A scoping review of the potential for chart stimulated recall as a clinical research method

Looking to "Level the Field": A Qualitative Study of How Clinicians Operationalize Social Determinants in Critical Care

Rationale: Current critical care practice does not integrate social determinants of health (SDOH) in systematic or standardized ways. Routine assessment of SDOH in the intensive care unit (ICU) may improve clinical decision making, patient- and family-centered outcomes, and clinician well-being. Objective: Given that the appropriateness and feasibility of SDOH assessment in the ICU is unknown, we aimed to understand how ICU clinicians think about and use SDOH. Methods: We conducted semistructured interviews with clinicians focused on barriers to and facilitators of assessing SDOH during critical illness and perceptions of screening for SDOH in the ICU. We used chart-stimulated recall to assist clinicians in reflecting on how SDOH applied to and was used in patients' care. After deidentifying interviews, we analyzed transcripts guided by a thematic analysis approach using a combination of inductive and deductive coding, the latter framed within the Centers for Disease Control and Prevention SDOH Healthy People framework. Results: We completed interviews with 30 clinicians in a variety of professional roles. The majority of clinicians self-identified as men (n = 17; 56.7%) of White race (n = 25; 83.3%). Clinicians contextualize their use of SDOH within three frames of reference: 1) their own identity and experiences; 2) their relationships and communication with patients and caregivers; and 3) immediate structures of care around ICU patients, including clinician advocacy, care transitions, and readmission. Clinicians identified that discussing SDOH could allow them to recognize bias faced by their patients, elucidate drivers of critical illness, and navigate communication with patients' caregivers. Clinicians worried about ICU-specific factors impeding the discussion of SDOH, including time constraints and acuity, high stakes and emotions, and negative anticipatory emotions. Conclusions: Clinicians gather SDOH during critical illness both to understand their patients' stories and to provide individualized care, which may lead to better clinician satisfaction and patient- and family-centered care outcomes. Educational and operational efforts to increase SDOH assessment and use in critical care should also gather and integrate the perspectives of patients and caregivers regarding the collection and use of SDOH in the ICU.

Is the Y-PEM useful for me? Perspectives of youth with visual impairment

PURPOSE

To explore how youth with visual impairments perceive the usefulness of the Y-PEM (Youth and Young-adult Participation and Environment Measure) in capturing their participation and how information generated contributes to their understanding of participation experiences.

MATERIALS AND METHODS

A qualitative descriptive design was employed among 11 youth with visual impairment (3 females, 8 males) aged 17-24 (x¯ = 21, SD = 2.6) involving two remote sessions one week apart. First, the Y-PEM and QQ-10 questionnaire were administered to evaluate Y-PEM's utility (value and burden), analyzed descriptively. Then, youth reflected on their Y-PEM results via an individual semi-structured Stimulated Recall Interview (SRI), analyzed thematically.

RESULTS

A mean value-score of 77% (SD = 10.4) and burden-score of 19% (SD = 5.6) on the QQ-10 indicated the Y-PEM was perceived as valuable with relatively low burden. Three themes emerged from the interviews. Insights on participation revealed increased awareness of participation patterns and environmental factors. This led to a reflection on personal attributes about levels of comfort and familiarity, efforts required to participate, and personal preferences influencing participation experiences. Finally, approaches to participation elucidated strategies used in decision-making processes about pursuing participation.

CONCLUSION

Findings suggest the Y-PEM is useful in capturing and promoting reflection of youth's participation patterns and environmental supports/barriers.

Exploring ambulance clinicians' clinical reasoning when training mass casualty incidents using virtual reality: a qualitative study

BACKGROUND

How ambulance clinicians (ACs) handle a mass casualty incident (MCI) is essential for the suffered, but the training and learning for the ACs are sparse and they don't have the possibility to learn without realistic simulation training. In addition, it is unclear what type of dilemmas ACs process in their clinical reasoning during an MCI. With virtual reality (VR) simulation, the ACs clinical reasoning can be explored in a systematic way. Therefore, the objective was to explore ambulance clinicians' clinical reasoning when simulating a mass casualty incident using virtual reality.

METHODS

This study was conducted as an explorative interview study design using chart- stimulated recall technique for data collection. A qualitative content analysis was done, using the clinical reasoning cycle as a deductive matrix. A high-fidelity VR simulation with MCI scenarios was used and participants eligible for inclusion were 11 senior ACs.

