Multischool, international survey of medical students' attitudes toward "holism"

Development and validation of traditional & complementary medicine (TCM) scales for nurses: Using structural equation modelling (SEM)

Objectives

This study aimed to develop and validate scales to assess attitudes towards patient’ s use of TCM (APUTCM) and to measure a communicative competence in TCM (CCTCM) among nurses.

Methods

The instrument development process was conducted from Sep 2013 to Jul 2014, using the following steps: 1) item development; 2) internal review and refinement; 3) face and content validation; 4) instrument administration to a development sample; and 5) evaluation of validity and reliability. A convenience sample was used to recruit registered and advanced practice nurses who worked in different regions throughout Taiwan. A total of 755 respondents completed the online questionnaire. Statistical analyses were performed using the software of SPSS Version 21.0 and Analysis of Moment Structures (AMOS) version 24.0.

Results

The scale-level indexes (S-CVI) of content validity for both scales were over 80%. The reliabilities for the 13-item APUTCM scale and for the five-item CCTCM scale were 0.88 and 0.84, respectively. The model suitability for both scales was assessed, and the findings revealed suitable parameters for all indicators: GFI = 0.954, AGFI = 0.932, CFI = 0.959, RMSEA = 0.62, and chi-square/df = 3.891 for APUTCM; and GFI = 0.992, AGFI = 0.969, CFI = 0.992, RMSEA = 0.63, and chi-square/df = 4.04 for CCTCM. The convergent and divergent validity of scores on both scales provided evidence in the expected direction.

Conclusion

This scale development study provides preliminary evidence that suggests that the 13-item APUTCM and the five-item CCTCM are reliable and valid scales for assessing attitudes toward patient’s TCM use and communicative competence in TCM.

'Not another safety culture survey': using the Canadian patient safety climate survey (Can-PSCS) to measure provider perceptions of PSC across health settings

Background

The importance of a strong safety culture for enhancing patient safety has been stated for over a decade in healthcare. However, this complex construct continues to face definitional and measurement challenges. Continuing improvements in the measurement of this construct are necessary for enhancing the utility of patient safety climate surveys (PSCS) in research and in practice. This study examines the revised Canadian PSCS (Can-PSCS) for use across a range of care settings.

Methods

Confirmatory factor analytical approaches are used to extensively test the Can-PSCS. Initial and cross-validation samples include 13 126 and 6324 direct care providers from 119 and 35 health settings across Canada, respectively.

Results

Results support a parsimonious model of direct care provider perceptions of patient safety climate (PSC) with 19 items in six dimensions: (1) organisational leadership support for safety; (2) incident follow-up; (3) supervisory leadership for safety; (4) unit learning culture; (5) enabling open communication I: judgement-free environment; (6) enabling open communication II: job repercussions of error. Results also support the validity of the Can-PSCS across a range of care settings.

Conclusions

The Can-PSCS has several advantages: (1) it is a theory-based instrument with a small number of actionable dimensions central to the construct of PSC; (2) it has robust psychometric properties; (3) it is validated for use across a range of care settings, therefore suitable for use in regionalised health delivery systems and can help to raise expectations about acceptable levels of PSC across the system; (4) it has been tested in a publicly funded universal health insurance system and may be suitable for similar international systems.

The H-PEPSS: an instrument to measure health professionals' perceptions of patient safety competence at entry into practice

BACKGROUND

Enhancing competency in patient safety at entry to practice requires introduction and integration of patient safety into health professional education. As efforts to include patient safety in health professional education increase, it is important to capture new health professionals' perspectives of their own patient safety competence at entry to practice. Existing instruments to measure patient safety knowledge, skills and attitudes have been developed largely to examine the impact of specific patient safety curricular initiatives and the psychometric analyses of the instruments used thus far have been exploratory in nature.

METHODS

Confirmatory factor analytic approaches are used to extensively test the Health Professional Education in Patient Safety Survey (H-PEPSS), a newly designed survey rooted in a patient safety competency framework and designed to measure health professionals' self-reported patient safety competence around the time of entry to practice. The H-PEPSS focuses primarily on the socio-cultural aspects of patient safety including culture, teamwork, communication, managing risk and understanding human factors.

RESULTS

Results support a parsimonious six-factor measurement model of health professionals' perceptions of patient safety competency. These results support the validity of a reduced version of the H-PEPSS and suggest it can be appropriately used at or near training completion with a variety of health professional groups.

CONCLUSIONS

Given increased demands for patient safety competency among health professionals at entry to practice and slow, but emerging changes in health professional education, ongoing research to understand the extent of patient safety competency among health professionals around the time of entry to practice will be important.

