radiology training.

METHODS

A Web-based survey was distributed electronically to the program directors and chief residents of 188 radiology residency programs. Survey responses were collected for two weeks in November-December 2006.

RESULTS

The survey was completed by 91 Program Directors and 165 Chief Residents. There were no statistically significant differences between the two groups of respondents on any of the 9 questions pertaining to the proposed call requirement change. Approximately 70% of the program directors and 80% of the chief residents disagreed or disagreed strongly that they were in favor of the proposed ACGME change. Strong opposition to the change was independent of both program size and current compliance with the proposed change. Over 70% in both groups disagree or strongly disagree that the proposed change would positively affect residency training.

CONCLUSIONS

The majority of survey respondents oppose changing the minimum required length of radiology residency training prior to residents' providing independent on-call radiology interpretations from 6 months to 12 months.

The Journey to the DNP Program and Beyond: What Can We Learn From Pharmacy?

Advanced practice nursing has been elevated to a new level with the introduction of the DNP (Doctorate of Nursing Practice). One of the justifications for its implementation is the promotion of parity between nurses and other health care providers who require a practice doctorate. Concerns surrounding parity, the ability of DNP-prepared nurses to affect health care outcomes, equitable salary issues, and the DNP program's effect on the academic PhD (Doctorate of Philosophy) program have been expressed. The purpose of this analysis is to explore these issues using pharmacy as an example for implementing a practice doctorate. Similarities and differences between the professions are examined, and lessons that nursing can learn from pharmacy are discussed.

Out of the Ashes: The new bachelor of midwifery curriculum at Victoria University

In the past decade, midwifery education has changed significantly in Australia. Previously, a nursing qualification (division 1) was required for entry into midwifery programs and on completion, graduands obtained a postgraduate diploma of midwifery. More recently, bachelor of midwifery programs have also been offered in Australia and currently, a considerable percentage of midwives are prepared for practice in this way. In Victoria, the bachelor of midwifery has been available since 2002, and at this time the third group of graduands are poised to enter the field. Implementation of the bachelor of midwifery program has given rise to many concerns about the development and applicability of this course. Concerns include: complexities of registration with a regulatory board set up primarily for nursing registration; concerns about readiness for practice among bachelor of midwifery graduands; escalating requirements within midwifery courses; and difficulties with meeting course requirements. As this course comes of age in Victoria, it is useful to reflect on some of the challenges encountered along the way. Thus, this paper reports on the journey of one university as it approaches the end of a first year of implementing an independent bachelor of midwifery program, following 5 years involvement as a consortium partner. In particular, it addresses concerns and difficulties encountered during early implementation of the program and then outlines strategies used to improve and strengthen the course. The basic premise of the paper is lessons learnt along the way.