RESULTS/CONCLUSION

All phases of the clinical reasoning cycle were found to be reflected upon by the participants during the interviews, however with a varying richness of analytic reflectivity. Non-analytic reasoning predominated when work tasks followed specific clinical guidelines, but analytical reasoning appeared when the guidelines were unclear or non-existent. Using VR simulation led to training and reflection on action in a safe and systematic way and increased self-awareness amongst the ACs regarding their preparedness for MCIs. This study increases knowledge both regarding ACs clinical reasoning in MCIs, and insights regarding the use of VR for simulation training.

Attention in hindsight: Using stimulated recall to capture dynamic fluctuations in attentional engagement

Attentional engagement is known to vary on a moment-to-moment basis. However, few self-report methods can effectively capture dynamic fluctuations in attentional engagement over time. In the current paper, we evaluated the utility of stimulated recall, a method wherein individuals are asked to remember their subjective states while using a mnemonic cue, for the measurement of temporal changes in attentional engagement. Participants were asked to watch a video lecture, during which we assessed their in-the-moment levels of attentional engagement using intermittent thought probes. Then, we used stimulated recall by cueing participants with short video clips from the lecture to retrospectively assess the levels of attentional engagement they had experienced when they first watched those clips within the lecture. Experiment 1 assessed the statistical overlap between in-the-moment and video-stimulated ratings. Experiment 2 assessed the generalizability of video-stimulated recall across different types of lectures. Experiment 3 assessed the impact of presenting video-stimulated probe clips in non-chronological order. Experiment 4 assessed the effect of video-stimulated recall on its own. Across all experiments, we found statistically robust correspondence between in-the-moment and video-stimulated ratings of attentional engagement, illustrating a strong convergence between these two methods of assessment. Taken together, our findings indicate that stimulated recall provides a new and practical methodological approach that can accurately capture dynamic fluctuations in subjective attentional states over time.

A Multimodal Qualitative Approach to Understanding Menstrual Health Equity among Adolescents and Young Adults

STUDY OBJECTIVE

Menstrual inequity-unequal access to menstrual health care or products-negatively affects well-being in relation to the menstrual cycle, a construct known as menstrual health. Few studies have explored menstrual inequities among adolescent and young adult populations in the United States. This multimodal qualitative research aimed to explore factors that influence the lived experience of menstruation among this population.

METHODS

This qualitative study consisted of individual interviews among menstruators ages 13-24, recruited from an urban academic medical center. Participants (N = 20) were a mean age of 19 years; 25% previously endorsed period poverty, and 90% were publicly insured. We conducted semi-structured interviews using participant video diaries in a video elicitation exercise. Data were coded by 2 investigators using thematic analysis driven by grounded theory.

RESULTS

Emergent themes included the need to normalize menstruation, the need for comprehensive menstrual health education, and the need for menstrual products to be more accessible. Twelve youth prepared video diaries, and all reported positive experiences with the video process.

CONCLUSIONS

This youth-centered, multimodal study is one of the first to qualitatively explore the lived experiences of menstruation among adolescents in the United States and identified key inequities in menstrual health from their own perspectives. Thematic findings were mapped onto a proposed framework for menstrual equity that can be applied to future research and efforts around policy change. More research is needed to assess the impacts of these policies.

An exposure-based implementation strategy to decrease clinician anxiety about implementing suicide prevention evidence-based practices: protocol for development and pilot testing (Project CALMER)

BACKGROUND

Clinicians often report that their own anxiety and low self-efficacy inhibit their use of evidence-based suicide prevention practices, including gold-standard screening and brief interventions. Exposure therapy to reduce clinician maladaptive anxiety and bolster self-efficacy use is a compelling but untested approach to improving the implementation of suicide prevention evidence-based practices (EBPs). This project brings together an interdisciplinary team to leverage decades of research on behavior change from exposure theory to design and pilot test an exposure-based implementation strategy (EBIS) to target clinician anxiety to improve suicide prevention EBP implementation.

