Change in frontline supervisors' safety leadership practices after participating in a leadership training program: Does company size matter?

INTRODUCTION

The majority of construction companies are small businesses and small business often lack the resources needed to ensure that their supervisors have the safety leadership skills to build and maintain a strong jobsite safety climate. The Foundations for Safety Leadership (FSL) training program was designed to provide frontline leaders in all sized companies with safety leadership skills. This paper examines the impact of the FSL training by size of business.

METHODS

Leaders, defined as foremen or other frontline supervisors, from small, medium, and large construction companies were recruited to participate in a study to evaluate the degree to which the FSL changed their understanding and use of the leadership skills, safety practices and crew reporting of safety-related conditions. We used linear mixed modeling methods to analyze pre-post training survey data.

RESULTS

Prior to the training, leaders from small and medium sized companies reported using safety leadership skills less frequently than those from large ones. After the training, regardless of business size, we observed that the FSL training improved leaders understanding of safety leadership skills from immediately before to immediately after the training. Additionally, leaders reported greater use of safety leadership skills, safety practices, and crew reporting of safety-related conditions from before to two-weeks after the training. However, those from small and medium sized companies reported the greatest improvement in their use of safety leadership skills.

CONCLUSIONS

The FSL training improves safety leadership outcomes regardless of the size company for which the leader worked. However, the FSL may be even more effective at improving the safety leadership skills of leaders working for smaller sized construction companies or those with lower baseline levels of safety leadership skills. Practical applications: The majority of construction companies employ a small number of employees and therefore may not have the resources to provide their frontline leaders with the leadership training they need to be effective leaders who can create a strong jobsite safety climate. The Foundations for Safety Leadership (FSL) training can help fill this gap.

Leadership skills for strengthening jobsite safety climate

INTRODUCTION

Construction foremen may lack the leadership skills needed to create a strong jobsite safety climate. Many construction companies address this by sending their lead workers to the OSHA 30-h course; however the course does not include a leadership training module. This article describes the development and pilot testing of such a module and evaluation surveys designed to address this training gap.

METHODS

A 17-member curriculum development team, numerous subject matter experts, and an instructional design company helped us develop a comprehensive set of teaching resources and a set of survey instruments for evaluating the materials' effectiveness on improving safety leadership and safety climate. All materials and surveys were pilot tested with representative members of the target population.

RESULTS

Pilot surveys showed high reliability and data collected on the resulting Foundations for Safety Leadership (FSL) module indicated that the majority of foremen thought the training was helpful or valuable, particularly the discussion questions. The majority said they intended to use the skills on the jobsite. With the exception of the role-play activities, the trainers rated highly all other components, especially the videos and discussion questions. Modifications were made to the training materials and surveys based on pilot test findings. The most important result of the development and pilot testing efforts is that the OSHA Training Institute (OTI) included the FSL as an elective in the OSHA 30-h course.

CONCLUSIONS

The FSL module fills a needed skills gap by providing safety leadership training to all foremen who might otherwise not have access to it through their company or union. The continued success of the FSL training will be ensured by dissemination via the OSHA 30-h course, an established nationwide safety training program. Practical applications: The FSL training module has already been widely accepted by the construction industry as a useful approach for providing construction foremen/See new abstract lead workers with the knowledge and skills they need to become more effective jobsite safety leaders.

A training intervention to improve frontline construction leaders' safety leadership practices and overall jobsite safety climate

INTRODUCTION

The 2.5 h Foundations for Safety Leadership (FSL) training program teaches construction supervisors the leadership skills they need to strengthen jobsite safety climate and reduce adverse safety-related outcomes.

METHODS

Using a quasi-experimental prospective switching replications study design, we examined (1) if FSL-trained jobsite safety leaders would report improved understanding and practice of the FSL leadership skills, safety practices and crew reporting of safety related conditions, and (2) if their crew perceived a change in (a) their supervisors' practices, (b) their own safety practices and reporting of safety-related conditions, and (c) overall jobsite safety climate. Twenty construction sub-contracting companies were recruited and randomly assigned to either an early or lagged-control training group. Participating supervisors and workers completed surveys at multiple time points before and after the FSL training. We used linear mixed modeling to test changes over time.

RESULTS

Only supervisors in the early group reported a statistically significant improvement in their understanding and practice of the leadership skills as well as safety practices from before to 2- and 4-weeks post-training. Overall, no significant change was detected in crew-reported outcomes from before to after their supervisors' participated in the FSL training.