Pakistani pharmacy students' perception about complementary and alternative medicine

OBJECTIVES

To assess Pakistani pharmacy students' perceptions of complementary and alternative medicine (CAM), the frequency with which they use CAM, and barriers to use of CAM.

METHOD

A CAM health belief questionnaire was administered to 595 students enrolled in a 5-year doctor of pharmacy program (PharmD) in Pakistan.

RESULTS

Attitudes of students towards CAM were positive. Lack of evidence supporting CAM practices was considered to be the major barrier toward more students using CAM. A majority of students (79%) agreed that clinical care should integrate conventional medicine and CAM practices. Many CAM-based therapies, such as dietary supplements, massage, herbal medicines, and homoeopathic medicines were used by the students. Significant gender differences in attitude were observed, with male students having more conservative attitudes toward CAM use. A high percentage of students desired more training in CAM.

CONCLUSIONS

Pakistani students exhibited positive attitudes about the value of CAM and most felt that CAM should be included in the PharmD curriculum.

Cultural similarities and differences in medical professionalism: a multi-region study

CONTEXT

Over the last two decades, many medical educators have sought to define professionalism. Initial attempts to do so were focused on defining professionalism in a manner that allowed for universal agreement. This quest was later transformed into an effort to 'understand professionalism' as many researchers realised that professionalism is a social construct and is culture-sensitive. The determination of cultural differences in the understanding of professionalism, however, has been subject to very little research, possibly because of the practical difficulties of doing so. In this multi-region study, we illustrate the universal and culture-specific aspects of medical professionalism as it is perceived by medical practitioners.

METHODS

Forty-six professional attributes were identified by reviewing the literature. A total of 584 medical practitioners, representing the UK, Europe, North America and Asia, participated in a survey in which they indicated the importance of each of these attributes. We determined the 'essentialness' of each attribute in different geographic regions using the content validity index, supplemented with kappa statistics.

RESULTS

With acceptable levels of consensus, all regional groups identified 29 attributes as 'essential', thereby indicating the universality of these professional attributes, and six attributes as non-essential. The essentialness of the rest varied by regional group.

CONCLUSIONS

This study has helped to identify regional similarities and dissimilarities in understandings of professionalism, most of which can be explained by cultural differences in line with the theories of cultural dimensions and cultural value. However, certain dissonances among regions may well be attributable to socio-economic factors. Some of the responses appear to be counter-cultural and demonstrate practitioners' keenness to overcome cultural barriers in order to provide better patient care.

Medical Student Attitudes toward Complementary, Alternative and Integrative Medicine

While the use of complementary, alternative and integrative medicine (CAIM) is substantial, it continues to exist at the periphery of allopathic medicine. Understanding the attitudes of medical students toward CAIM will be useful in understanding future integration of CAIM and allopathic medicine. This study was conducted to develop and evaluate an instrument and assess medical students' attitudes toward CAIM. The Complementary, Alternative and Integrative Medicine Attitudes Questionnaire (CAIMAQ) was developed by a panel of experts in CAIM, allopathic medicine, medical education and survey development. A total of 1770 CAIMAQ surveys (51% of US medical schools participated) were obtained in a national sample of medical students in 2007. Factor analysis of the CAIMAQ revealed five distinct attitudinal domains: desirability of CAIM therapies, progressive patient/physician health care roles, mind-body-spirit connection, principles of allostasis and a holistic understanding of disease. The students held the most positive attitude for the "mind-body-spirit connection" and the least positive for the "desirability of CAIM therapies". This study provided initial support for the reliability of the CAIMAQ. The survey results indicated that in general students responded more positively to the principles of CAIM than to CAIM treatment. A higher quality of CAIM-related medical education and expanded research into CAIM therapies would facilitate appropriate integration of CAIM into medical curricula. The most significant limitation of this study is a low response rate, and further work is required to assess more representative populations in order to determine whether the relationships found in this study are generalizable.

Validation of the Korean Integrative Medicine Attitude Questionnaire (IMAQ)

Background

To develop a Korean version of the Integrative Medicine Attitude Questionnaire (IMAQ) in order to evaluate physician attitudes toward integrative medicine/complementary and alternative medicine (CAM).

Methods

We developed a Korean IMAQ through careful translation of the 28-item questionnaire developed by Schmidt et al. A web-based survey was sent via email to 118 primary care physicians in Korea. The complete respose rate wasa 52.5%. The questionnaire's reliability and validity were verified using Cronbach's α, factor analysis, and discriminant analysis.