METHODS

We will develop, iteratively refine, and pilot test an EBIS paired with implementation as usual (IAU; didactic training and consultation) in preparation for a larger study of the effect of this strategy on reducing clinician anxiety, improving self-efficacy, and increasing use of the Columbia Suicide Severity Rating Scale and the Safety Planning Intervention in outpatient mental health settings. Aim 1 of this study is to use participatory design methods to develop and refine the EBIS in collaboration with a stakeholder advisory board. Aim 2 is to iteratively refine the EBIS with up to 15 clinicians in a pilot field test using rapid cycle prototyping. Aim 3 is to test the refined EBIS in a pilot implementation trial. Forty community mental health clinicians will be randomized 1:1 to receive either IAU or IAU + EBIS for 12 weeks. Our primary outcomes are EBIS acceptability and feasibility, measured through questionnaires, interviews, and recruitment and retention statistics. Secondary outcomes are the engagement of target implementation mechanisms (clinician anxiety and self-efficacy related to implementation) and preliminary effectiveness of EBIS on implementation outcomes (adoption and fidelity) assessed via mixed methods (questionnaires, chart-stimulated recall, observer-coded role plays, and interviews).

DISCUSSION

Outcomes from this study will yield insight into the feasibility and utility of directly targeting clinician anxiety and self-efficacy as mechanistic processes informing the implementation of suicide prevention EBPs. Results will inform a fully powered hybrid effectiveness-implementation trial to test EBIS' effect on implementation and patient outcomes.

TRIAL REGISTRATION

Clinical Trials Registration Number: NCT05172609 . Registered on 12/29/2021.

Clinical reasoning in pragmatic trial randomization: a qualitative interview study

BACKGROUND

Pragmatic trials, because they study widely used treatments in settings of routine practice, require intensive participation from clinicians who determine whether patients can be enrolled. Clinicians are often conflicted between their therapeutic obligation to patients and their willingness to enroll them in trials in which treatments are randomly determined and thus potentially suboptimal. Refusal to enroll eligible patients can hinder trial completion and damage generalizability. In order to help evaluate and mitigate clinician refusal, this qualitative study examined how clinicians reason about whether to randomize eligible patients.

METHODS

We performed interviews with 29 anesthesiologists who participated in REGAIN, a multicenter pragmatic randomized trial comparing spinal and general anesthesia in hip fracture. Interviews included a chart-stimulated section in which physicians described their reasoning pertaining to specific eligible patients as well as a general semi-structured section about their views on clinical research. Guided by a constructivist grounded theory approach, we analyzed data via coding, synthesized thematic patterns using focused coding, and developed an explanation using abduction.

RESULTS

Anesthesiologists perceived their main clinical function as preventing peri- and intraoperative complications. In some cases, they used prototype-based reasoning to determine whether patients with contraindications should be randomized; in others, they used probabilistic reasoning. These modes of reasoning involved different types of uncertainty. In contrast, anesthesiologists expressed confidence about anesthetic options when they accepted patients for randomization. Anesthesiologists saw themselves as having a fiduciary responsibility to patients and thus did not hesitate to communicate their inclinations, even when this complicated trial recruitment. Nevertheless, they voiced strong support for clinical research, stating that their involvement was mainly hindered by production pressure and workflow disruptions.

CONCLUSIONS

Our findings suggest that prominent ways of assessing clinician decisions about trial randomization are based on questionable assumptions about clinical reasoning. Close examination of routine clinical practice, attuned to the features of clinical reasoning we reveal here, will help both in evaluating clinicians' enrollment determinations in specific trials and in anticipating and responding to them.

TRIAL REGISTRATION

Regional Versus General Anesthesia for Promoting Independence After Hip Fracture (REGAIN).

CLINICALTRIALS

gov NCT02507505. Prospectively registered on July 24, 2015.

Towards a better understanding of mental health care delivery systems: From stories to system components

The growing demand for better quality of care, together with an increasing awareness of limited resources, is bringing attention to the need for design in healthcare. In mental health, considered the largest single cause of disability in the UK, the need is great. Existing services often fail to meet current levels of demand and do not consistently deliver good quality care for all service users. The design of better delivery systems has the potential to improve service user experience and care outcomes. This paper reports how through the interactive and participatory method of storytelling, the key components of a mental health delivery system were identified. We explain each of the ten components and discuss their implications for system understanding and service design. A model of a mental health delivery system has also been proposed.

Use of Chart-Stimulated Recall to Explore Uncertainty in Medical Decision-Making Among Senior Internal Medicine Residents

BACKGROUND

Uncertainty is common and impacts both patients and clinicians. The approach to uncertainty in medical trainees may be distinct from that of practicing clinicians and has important implications for medical education.