CONCLUSIONS

These results provide evidence that the FSL training can, at least in the short-term, improve construction frontline leaders' jobsite leadership skills. Future research could include an evaluation of FSL refresher activities and a longer-term follow-up. Practical applications: The Foundations for Safety Leadership (FSL) program fills an identified need for construction frontline supervisors to learn and practice critical safety leadership skills on the jobsite. It has already reached over 60,000 leaders and has the potential to reach over 100,000 each year during either an OSHA 30-h or a stand-alone course.

The Safety Climate Assessment Tool (S-CAT): A rubric-based approach to measuring construction safety climate

INTRODUCTION

This paper presents the development and validation of a new rubric-based Safety Climate Assessment Tool (S-CAT). The S-CAT gives companies the opportunity to use rubric descriptors, rather than traditional Likert scale responses, to self-assess their level of safety climate maturity and receive a composite score benchmarked against others in the S-CAT database.

METHOD

The S-CAT is composed of 37 separate indicators of 8 safety climate factors identified by construction industry subject matter experts. The eight factors have between three and six indicators each with its own rubric-based response-scale. The scales comprise descriptors for five levels of safety climate maturity ranging from "inattentive" to "exemplary." Nine hundred and eighty-five respondents working in the construction industry completed the S-CAT via our online safety climate website. We used company recordable incident rates (RIR) to assess the S-CAT's criterion-related validity.

RESULTS

Cronbach alphas for each factor ranged from 0.77 to 0.90 and a confirmatory factor analysis supported the hypothesized eight factor structure with a higher-order safety climate factor. Seven of the eight factor scores, as well as the overall S-CAT score, were significantly negatively correlated with RIR. Moreover, a relative weights analysis indicated that a weighted combination of the eight safety climate factors explained 27% of the variance in organizational RIR.

CONCLUSIONS

These findings provide evidence that the S-CAT is a reliable tool allowing construction companies to self-assess their safety climate along eight different factors. Moreover, the S-CAT was significantly associated with organizational injury rates. Practical applications: We discuss how companies can use the rubric descriptors to strengthen their safety management systems and improve their safety climate maturity.

Research Methodologies for Total Worker Health®: Proceedings From a Workshop

OBJECTIVE

There is growing interest in the NIOSH Total Worker Health program, specifically in the process of designing and implementing safer, health-promoting work and workplaces. A Total Worker Health (TWH) Research Methodology Workshop was convened to discuss research methods and future needs.

METHODS

Twenty-six experts in occupational safety and health and related fields reviewed and discussed current methodological and measurement issues and those showing promise.

RESULTS

TWH intervention studies face the same challenges as other workplace intervention studies and some unique ones. Examples are provided of different approaches and their applications to TWH intervention studies, and desired developments in the TWH literature.

CONCLUSIONS

This report discusses and outlines principles important to building the TWH intervention research base. Rigorous, valid methodologic, and measurement approaches are needed for TWH intervention as well as for basic/etiologic, translational, and surveillance research.

Defining and Measuring Safety Climate: A Review of the Construction Industry Literature

Safety climate measurements can be used to proactively assess an organization's effectiveness in identifying and remediating work-related hazards, thereby reducing or preventing work-related ill health and injury. This review article focuses on construction-specific articles that developed and/or measured safety climate, assessed safety climate's relationship with other safety and health performance indicators, and/or used safety climate measures to evaluate interventions targeting one or more indicators of safety climate. Fifty-six articles met our inclusion criteria, 80% of which were published after 2008. Our findings demonstrate that researchers commonly defined safety climate as perception based, but the object of those perceptions varies widely. Within the wide range of indicators used to measure safety climate, safety policies, procedures, and practices were the most common, followed by general management commitment to safety. The most frequently used indicators should and do reflect that the prevention of work-related ill health and injury depends on both organizational and employee actions. Safety climate scores were commonly compared between groups (e.g. management and workers, different trades), and often correlated with subjective measures of safety behavior rather than measures of ill health or objective safety and health outcomes. Despite the observed limitations of current research, safety climate has been promised as a useful feature of research and practice activities to prevent work-related ill health and injury. Safety climate survey data can reveal gaps between management and employee perceptions, or between espoused and enacted policies, and trigger communication and action to narrow those gaps. The validation of safety climate with safety and health performance data offers the potential for using safety climate measures as a leading indicator of performance. We discuss these findings in relation to the related concept of safety culture and offer suggestions for future research and practice including (i) deriving a common definition of safety climate, (ii) developing and testing construction-specific indicators of safety climate, and (iii) focusing on construction-specific issues such as the transient workforce, subcontracting, work organization, and induction/acculturation processes.