Results

Although the Korean IMAQ exhibited excellent internal consistency, its validity was insufficient. Our results suggest that Western and Korean physicians may have different understandings of CAM and the concept of holism, as factor analysis showed that incorrectly classified items were mainly part of the holism conceptual domain. Furthermore, the sum of the items within the holism conceptual domain was not significantly different for physicians who had previously received CAM education.

Conclusion

This study developed and tested the first Korean IMAQ. We found that this version of the questionnaire lacks sufficient validity and requires further modification.

Referral to and attitude towards traditional Chinese medicine amongst western medical doctors in postcolonial Hong Kong

Recognizing the international trend for patients to choose both allopathic western medicine (WM) and traditional, complementary and alternative medicine (TCAM), the World Health Organization has called for stronger collaboration between WM doctors (WMD) and TCAM practitioners. This resonates with the situation in Hong Kong where the dominant modality of patient care is primarily based on WM practice while traditional Chinese medicine (TCM) is often used as a complement. The roots of this utilization pattern lie in colonial history when TCM was marginalised during the British administration. However since 1997 when China regained sovereignty, policies to regulate and professionalize TCM practices have been formally introduced. Despite both its popularity and this policy shift, progress on implementing collaboration between WM and TCM clinicians has been slow. This study, the first since 1997, explores current attitudes and referral behaviours of WMD towards use of TCM. We hypothesised that WMD would have positive attitudes towards TCM, due to regulation and cultural affinity, but that few actual TCM referrals would be made given the lack of a formal collaboration policy between elements within the healthcare system. Our results support these hypotheses, and this pattern possibly rooted from structural inhibitions originating from the historical dominance of WM and failure of services to respond to espoused policy. These have shaped Hong Kong's TCAM policy process to be closer with situations in the West, and have clearly differentiated it from integration experiences in other East Asian health systems where recent colonial history is absent. In addition, our results revealed that self use and formal education of TCM, rather than use of evidence in decision making, played a stronger role in determining referral. This implies that effective TCAM policies within WM dominated health systems like Hong Kong would require structural and educational solutions that foster both increased understanding and safe referrals.

Medical students' attitudes to complementary and alternative medicine: further validation of the IMAQ and findings from an international longitudinal study

BACKGROUND

Current research mainly employs cross-sectional designs to examine changes in medical students' attitudes towards complementary and alternative medicine (CAM).

AIMS

This paper reports the findings of a longitudinal study to further validate the Integrative Medicine Attitude Questionnaire (IMAQ) and examine changes in medical students' attitudes over 3 years.

METHODS

A total of 154 medical students from four schools in three countries completed a modified version of the IMAQ during their first (T1) and fourth year (T2).

RESULTS

We established the validity of a three-factor model for the IMAQ: (1) attitudes towards holism; (2) attitudes towards the effectiveness of CAM therapies, and (3) attitudes towards introspection and the doctor-patient relationship. We found that IMAQ factor scores did not differ significantly from T1 to T2, emphasizing the relative stability in attitudes across time. Various student characteristics were significantly associated with IMAQ factor scores at T2: age, gender, CAM use, CAM education and school; and two variables (gender and CAM use) predicted changes in medical students' attitudes between T1 and T2.

CONCLUSIONS

We urge medical educators to continue exploring medical students' attitude changes towards CAM and we provide examples of what further research is needed.

Readiness for self-directed change in professional behaviours: factorial validation of the Self-Reflection and Insight Scale

CONTEXT

Self-reflection, the practice of inspecting and evaluating one's own thoughts, feelings and behaviour, and insight, the ability to understand one's own thoughts, feelings and behaviour, are central to the self-regulation of behaviours. The Self-Reflection and Insight Scale (SRIS) measures three factors in the self-regulation cycle: need for reflection; engagement in reflection, and insight.

METHODS

We used structural equation modelling to undertake a confirmatory factor analysis of the SRIS. We re-specified our model to analyse all of the data to explain relationships between the SRIS, medical student characteristics, and responses to issues of teaching and learning in professionalism.

RESULTS

The factorial validity of a modified SRIS showed all items loading significantly on their expected factors, with a good fit to the data. Each subscale had good internal reliability (> 0.8). There was a strong relationship between the need for reflection and engagement in reflection (r = 0.77). Insight was related to need for reflection (0.22) and age (0.21), but not to the process of engaging in reflection (0.06).

CONCLUSIONS

Validation of the SRIS provides researchers with a new instrument with which to measure and investigate the processes of self-reflection and insight in the context of students' self-regulation of their professionalism. Insight is related to the motive or need for reflection, but the process of reflection does not lead to insight. Attending to feelings is an important and integral aspect of self-reflection and insight. Effective strategies are needed to develop students' insight as they reflect on their professionalism.

