A Multistakeholder Approach to the Development of Entrustable Professional Activities in Complex Care

Using simulation to teach paediatric complex care

BACKGROUND

Training paediatric residents regarding the care of children with medical complexity (CMC) remains an important challenge given how frequently these patients are treated by trainees and the lack of educational activities specific to these patients. Our goal was to develop and assess a novel simulation regarding the acute care of CMC to improve residents' perceived confidence in areas related to CMC care.

APPROACH

We developed a case of a patient with multiple chronic medical conditions who presented with acute vital sign changes and worsening discomfort due to an occult femur fracture related to a recent transfer. Paediatric residents worked in teams to complete a full physical exam, create a differential diagnosis, evaluate laboratory and imaging results and create a management plan.

EVALUATION

Thirty-three residents out of a total possible sample of 97 (34%) participated in the simulation, which was evaluated using pre- and post-surveys immediately before and after the simulation assessing resident confidence completing tasks related to CMC care. Residents perceived significant improvement in confidence regarding evaluating a differential diagnosis of vital sign and exam changes in CMC (p = 0.023), managing vital sign and exam changes in CMC (p = 0.009) and communicating with team members of CMC (p = 0.049).

IMPLICATIONS

An innovative high-fidelity and low-stakes simulation was effective in teaching trainees about acute management of concerns related to CMC. This simulation may be appropriate for implementation at other institutions, serving as a foundation for use in resident education regarding CMC.

Caring for Children With Medical Complexity: A Clinical, Patient-Focused Curriculum

Introduction

Caring for children with medical complexity (CMC) requires specialized knowledge and skills. However, no standardized curricula are used across training programs as institutions have varying needs and resources.

Methods

We created a patient-focused, interactive curriculum for two CMC topics: feeding/nutrition and pain/irritability. We integrated the 45-minute sessions into morning protected patient-care time on an inpatient pediatric team at an urban tertiary care hospital. Targeted toward all pediatric residents and medical students rotating in inpatient pediatrics over a 12-month period, the sessions used a mix of didactic, discussion, and hands-on activities. Learners on one of two inpatient teams received the curriculum, while those on the other received a curriculum unrelated to CMC and served as a control group. Both groups completed retrospective pre/post self-assessments to evaluate self-efficacy with respect to the learning objectives.

Results

Over the 12-month period, 72 surveys were completed for the feeding/nutrition session, 78 surveys for the pain/irritability session, and 42 control surveys. The intervention group saw the greatest increase in self-efficacy scores generally in the feeding/nutrition session. All eight learning objectives saw significant improvement in self-efficacy scores for the intervention group. There was significantly greater improvement in self-efficacy for the intervention group compared to the control for all eight learning objectives.

Discussion

Through this patient-focused curriculum, learners had improved self-efficacy scores compared to the natural learning occurring on the inpatient service. The curriculum could be adapted to fit the needs of other institutions and provides a practical, hands-on approach to learning about caring for CMC.

A Pediatric Resident Advocacy in Complex Care Curriculum

Introduction

Children and youth with special health care needs (CYSHCN) are a special, vulnerable population. Children with medical complexity (CMC) represent a smaller, medically fragile sliver (6%) of the US child population. Several professional pediatric entities direct (or require) pediatric educators to instruct residents in advocacy for all children, explicitly including CYSHCN/CMC populations. While many existing curricula address pediatric advocacy education, a gap remains in curricula specifically designed to aid learners in advocacy of CYSHCN/CMC.

Methods

Using Kolb's experiential learning cycle as a framework, we designed and delivered a comprehensive outpatient complex care curriculum, including several didactic video lectures (total: 60:04 minutes, median: 6:25 minutes) and experiential site visits devoted to advocacy topics for CMC, as one portion of a 4-week elective complex care rotation. Residents completed pre- and posttests of knowledge and pre- and postsurveys to self-assess attitudes, comfort, and behavior; viewed didactic video lectures; and engaged in experiential site visits. Reflective statements captured attitudes regarding advocacy for CMC.

Results

Between July 2016 and June 2020, 47 trainees completed the rotation; data were available for 30 trainees. Residents demonstrated a statistically significant improvement in knowledge (p < .001), as well as improved attitudes, diversity sensitivity, and comfort in advocating for CMC postrotation. Qualitative comments showed overwhelmingly positive learner reaction.

Discussion

This curriculum, which can be offered as a stand-alone resource or a supplement to a comprehensive complex care curriculum, incorporates didactic and experiential teaching methods and addresses a significant competency in advocacy education.

A Comprehensive Outpatient Pediatric Resident Complex Care Curriculum

Introduction

Pediatric resident training typically prepares learners to care for children with medical complexity (CMC) when acutely ill; however, residents often do not receive formal primary care training for this population. We designed a curriculum to improve pediatric resident knowledge, skills, and behavior when providing a medical home for CMC.

Methods

Guided by Kolb's experiential cycle, we designed and offered a complex care curriculum as a block elective to pediatric residents and pediatric hospital medicine fellows. Participating trainees completed a prerotation assessment to establish baseline skills and self-reported behaviors (SRB) and four pretests to document baseline knowledge and skills. Residents viewed online didactic lectures weekly. During four half-day patient care sessions per week, faculty reviewed documented assessments and plans. Additionally, trainees attended community-based site visits to appreciate the socioenvironmental perspective of CMC families. Trainees completed posttests and a postrotation assessment of skills and SRB.