If you've seen one construction worksite stretch and flex program … you've seen one construction worksite stretch and flex program

BACKGROUND

Work-related Musculoskeletal Disorders (WMSD) account for approximately one-third of all injuries in the U.S. construction industry. Many companies have implemented stretch and flex (s/f) programs to reduce WMSD despite a lack of evidence showing effectiveness.

METHODS

We conducted a mixed-methods study to understand (a) why employers continue devoting resources to s/f programs; (b) how programs vary; and (c) any actual or perceived benefits.

RESULTS

Nineteen safety and health professionals were interviewed and 133 more (13.3% response rate) completed an on-line survey. Fifty-six percent had implemented an s/f program with the primary goal of reducing WMSDs; though most did not review data to determine goal achievement. Program structure varied in terms of duration, frequency, and type of stretches. There was strong agreement about mandating attendance but not participation, due primarily to liability issues. Cost was a factor when deciding to implement a program but not for sustaining one. The majority had not implemented other ergonomic prevention activities, but many had started conducting daily safety huddles for task and safety planning. Those reporting a reduction in WMSDs agreed that it was not due to the s/f program alone and that other benefits included increased worker camaraderie, communication, and collaboration.

CONCLUSION

Although there is little to no scientific evidence showing that they work as intended, construction companies continue to implement s/f programs with the goal of reducing WMSDs. Bringing work crews together for s/f activities has prompted employers to also begin conducting daily safety huddles. Although employers may not be able to link reduced WMDS to an s/f program, the ancillary benefits may warrant the time and resources.

PRACTICAL APPLICATIONS

S/f programs should be only one component of a more comprehensive ergonomics prevention program. Conducting daily safety huddles at the same time also may enhance worker communication, camaraderie, collaboration and improve safety outcomes.

Using goal-directed design to create a novel system for improving chronic illness care

BACKGROUND

A learning health system enables patients, clinicians, and researchers to work together to choose care based on the best evidence, drive discovery as a natural outgrowth of patient care, and ensure innovation, quality, safety, and value in health care; all in a more real-time fashion.

OBJECTIVE

Our paper describes how goal-directed design (GDD) methods were employed to understand the context and goals of potential participants in such a system as part of a design process to translate the concept of a learning health system into a prototype collaborative chronic care network (C3N), specifically for pediatric inflammatory bowel disease.

METHODS

Thirty-six one-on-one in-depth interviews and observations were conducted with patients (10/36, 28%), caregivers (10/36, 28%), physicians/researchers (10/36, 28%), and nurses (6/36, 17%) from a pediatric gastroenterology center participating in the ImproveCareNow network. GDD methods were used to determine the context and goals of participants. These same methods were used in conjunction with idealized design process techniques to help determine characteristics of a learning health system for this pediatric health care ecology. Research was conducted in a clinic and, in the case of some patients and caregivers, at home.

RESULTS

Thematic analysis revealed 3 parent-child dyad personas (ie, representations of interviewees' behavior patterns, goals, skills, attitudes, and contextual information) that represented adaptation to a chronic illness over time. These were used as part of a design process to generate scenarios (potential interactions between personas and the learning health system under design) from which system requirements were derived. These scenarios in turn helped guide generation, prioritization, design, measurement, and implementation of approximately 100 prototype interventions consistent with the aim of C3N becoming a learning health network.

CONCLUSIONS

GDD methods help ensure human goals and contexts inform the design of a network of health care interventions which reflect the shape and purpose of a C3N in pediatric chronic illness care. Developing online and in-person interventions according to well-documented context and motivations of participants increases the likelihood that a C3N will enable all participants to act in ways that achieve their goals with grace and dignity. GDD methods complemented quality-improvement methods to generate prototypes consistent with clinical and research aims, as well as the goals of patient disease management.

A qualitative study examining the influences on situation awareness and the identification, mitigation and escalation of recognised patient risk

BACKGROUND

Situation awareness (SA)-the perception of data elements, comprehension of their meaning and projection of their status in the near future-has been associated with human performance in high-risk environments, including aviation and the operating room. The influences on SA in inpatient medicine are unknown.

METHODS

We conducted seven focus groups with nurses, respiratory therapists and resident physicians using a standardised semistructured focus group guide to promote discussion. Recordings of the focus groups were transcribed verbatim, and transcripts were qualitatively analysed by two independent reviewers to identify convergent and divergent themes.

RESULTS

Three themes emerged: (1) team-based care, (2) availability of standardised data and (3) standardised processes and procedures. We categorised these into social, technological and organisational influences on SA. Subthemes that emerged from each focus group were shared language to describe at-risk patients, provider experience in critical care/deterioration and interdisciplinary huddles to identify and plan for at-risk patients. An objective early warning score, proactive assessment and planning, adequate clinician staffing and tools for entering, displaying and monitoring data trends were identified by six of seven groups. Our data better reflected the concepts of team SA and shared SA than individual SA.