Comparative analysis of 1st, 2nd, and 4th year MD students' attitudes toward Complementary Alternative Medicine (CAM)

BACKGROUND

To identify and report the attitudes and beliefs of 1st, 2nd, and 4th year medical students toward complementary alternative medicine (CAM).

METHODS

The previously validated and reliability tested CHBQ was administered to medical students attending the University of South Florida School of Medicine.

RESULTS

Significant changes were found between both 1st (46.0 +/- 7.7) and 4th (37.8 +/- 15.7) year students and 2nd (48.3 +/- 7.8) and 4th (37.8 +/- 15.7) year students. No significant difference was found between 1st (46.0 +/- 7.7) and 2nd (48.3 +/- 7.8) year students. When comparing scores based on gender, a significant difference was present between males (41.2 +/- 12.2) and females (46.1 +/- 11.0).

CONCLUSION

CHBQ scores were significantly more positive in both 1st and 2nd year medical students in comparison with 4th year student's scores. These findings suggest that as student exposure to allopathic techniques and procedures increases during the last year of medical school, their attitudes toward CAM decrease. Females were also significantly more likely to have stronger positive attitudes toward CAM than males, though both genders represented an overall positive attitude toward CAM.

Investigating differential item functioning by chronic diseases in the SF-36 health survey: a latent trait analysis using MIMIC models

OBJECTIVES

Differential item functioning (DIF) is present when respondents of unique subgroups endorse certain items differently given the respondents have the same underlying ability. This study investigates the presence of DIF regarding chronic illnesses among items of the physical functioning (PF) and mental health (MH) domains of the SF-36 health survey.

METHODS

Multiple indicators multiple causes (MIMIC) model was applied to data extracted from the Kaiser Permanente database for members who completed the SF-36 during 1994-1995 (N = 7538). DIF effects were evaluated for sociodemographic variables and for indicators of 5 chronic conditions: hypertension, rheumatic conditions, diabetes, respiratory diseases, and depression. An iterative strategy with backward selection was applied to build DIF models, which were estimated by weighted least squares. The Hochberg procedure was applied to P values for multiple tests.

RESULTS

After controlling for the selected covariates and the latent ability, DIF was present in 3 items for hypertension, one for respiratory diseases, and one for diabetes. Adjusting for DIF did not modify the overall pattern of exogenous variables' effects on PF or MH, except Hispanic and other ethnicity on PF, education on MH became insignificant; and black ethnicity on PF, old ages and other ethnicity on MH became significant.

CONCLUSIONS

Considering the number of items and disease subgroups compared, the presence of DIF was minimal among items of the PF and MH domains of the SF-36. DIF had little effect on comparisons of sociodemographic or disease groups.

Content Validity of the Integrative Medicine Attitude Questionnaire: Perspectives of a Hong Kong Chinese Expert Panel

BACKGROUND

Although the Integrative Medicine Attitude Questionnaire (IMAQ) is a validated instrument developed in the United States for measuring allopathic physicians' attitudes toward complementary and alternative medicine, little is known about attitudes among western-trained doctors in other societies, particularly in the Far East. In Hong Kong, cultural and historical forces have created a unique environment for integration. Thus, consideration of such forces suggests that direct use of the original IMAQ for assessing attitudes of allopathic physicians' views on Traditional Chinese Medicine (TCM) in Hong Kong would be inappropriate. This hypothesis was tested using content validity judgment and local experts' opinions, to assess the three domains of IMAQ: "holism," "introspection and doctor-patient relationship," and "effectiveness of integrative treatment."

METHOD

Standard content validity establishment methodologies were followed. An 8-member panel (4 with TCM and 4 with allopathic medicine backgrounds) was convened to assess the content validity of a modified Hong Kong TCM specific IMAQ. Experts were provided with explicit instructions on how to evaluate the content validity of individual items, and the instrument as a whole, both quantitatively and qualitatively.

RESULT

Of 28 items, 12 items of the modified IMAQ were content validity adequate (Content Validity Index (CVI) > 0.70 and kappa > 0.4). Seven items were considered content invalid and removed. The overall CVI and kappa of the instrument were 0.71 and 0.09, respectively, indicating the need to modify 9 marginally valid items that remained in the questionnaire. Qualitative expert comments were used for the revision.

CONCLUSION

The process of validation showed that it would be inappropriate for the U.S.-derived IMAQ to be used without modification in Hong Kong. Most of the content valid items were in the "effectiveness of integrative treatment" domain, which reflected the influence of the evidence-based TCM movement on the experts' judgment.