Results

Between July 2016 and June 2021, 47 trainees participated in the rotation, with data available for 35 trainees. Residents demonstrated significant improvement in knowledge (p < .001), self-assessed skills (average Likert-scale rating prerotation = 2.5 vs. postrotation = 4.2), and SRB (average Likert-scale rating prerotation = 2.3 vs. postrotation = 2.8) based on test scores and trainees' postrotation self-assessments. Learner evaluations of the rotation site visits (15 out of 35, 43%) and video lectures (eight out of 17, 47%) demonstrated overwhelmingly positive reaction.

Discussion

This comprehensive outpatient complex care curriculum addressing seven of 11 nationally recommended topics demonstrated improvement in trainees' knowledge, skills, and behaviors.

Is it too complex? A survey of pediatric residency program's educational approach for the care of children with medical complexity

BACKGROUND

Although Entrustable Professional Activities (EPAs) regarding pediatric training in care for children with medical complexity (CMC) exist, it is unknown what US pediatric training programs provide for education related to care of CMC and whether educators perceive that pediatric residents are prepared to care for CMC upon graduation.

METHODS

From June, 2021 through March 2022, we surveyed US pediatric residency program delegates about practice settings, current educational offerings, perception of resident preparedness regarding care of CMC, and likelihood to implement CMC education in the future.

RESULTS

Response rate was 29% (56 /195). A third of responding programs (34%, n = 19) provide a specific educational CMC offering including combinations of traditional didactics (84%, n = 16), asynchronous modules/reading (63%, n = 12), experiential learning (58%, n = 11), and simulation-based didactics (26%, n = 5). The majority (93%, n = 52) of respondents agreed residents should be competent in providing primary care for CMC upon graduation and CMC should receive primary care from a resident (84%, n = 47). A total of 49% (n = 27) of respondents reported their residents are very or extremely well prepared to care for CMC after graduation. A total of 33% (n = 18) of programs reported CMC receive primary care from residents. Respondent average perception of resident preparedness was significantly higher in programs with educational offerings in five of eleven EPAs (nutrition and weight, transitions, feeding tubes, advocacy, and care coordination). The majority (78%, n = 29) of programs without educational offerings are at least somewhat likely to implement CMC curricula in the next three years.

CONCLUSION

Pediatric residency programs report residents should be competent in care for CMC upon graduation. Pediatric residents are exposed to a wide variety of clinical care models for CMC. The minority of responding programs have intentional CMC educational offerings. Of those programs that provide CMC education, the offerings are variable and are associated with a perception of improved preparedness to care for CMC upon graduation.

Family-Educator Partnership in the Development of Entrustable Professional Activities in Complex Care

PROBLEM

Incorporating patient and family voices in the development of entrustable professional activities (EPAs) is not standard practice. Care of children with medical complexity (CMC) is an area of pediatrics that relies on family partnership, and families of CMC are ideal partners in EPA development given their expertise in their child's care and experience interacting with the health care system. The authors describe their model for partnering with families to develop EPAs and reflect on the unique contributions of family leaders to the process.

APPROACH

After recruitment of family leaders from a national organization of families and friends of children with special health care needs, the authors used a multistage process for EPA development from June 2019 to February 2021. Family leaders were integrated throughout the process, including creating EPA descriptions, revising content across all EPAs, appraising EPAs through virtual focus groups with other key stakeholders, and finalizing and publishing EPAs. The authors used content analysis to identify recommendations for patient- and family-integrated EPA development.

OUTCOMES

Family leaders and educators partnered in every phase of developing EPAs for the care of CMC, including as content experts, editors, focus group facilitators, and coauthors. Family leaders recommended substantive changes to all EPAs, including revising language, augmenting content, and modifying scope of practice. In addition, content analysis of family leaders' revisions yielded 10 recommendations to ensure that written EPA descriptions are patient- and family-centered.

NEXT STEPS

The described process of EPA development for the care of CMC models how families can be integrated into competency framework development and highlights their contributions. Family leader recommendations for embedding patient and family voices in EPA descriptions can serve as a guide for EPA development in other specialties.

Does patient and public involvement influence the development of competency frameworks for the health professions? A systematic review

Competency frameworks typically describe the perceived knowledge, skills, attitudes and other characteristics required for a health professional to practice safely and effectively. Patient and public involvement in the development of competency frameworks is uncommon despite delivery of person-centered care being a defining feature of a competent health professional. This systematic review aimed to determine how patients and the public are involved in the development of competency frameworks for health professions, and whether their involvement influenced the outcome of the competency frameworks. Studies were identified from six electronic databases (MEDLINE, CINAHL, PsycINFO, EMBASE, Web of Science and ERIC). The database search yielded a total of 8,222 citations, and 43 articles were included for data extraction. Most studies were from the United Kingdom (27%) and developed through multidisciplinary collaborations involving two or more professions (40%). There was a large variation in the number of patients and members of the public recruited (range 1–1,398); recruitment sources included patients and carers with the clinical condition of interest (30%) or established consumer representative groups (22%). Common stages for involving patients and the public were in generation of competency statements (57%) or reviewing the draft competency framework (57%). Only ten studies (27%) took a collaborative approach to the engagement of patients and public in competency framework development. The main ways in which involvement influenced the competency framework were validation of health professional-derived competency statements, provision of desirable behaviors and attitudes and generation of additional competency statements. Overall, there was a lack of reporting regarding the details and outcome of patient and public involvement. Further research is required to optimize approaches to patient and public involvement in competency framework development including guidance regarding who, how, when and for what purposes they should be engaged and the requirements for reporting.