CONCLUSIONS

Team-based care and standardisation support SA and the identification and treatment of patient risk in the complex environment of inpatient care. These findings can be used to guide the development and implementation of targeted interventions such as huddles to proactively scan for risk and electronic health record displays of data trends.

Transitioning from a computerized provider order entry and paper documentation system to an electronic health record: expectations and experiences of hospital staff

OBJECTIVES

To examine healthcare worker's perceptions, expectations, and experiences regarding how work processes, patient-related safety, and care were affected when a quaternary care center transitioned from one computerized provider order entry (CPOE) system to a full electronic health record (EHR).

METHODS

The I-SEE survey was administered prior to and 1-year after transition in systems. The construct validity and reliability of the survey was assessed within the current population and also compared to previously published results. Pre- and 1-year post-implementation scale means were compared within and across time periods.

RESULTS

The majority of respondents were nurses and personnel working in the acute care setting. Because a confirmatory factor analysis indicated a lack of fit of our data to the I-SEE survey's 5-factor structure, we conducted an exploratory factor analysis that resulted in a 7-factor structure which showed better reliability and validity. Mean scores for each factor indicated that attitudes and expectations were mostly positive and score trends over time were positive or neutral. Nurses generally had less positive attitudes about the transition than non-nursing respondents, although the difference diminished after implementation.

CONCLUSIONS

Findings demonstrate that the majority of responding staff were generally positive about transitioning from CPOE system to a full electronic health record (EHR) and understood the goals of doing so, with overall improved ratings over time. In addition, the I-SEE survey, when modified based on our population, was useful for assessing patient care and safety related expectations and experiences during the transition from one CPOE system to an EHR.

Huddling for high reliability and situation awareness

BACKGROUND

Studies show that implementing huddles in healthcare can improve a variety of outcomes. Yet little is known about the mechanisms through which huddles exert their effects. To help remedy this gap, our study objectives were to explore hospital administrator and frontline staff perspectives on the benefits and challenges of implementing a tiered huddle system; and propose a model based on our findings depicting the mediating pathways through which implementing a huddle system may reduce patient harm.

METHODS

Using qualitative methods, we conducted semi-structured interviews and focus groups to obtain a deeper understanding of the huddle system and its outcomes as implemented in an academic tertiary care children's hospital with 539 inpatient beds. We recruited healthcare providers representing all levels using a snowball sampling technique (10 interviews), and emails, flyers, and paper invitations (six focus groups). We transcribed recordings and analysed the data using established techniques.

RESULTS

Five themes emerged and provided the foundational constructs of our model. Specifically we propose that huddle implementation leads to improved efficiencies and quality of information sharing, increased levels of accountability, empowerment, and sense of community, which together create a culture of collaboration and collegiality that increases the staff's quality of collective awareness and enhanced capacity for eliminating patient harm.

CONCLUSIONS

While each construct in the proposed model is itself a beneficial outcome of implementing huddles, conceptualising the pathways by which they may work allows us to design ways to evaluate other huddle implementation efforts designed to help reduce failures and eliminate patient harm.

An International Health Track Is Associated With Care for Underserved US Populations in Subsequent Clinical Practice

BACKGROUND

Recent efforts to increase insurance coverage have revealed limits in primary care capacity, in part due to physician maldistribution. Of interest to policymakers and educators is the impact of nontraditional curricula, including global health education, on eventual physician location. We sought to measure the association between graduate medical education in global health and subsequent care of the underserved in the United States.

METHODS

In 2005, we surveyed 137 graduates of a family medicine program with one of the country's longest-running international health tracks (IHTs). We compared graduates of the IHT, those in the traditional residency track, and graduates prior to IHT implementation, assessing the anticipated and actual involvement in care of rural and other underserved populations, physician characteristics, and practice location and practice population.

RESULTS

IHT participants were more likely to practice abroad and care for the underserved in the United States in the first 5 years following residency than non-IHT peers. Their current practices were more likely to be in underserved settings and they had higher percentages of uninsured and non-English-speaking patients. Comparisons between pre-IHT and post-IHT inception showed that in the first 5 years following residency, post-IHT graduates were more likely to care for the underserved and practice in rural areas and were likely to offer volunteer community health care services but were not more likely to practice abroad or to be in an academic practice.

CONCLUSIONS

Presence of an IHT was associated with increased care of underserved populations. After the institution of an IHT track, this association was seen among IHT participants and nonparticipants and was not associated with increased long-term service abroad.