OBJECTIVE

Describe trainee approach to uncertainty with the use of chart-stimulated recall (CSR)-based interviews, as well as the utility of such interviews in promoting reflection about decision-making among senior internal medicine (IM) residents.

DESIGN

Qualitative analysis of CSR-based interviews with IM residents.

PARTICIPANTS

Senior IM residents rotating on inpatient night float at the University of Pittsburgh Medical Center from February to September 2019.

INTERVENTION

Each participant completed one, 20-min CSR session based on a self-selected case in which there was uncertainty in decision-making. Interviews explored the sources of, approaches to, and feelings about uncertainty.

APPROACH

Two independent coders developed a codebook and independently coded all transcripts. Transcripts were then analyzed using thematic analysis.

KEY RESULTS

The perceived acuity of the patient presentation was the main driver of the approach to and stress related to uncertainty. Perceived level of responsibility in resolving uncertainty during the overnight shift also varied among individual participants. Attending expression of uncertainty provided comfort to residents and alleviated stress related to uncertainty. Residents felt comfortable discussing their uncertainty and felt that the opportunity to think aloud during the exercise was valuable.

CONCLUSIONS

Our study demonstrated a novel approach to the exploration of uncertainty in medical decision-making, with the use of CSR. Variations in resident perceived level of responsibility in resolving uncertainty during the overnight shift suggest a need for curriculum development in approach to uncertainty during night shifts. Though residents often experienced stress related to uncertainty, attending expression of uncertainty was an important mitigator of that stress, emphasizing the important role that the trainee-attending interaction plays in the diagnostic process.

Education leads to increased adherence to the 'Australian Competency Standards for Occupational Therapy Driver Assessors'

BACKGROUND

Occupational therapy competency standards provide an evidence-base to inform clinical best practice, however it is not known whether education about competency standards will increase occupational therapists' adherence to their use.

AIMS/OBJECTIVES

To investigate if education about the 'Australian Competency Standards for Occupational Therapy Driver Assessors' leads to increased adherence to the competency standards in the clinical practice of occupational therapy driver assessors.

MATERIALS AND METHODS

A mixed methods multiple case study design was used to evaluate 5 occupational therapy driver assessors' adherence to the competency standards. An audit of 25 client files and interviews were conducted to evaluate practice against the competency standards prior to an education session, followed by an audit of a further 25 files, interview and feedback after education.

RESULTS

Qualitative and quantitative analyses suggest that education about the 'Australian Competency Standards for Occupational Therapy Driver Assessors' was associated with increased adherence to the competency standards in clinical practice. The results also support the use of competency standards in clinical practice.

CONCLUSIONS AND SIGNIFICANCE

Competency standards can be used to inform and guide clinical practice, and individualised education and feedback of practice against the competency standards can increase occupational therapists' adherence to these standards.

Pain assessment from Swedish nurses' perspective

METHODS

This study is a qualitative interview study. The authors used the stimulated recall interview (SRI) with nurses working at a children's hospital in southern Sweden for the data collection. In total twelve nurses were interviewed and qualitative content analysis was used for the data analysis.

RESULTS

The results are presented as one theme: Need for higher competencies and evidence, and three categories: Routines can enable pain assessment, Trusting one's own assessment of the whole picture, and Pain assessment scales as an extra workload. The interviewed nurses acknowledged that pain assessment tools are a vital part of the field of pain treatment. They also had trust issues with measuring and estimating pain by means of a tool such as pain scale. Furthermore, their opinion was that too many different tools and methods add up towards a more blurry and stress-related environment and due to a lack of consistent routines, pain assessment is seen as a work-related burden in the daily routines.

CONCLUSION

Results from the present study indicated that nurses need clear routines in combination with continued education regarding pain assessment with pain scales, which might be the key to successful pediatric pain assessment and thus to better pain management within pediatrics.

GPs' mindlines on deprescribing antihypertensives in older patients with multimorbidity: a qualitative study in English general practice

Background

Optimal management of hypertension in older patients with multimorbidity is a cornerstone of primary care practice. Despite emphasis on personalised approaches to treatment in older patients, there is little guidance on how to achieve medication reduction when GPs are concerned that possible risks outweigh potential benefits of treatment. Mindlines — tacit, internalised guidelines developed over time from multiple sources — may be of particular importance in such situations.