Critical care education during internal medicine residency: a national survey

BACKGROUND

Current training practices and teaching methods for critical care medicine education during internal medicine residency have not been well described. This study explored critical care medicine education practices and environments for internal medicine residents in the United States.

METHODS

A web-based survey recruited Pulmonary and Critical Care Medicine fellowship program directors involved with internal medicine residency programs at academic institutions in the United States.

RESULTS

Of 127 accredited Pulmonary and Critical Care Medicine programs in 2007, 63 (50%) responded. Demographics of the intensive care units varied widely in size (7-52 beds), monthly admissions (25-300 patients), and presence of a "night float" (22%) or an admissions "cap" (34%). All programs used bedside teaching, and the majority used informal sessions (91%) or didactic lectures (75%). More time was spent on resident teaching in larger (≥20 bed) medical intensive care units, on weekdays, in programs with a night-float system, and in programs that suspended residents' primary care clinic duties during their intensive care unit rotation.

CONCLUSIONS

Although similar teaching methods were used within a wide range of training environments, there is no standardized approach to critical care medicine education for internal medicine residents. Some survey responses indicated a correlation with additional teaching time.

Reflective practice and competencies in global health training: lesson for serving diverse patient populations

BACKGROUND

Resident interest in global health care training is growing and has been shown to have a positive effect on participants' clinical skills and cultural competency. In addition, it is associated with career choices in primary care, public health, and in the service of underserved populations. The purpose of this study was to explore, through reflective practice, how participation in a formal global health training program influences pediatric residents' perspectives when caring for diverse patient populations.

METHODS

Thirteen pediatric and combined-program residents enrolled in a year-long Global Health Scholars Program at Cincinnati Children's Hospital Medical Center during the 2007-2008 academic year. Educational interventions included a written curriculum, a lecture series, one-on-one mentoring sessions, an experience abroad, and reflective journaling assignments. The American Society for Tropical Medicine and Hygiene global health competencies were used as an a priori coding framework to qualitatively analyze the reflective journal entries of the residents.

RESULTS

Four themes emerged from the coded journal passages from all 13 residents: (1) the burden of global disease, as a heightened awareness of the diseases that affect humans worldwide; (2) immigrant/underserved health, reflected in a desire to apply lessons learned abroad at home to provide more culturally effective care to immigrant patients in the United States; (3) parenting, or observed parental, longing to assure that their children receive health care; and (4) humanitarianism, expressed as the desire to volunteer in future humanitarian health efforts in the United States and abroad.

CONCLUSIONS

Our findings suggest that participating in a global health training program helped residents begin to acquire competence in the American Society for Tropical Medicine and Hygiene competency domains. Such training also may strengthen residents' acquisition of professional skills, including the Accreditation Council for Graduate Medical Education competencies.

Characteristics of discussions on cardiopulmonary resuscitation between physicians and surrogates of critically ill patients

PURPOSE

In the intensive care unit (ICU), critically ill patients are often unable to participate in discussions about cardiopulmonary resuscitation (CPR), and decisions on CPR are often made by surrogate decision makers. The objective of this study is to determine the prevalence, content, and perceptions of CPR discussions between critically ill patients' surrogates and ICU physicians and their effect on resuscitation decisions.

MATERIALS AND METHODS

Eligible patients' surrogates were interviewed using a structured questionnaire more than 24 hours after admission to the medical ICUs at 2 university-affiliated medical centers. Data from surrogates who did and did not participate in a CPR discussion were compared and correlated with patient characteristics and outcomes.

RESULTS

Of 84 surrogates interviewed, 54% participated in more than 1 CPR discussion. Although most (73%) recalled discussing endotracheal intubation, 49% and 44% recalled discussing chest compressions or electrical cardioversion, respectively, and 68% to 84% stated they understood these components. Mortality was higher in the discussion group compared to the no-discussion group (37% vs. 8%; P < .05), although changes in CPR decisions were similar in both groups (25% vs 18%, P = .5).

CONCLUSIONS

Only half of critically ill patients' surrogates participated in CPR discussions. For those who did participate, most reported good understanding of resuscitation techniques, but less than half recalled the core components of CPR.

Intervention effectiveness evaluation criteria: promoting competitions and raising the bar

The Intervention Evaluation Competition at the Work, Stress, and Health conference in Miami (March 2006) highlighted the importance of intervention evaluation studies that promote safety and health at work. A retitled, "Best Practices Evaluation Competition," has been included in the March, 2008, Work, Stress, and Health conference, in Washington, DC. This brief note describes the development of the criteria used to evaluate the manuscripts. The criteria are discussed with respect to (a) improving the science of evaluation methodology, (b) promoting the highest ethical standards in intervention evaluation, and (c) using the current criteria as a starting point for continuing to raise the bar for evaluation methodology. The policy implications of the evaluation criteria are discussed as well.

The effect of offering international health training opportunities on family medicine residency recruiting

BACKGROUND AND OBJECTIVES

While medical students' interest in family medicine declines, and residency programs face recruiting challenges, interest in international health is increasing. We studied the influence of offering an international health track (IHT) on residency recruitment.

METHODS

We surveyed all graduates between the years 1994--2003 of a family medicine residency program offering an optional IHT (n=90). Descriptive and bivariate analyses characterized and compared the geographic scope and residency selection criteria of IHT participants and nonparticipants.

RESULTS

The response rate was 77%. Compared to nonparticipants in the IHT, residents who participated in the IHT reported coming a significantly greater median distance from their medical school training site (250--499 miles versus 0--99) and from their "home" (500--999 miles versus 100--249) for residency training. Participants reported that the factor most positively influencing their choice of this residency training site over others was the IHT (mean=+2.5, standard deviation [SD]=0.90), outscoring, on average, location, faculty quality, resident quality, and spousal preference. Nonparticipants' choices were influenced most by the traditionally reported selection factors location (mean=+2.37, SD=1.14) and faculty quality (mean=+2.29, SD=0.97).

CONCLUSIONS

One program's experience suggests that the presence of international health training opportunities may influence the residency selection choices of family medicine residents. As family medicine moves to reinvent residency education and to recapture student interest, attractive training models that integrate clinical, community, and public health should be evaluated further.

Ready or not, here they come: acting interns' experience and perceived competency performing basic medical procedures

OBJECTIVE

To assess acting interns' (AI's) experience with and perceived level of competency performing 6 basic medical procedures.

DESIGN

Fourth-year medical students at the University of Cincinnati (UCCOM) are required to complete 2 AI rotations in Internal Medicine. All AIs in 2003-2004 (n = 150) and 2004-2005 (n = 151) were asked to complete a survey about whether during each of their rotations they had performed and felt competent performing the following procedures: phlebotomy, intravenous (IV) catheter insertion, arterial blood gas (ABG), nasogastric (NG) tube insertion, lumbar puncture (LP), and Foley catheter insertion.

RESULTS

Four hundred sixty-seven of 601 possible surveys (across both years and both rotations) were completed (78% response rate). During both rotations, relatively few students performed the procedures, ranging from 9% for Foley catheter insertion (24/208) to 50% for both ABG and NG tube insertion (130/259). The two procedures most often performed were ABG (range 46-50%) and NG tube insertion (range 42-50%). Feelings of competency varied from 12% (LP) to 82% (Foley catheter). Except for LP, if students performed a procedure at least once, they reported feeling more competent (range 85% for ABG to 96% for Foley catheter insertion). Among the students who performed LP during a rotation, many still did not feel competent performing LPs: 23 (74%) in rotation 1 and 20 (40%) in rotation 2.

CONCLUSION

Many fourth-year students at UCCOM do not perform basic procedures during their acting internship rotations. Procedural performance correlates with feelings of competency. Lumbar puncture competency may be too ambitious a goal for medical students.

Utilization of a formative evaluation card in a psychiatry clerkship

OBJECTIVE

This article discusses how formative feedback to medical students during their clinical rotations facilitates their successfully meeting the rotation's educational objectives. To help students initiate mid-rotation feedback and to help preceptors structure that feedback, the authors designed the Instant Feedback Card (IFc). The goal of this study was to examine the degree to which the IFc facilitated the formative feedback process from the perspectives of both students and faculty.

METHOD

The IFc contains a checklist of the 13 clinical competencies that are also used to provide summative evaluations to students. One hundred and sixty-five medical students completing a 6-week psychiatry clerkship between January and December 2004 were given an IFc to present to their inpatient preceptor at one of their two inpatient sites. At the end of each 3-week inpatient rotation, all students were e-mailed a brief questionnaire about the formative feedback received during the preceding rotation. At the end of the 12-month study period, faculty were e-mailed a brief questionnaire about how useful the IFc was in helping to facilitate the feedback process.

RESULTS

One hundred thirty-eight students (80%) participated in the study and returned 267 questionnaires (1.9/student, 97% response rate). Two hundred five students indicated on 77% of the questionnaires returned that they received mid-rotation feedback and of those, 84% revealed that feedback was helpful. Eighty-five percent of the students received mid-rotation feedback when they used the IFc and only 69% received mid-rotation feedback without the IFc. A majority of the 14 faculty serving as inpatient preceptors during the study period found the cards useful for stimulating feedback discussions, for reducing the stress of providing feedback, and for getting students to request feedback.