Aim

To explore GPs’ decision-making on deprescribing antihypertensives in patients with multimorbidity aged ≥80 years, drawing on the concept of mindlines.

Design and setting

Qualitative interview study set in English general practice.

Method

Thematic analysis of face-to-face interviews with a sample of 15 GPs from seven practices in the East of England, using a chart-stimulated recall approach to explore approaches to treatment for older patients with multimorbidity with hypertension.

Results

GPs are typically confident making decisions to deprescribe antihypertensive medication in older patients with multimorbidity when prompted by a trigger, such as a fall or adverse drug event. GPs are less confident to attempt deprescribing in response to generalised concerns about polypharmacy, and work hard to make sense of multiple sources (including available evidence, shared experiential knowledge, and non-clinical factors) to guide decision-making.

Conclusion

In the absence of a clear evidence base on when and how to attempt medication reduction in response to concerns about polypharmacy, GPs develop ‘mindlines’ over time through practicebased experience. These tacit approaches to making complex decisions are critical to developing confidence to attempt deprescribing and may be strengthened through reflective practice.

Operational failures and how they influence the work of GPs: a qualitative study in primary care

BACKGROUND

Operational failures, defined as inadequacies or errors in the information, supplies, or equipment needed for patient care, are known to be highly consequential in hospital environments. Despite their likely relevance for GPs' experiences of work, they remain under-explored in primary care.

AIM

To identify operational failures in the primary care work environment and to examine how they influence GPs' work.

DESIGN AND SETTING

Qualitative interview study in the East of England.

METHOD

Semi-structured interviews were conducted with GPs (n = 21). Data analysis was based on the constant comparison method.

RESULTS

GPs reported a large burden of operational failures, many of them related to information transfer with external healthcare providers, practice technology, and organisation of work within practices. Faced with operational failures, GPs undertook 'compensatory labour' to fulfil their duties of coordinating and safeguarding patients' care. Dealing with operational failures imposed significant additional strain in the context of already stretched daily schedules, but this work remained largely invisible. In part, this was because GPs acted to fix problems in the here-and-now rather than referring them to source, and they characteristically did not report operational failures at system level. They also identified challenges in making process improvements at practice level, including medicolegal uncertainties about delegation.

CONCLUSION

Operational failures in primary care matter for GPs and their experience of work. Compensatory labour is burdensome with an unintended consequence of rendering these failures largely invisible. Recognition of the significance of operational failures should stimulate efforts to make the primary care work environment more attractive.

Primary Care Cluster RCT to Increase Diabetes Prevention Program Referrals

INTRODUCTION

The Diabetes Prevention Program, an intensive lifestyle change program, effectively reduces the risk of progression from prediabetes to type 2 diabetes but is underutilized. An implementation study using formative research was undertaken to increase Diabetes Prevention Program referrals at a primary care clinic.

STUDY DESIGN

A pragmatic, cluster randomized, mixed-methods study.

SETTING/PARTICPANTS

Clusters were teams of primary care clinicians from 2 primary care clinics. The 3 intervention clusters had 8-11 clinicians, and the 3 control clusters had 7-20 clinicians.

INTERVENTION

Implementation activities occurred from December 2017 to February 2019. The activities included targeted clinician education, a prediabetes clinician champion, and a custom electronic health record report identifying patients with prediabetes.

MAIN OUTCOME MEASURES

The primary outcome was referral of patients with prediabetes to the institutional Diabetes Prevention Program. Study data, including patient demographic and clinical variables, came from electronic health record. Interviews with clinicians evaluated the implementation strategies. Generalized estimating equation analyses that accounted for multiple levels of correlation and interview content analysis occurred in 2019.

RESULTS

Study clinicians cared for 2,992 patients with a prediabetes diagnosis or HbA1c indicative of prediabetes (5.7%-6.4%). Clinicians in the intervention clusters referred 6.9% (87 of 1,262) of patients with prediabetes to the Diabetes Prevention Program and those in the control clusters referred 1.5% (26 of 1,730). When adjusted for patient age, sex, race, HbA1c value, HbA1c test location, and insurance type, intervention clinicians had 3.85 (95% CI=0.40, 36.78) greater odds of referring a patient with prediabetes to the Diabetes Prevention Program. The 11 interviewed intervention clinicians had mixed opinions about the utility of the interventions, reporting the prediabetes clinic champion (n=7, 64%) and educational presentations (n=6, 55%) as most helpful.