CONCLUSIONS

The results of this pilot study are not definitive, but they do indicate that the Instant Feedback card (IFc) did facilitate the process and structure of providing and receiving formative feedback as indicated by a significantly greater number of students receiving formative feedback when they used the IFc.

Effectiveness of a Geriatric Medical Student Scholars Program: A Qualitative Assessment

In 2003, the University of Cincinnati College of Medicine initiated a 4-year Geriatric Medical Student Scholars (GMSS) program in which a selected group of 14 medical students participated in a variety of extracurricular geriatrics-related activities such as one-on-one mentoring and discussion groups. These students were also required to compose journal entries describing GMSS program-related activities using a semistructured on-line computer program designed specifically for this purpose. The reflective journals, in combination with the American Geriatrics Society (AGS) competencies, were used to evaluate the degree to which the GMSS program achieved its goal of enhancing students' understanding of the complex health and social challenges facing older adults. Using a confirmatory qualitative analysis strategy, the AGS competencies served as an a priori codebook to evaluate the student journal entries. Of the original 53 AGS competencies identified as being relevant for a first- or second-year medical student, 74% were used at least one time, and only 26% were never used. These findings strongly suggest that the GMSS program successfully moved this group of first- and second-year medical students closer to at least understanding the content of many of the AGS competencies by providing them with geriatrics-related experiences and a geriatrics-related framework they could draw on when participating in curricular and extracurricular activities. The findings also point to the potential value of using reflective journaling as a tool for conducting process evaluation of medical education interventions.

Preferences regarding the computerized delivery of lecture content:a survey of medical students

Available technology allows for the capture and rebroadcast of lectures via computer-based tools. Such tools have the potential to enhance medical education. Medical schools are beginning to offer such services, but little is known about end-user preferences. We surveyed students at one US medical school to gather their preferences for the availability and use of computer-based lecture presentation. These findings add to the limited literature regarding use of such tools for medical education.

Professionalism deficits among medical students: models of identification and intervention

OBJECTIVE

This study compares the instruments and interventions utilized to identify and remediate unprofessional behaviors in medical students across U.S. psychiatry clerkships.

METHODS

A 20-item questionnaire was distributed to 120 psychiatry clerkship directors and directors of medical student education, in the U.S., inquiring into the procedures utilized for identifying, monitoring, and remediating unprofessional behaviors among medical students during their psychiatry clerkship.

RESULTS

Fifty seven (47.5%) clerkship directors responded to the questionnaire. Professionalism is evaluated by 96% of the clerkships with the most frequent goals being to provide feedback to students and to specifically identify problematic behaviors. Seventy percent of the clerkships identify one to three students per year with unprofessional behaviors that warrant intervention. The majority (86%) of the respondents note that unprofessional behaviors may impede the advancement of students during their medical education. A recommendation for a mental health evaluation occurs in at least 76% of cases. Dismissal from medical school for unprofessional behaviors is most likely recommended based on the severity and/or repetitiveness of the acts.

CONCLUSIONS

There is concordance among clerkship directors regarding the importance of identifying unprofessional behaviors among medical students although there exists a range of modalities for monitoring, remediating, and disciplining such behaviors.

Practice patterns of physician members of the American Urogynecologic Society regarding female sexual dysfunction: results of a national survey

The purpose of the study was to evaluate practice patterns of members of the American Urogynecologic Society (AUGS) with respect to female sexual dysfunction (FSD). A brief self-administered survey of 20 questions was mailed to 966 physician members of the AUGS in the United States of America and Canada; 471 surveys were returned (49% response rate). The majority of responders see urogynecology (19%) or urogynecology and general gynecology patients (43%). Sixty-eight percent of physicians were familiar with questionnaires to assess FSD; however, only 13% said they use these for screening purposes. Most said they believed screening for FSD was somewhat (47%) or very important (42%). Despite having these beliefs, only 22% of the responding physicians stated they always screen for FSD, while 55% do so most of the time and 23% admitted they never or rarely screen. Similar results were obtained regarding screening following urogynecologic surgery. Several barriers to screening for FSD existed, the most common being lack of time. The majority of respondents (69%) underestimated the prevalence of FSD in their patient population. Finally, although more than half of responders had received post-residency training in urogynecology (59%), 50% of them stated the training with respect to FSD was unsatisfactory, while only 10% were satisfied. Overall, many urogynecologists do not consistently screen for FSD, underestimate its prevalence, and feel they received unsatisfactory training.