CONCLUSIONS

Intervention clinicians were more likely to make Diabetes Prevention Program referrals; however, the study lacked power to achieve statistical significance. Clinician interviews suggested that intervention components that triggered Diabetes Prevention Program referrals varied among clinicians.

Assessment of Clinician Decision-making on Cancer Screening Cessation in Older Adults With Limited Life Expectancy

IMPORTANCE

Despite clinical practice guidelines recommending against routine cancer screening in older adults with limited life expectancy, older adults are still frequently screened for breast, colorectal, and prostate cancers.

OBJECTIVE

To examine primary care clinicians' decision-making on stopping breast, colorectal, or prostate cancer screening in older adults with limited life expectancy.

DESIGN, SETTING, AND PARTICIPANTS

In qualitative interviews coupled with medical record-stimulated recall, clinicians from 17 academic and community clinics affiliated with a large health system were asked how they came to specific cancer screening decisions in 2 or 3 of their older patients with less than 10-year of estimated life expectancy, including patients with and without recent screening. Patients were surveyed by telephone. Data collection occurred between October 2018 and May 2019.

MAIN OUTCOMES AND MEASURES

Clinician interviews were audio-recorded and transcribed verbatim. Transcripts were analyzed with qualitative content analysis to identify major themes. Patient surveys assessed perception of cancer screening decisions, importance of clinician recommendation, and willingness to stop screening.

RESULTS

Twenty-five primary care clinicians (mean [SD] age, 47.1 [9.7] years; 14 female [56%]) discussed 53 patients during medical record-stimulated recall, ranging from 2 to 3 patients per clinician; 46 patients and 1 caregiver (mean [SD] age 74.9 [5.4]; 31 female [66%]) participated in the survey. Clinician interviews revealed 5 major themes: (1) cancer screening decisions were not always conscious, deliberate decisions; (2) electronic medical record alerts were connected with less deliberate decision-making; (3) cancer screening was not binary and clinicians often considered other options to scale back screening without actually stopping; (4) in addition to patient characteristics, clinicians were influenced by patient request and anecdotal experiences; and (5) influences outside of the primary care clinician-patient dyad were important, such as from specialists and patients' family or friends. Patient surveys asked approximately 64 cancer screening decisions of 47 patients. Patients did not recall approximately half (31 of 64) of their cancer screening decisions. Among those with recent screening, the mean score for willingness to stop screening was 3.2 (95% CI 2.5-3.9) on a 5-point Likert scale (with 1 indicating "extremely unlikely" and 5 indicating "extremely likely"). In most screening decisions that involved specialists (13 of 16), patients valued specialists' recommendations over those of primary care clinicians.

CONCLUSIONS AND RELEVANCE

Cancer screening decision-making is complex. Study findings suggest that strategies that facilitate more deliberate decision-making may be important in cancer screening of older adults with limited life expectancy.

Evaluation of Pharmacy Model in a Trial of Free Essential Medicine Access

Background: In Canada, pharmacists accessing electronic health records (EHR) and mailing medications to patients are relatively uncommon. We evaluated a pharmacy model implemented in a clinical trial that combined allowing the pharmacist access to patients' EHR and mailing medications to participants. Methods: We conducted thematic analysis of comments made by participants and prescribers, and chart stimulated recalls with the pharmacist involved with the novel pharmacy model implemented in a clinical trial. Results: Major themes from participant's comments related to the ease of obtaining information about medications from the pharmacy and satisfaction with the delivery. Prescribers felt that this model facilitated collaboration with the pharmacist and welcomed suggestions regarding therapeutic medication changes. Major themes from the pharmacist's chart stimulated recalls were that access to participants' EHRs allowed for improved drug therapy management and participant experience, and this pharmacy model increased participant's access to pharmacy services. Discussion: According to the pharmacist and prescribers, this pharmacy model facilitated their collaboration in prescribing appropriate medications and participants were generally satisfied with the delivery of medications. Conclusion: Participants and prescribers were generally supportive of a pharmacy model that combined allowing the pharmacist access to participants' EHR and medication mailing. This allowed the pharmacist more opportunities for drug therapy management and collaboration with prescribers. It also improved the participant's access to pharmacy services, although those services were not always fully utilized.

General practitioners' views on malnutrition management and oral nutritional supplementation prescription in the community: A qualitative study

BACKGROUND & AIMS

Malnutrition or undernutrition, arising from a deficiency of energy and protein intake, occurs commonly among community-dwelling individuals in developed countries. Once identified, malnutrition can be effectively treated in the majority of cases with dietary advice and the prescription of oral nutritional supplements (ONS) for patients who can eat and drink orally. However, previous research has reported inadequate screening and treatment of malnutrition in the community. The aim of this qualitative study was to explore general practitioners' (GPs) experiences and opinions on the management of malnutrition and the prescription of ONS in the primary care/community setting in Ireland.

METHODS

Sixteen semi-structured interviews including chart stimulated recalls (CSR) were conducted with GPs. The interviews and CSRs explored, among others, the following domains; barriers and facilitators in the management of malnutrition, ONS prescribing in the primary care/community setting, and future directions in the management of malnutrition and ONS prescribing. Recorded interviews were transcribed and analysed following a generic qualitative approach with inductive thematic analysis using NVIVO 12 to facilitate data management.

RESULTS

Three main themes were identified. Theme 1: 'Malnutrition is a secondary concern', encapsulating the idea that the identification of malnutrition is usually secondary to other clinical issues or disease rather than an independent clinical outcome. This theme also includes the idea that obesity is viewed as a dominant nutritional issue for GPs. Theme 2: 'Responsibility for malnutrition and ONS management in the community', highlighting that GPs feel they do not know who is responsible for the management of malnutrition in the community setting and expressed their need for more support from other healthcare professionals (HCPs) to effectively monitor and treat malnutrition. Theme 3: 'Reluctance to prescribe ONS', emerging from the GPs reported lack of knowledge to prescribe the appropriate ONS, their concern that ONS will replace the patient's meals and the costs associated with the prescription of ONS.

CONCLUSIONS

GPs in Ireland do not routinely screen for malnutrition in their clinics as they feel unsupported in treating and managing malnutrition in the community due to limited or no dietetic service availability and time constraints. GPs also view malnutrition as a secondary concern to disease management and prioritise referral to dietetic services for patients with overweight and obesity. GPs reported that they have insufficient knowledge to change or discontinue ONS prescriptions. This study demonstrates that there is a clear need for primary care training in malnutrition identification, treatment and management and more community dietetic services are needed in order to support GPs and deliver high quality care to patients.

Shifting gears versus sudden stops: qualitative study of consultations about driving in patients with cognitive impairment

OBJECTIVE

General practitioners (GPs) report finding consultations on fitness to drive (FtD) in people with cognitive impairment difficult and potentially damaging to the physician-patient relationship. We aimed to explore GP and patient experiences to understand how the negative impacts associated with FtD consultations may be mitigated.

METHODS

Individual qualitative interviews were conducted with GPs (n=12) and patients/carers (n=6) in Ireland. We recruited a maximum variation sample of GPs using criteria of length of time qualified, practice location and practice size. Patients with cognitive impairment were recruited via driving assessment services and participating general practices. Interviews were audio-recorded, transcribed and analysed thematically by the multidisciplinary research team using an approach informed by the framework method.

RESULTS

The issue of FtD arose in consultations in two ways: introduced by GPs to proactively prepare patients for future driving cessation or by patients who urgently needed a medical report for an expiring driving license. The former strategy, implementable by GPs who had strong relational continuity with their patients, helped prevent crisis consultations from arising. The latter scenario became acrimonious if cognition had not been openly discussed with patients previously and was now potentially impacting on their right to drive. Patients called for greater clarity and empathy for the threat of driving cessation from their GPs.

CONCLUSION

GPs used their longitudinal relationship with cognitively impaired patients to reduce the potential for conflict in consultations on FtD. These efforts could be augmented by explicit discussion of cognitive impairment at an earlier stage for all affected patients. Patients would benefit from greater input into planning driving cessation and acknowledgement from their GPs of the impact this may have on their quality of life.

The Clinical Learning Environment and Workplace-Based Assessment: Frameworks, Strategies, and Implementation

This article provides an overview of the role played by the clinical learning environment in providing opportunities for assessment of trainee performance and how those assessments can guide learning. It reviews the importance of competency models as frameworks to facilitate the creation of a shared mental model of what is to be learned between learners and supervisors. In addition, it discusses how assessment can be used to drive mastery learning as well as the components necessary for a program of assessment.