The Ophthalmic Clinical Evaluation Exercise (OCEX)

PURPOSE

New concise tools must be developed to assess reliably and validly the core residency competencies identified by the Accreditation Council for Graduate Medical Education.

PARTICIPANTS

Eighteen content experts (residency program directors).

METHODS

A 1-page Ophthalmic Clinical Exercise Examination (OCEX) checklist, for use during observed resident-patient interactions, was developed by an American Board of Ophthalmology taskforce. The OCEX checklist was sent to 18 content experts for their review and constructive comments.

RESULTS

Experts' comments were incorporated, establishing face and content validity.

CONCLUSIONS

The OCEX has face and content validity. It can be used to assess a resident's patient care skills, medical knowledge, and interpersonal skills. Reliability and predictive validity still need to be determined.

A national survey on the current status of general internal medicine residency education in geriatric medicine

OBJECTIVES

The dramatic increase in the U.S. elderly population expected over the coming decades will place a heavy strain on the current health care system. General internal medicine (GIM) residents need to be prepared to take care of this population. In this study, we document the current and future trends in geriatric education in GIM residency programs.

DESIGN, SETTING, PARTICIPANTS

An original survey was mailed to all the GIM residency directors in the United States (N = 390).

RESULTS

A 53% response rate was achieved (n = 206). Ninety-three percent of GIM residencies had a required geriatrics curriculum. Seventy one percent of the programs required 13 to 36 half days of geriatric medicine clinical training during the 3-year residency, and 29% required 12 half days or less of clinical training. Nursing homes, outpatient geriatric assessment centers, and nongeriatric ambulatory settings were the predominant training sites for geriatrics in GIM. Training was most often offered in a block format. The average number of physician faculty available to teach geriatrics was 6.4 per program (2.8 full-time equivalents). Conflicting time demands with other curricula was ranked as the most significant barrier to geriatric education.

CONCLUSIONS

A required geriatric medicine curriculum is now included in most GIM residency programs. Variability in the amount of time devoted to geriatrics exists across GIM residencies. Residents in some programs spend very little time in specific, required geriatric medicine clinical experiences. The results of this survey can guide the development of future curricular content and structure. Emphasizing geriatrics in GIM residencies helps ensure that these residents are equipped to care for the expanding aging population.

Geriatric medicine fellowship programs: a national study from the Association of Directors of Geriatric Academic Programs' Longitudinal Study of Training and Practice in Geriatric Medicine

This report documents the development and growth of geriatric medicine fellowship training in the United States through 2002. A cross-sectional survey of geriatric medicine fellowship programs was conducted in the fall 2001. All allopathic (119) and osteopathic (7) accredited geriatric medicine fellowship-training programs in the United States were involved. Data were collected using self-administered mailed and Web-based survey instruments. Longitudinal data from the American Medical Association (AMA) and the Association of American Medical Colleges' (AAMC) National Graduate Medical Education (GME) Census, the Accreditation Council for Graduate Medical Education (ACGME), and the American Osteopathic Association (AOA) were also analyzed. The survey instrument was designed to gather data about faculty, fellows, program curricula, and program directors (PDs). In addition, annual AMA/AAMC data from 1991 to the present was compiled to examine trends in the number of fellowship programs and the number of fellows. The overall survey response rate was 76% (96 of 126 PDs). Most (54%) of the PDs had been in their current position 4 or more years (range: <1-20 years), and 59% of PDs reported that they had completed formal geriatric medicine fellowship training. The number of fellowship programs and the number of fellows entering programs has slowly increased over the past decade. During 2001-02, 338 fellows were training in allopathic programs and seven in osteopathic programs (all years of training). Forty-six percent (n = 44) of responding programs offered only 1-year fellowship-training experiences. PDs reported that application rates for fellowship positions were stable during the academic years (AYs) 1999-2002, with the median number of applications per first year position available in AY 2000-01 being 10 (range: 1-77). In 2001-02, data from the AMA/AAMC National GME Census indicated a fill rate for first-year geriatric medicine fellowship positions of 69% (259 first-year fellows for 373 positions). During 2001-02, more than half of programs (53%) reported having two or fewer first-year fellows, whereas 31% had three or four first-year fellows. Thirty-three programs (36%) reported having no U.S. medical school graduate first-year fellows, and another 25 (28%) reported having only one. Of the 51 programs offering second-year fellowship training, PDs reported 61 post-first-year fellows (median 1, range: 0-7). During the past 10 years, 27 new allopathic geriatric medicine fellowship programs opened; there are now 119 programs. There are also seven osteopathic programs. The recruitment of high-quality U.S. medical school graduates into these programs remains a challenge for the discipline. Furthermore, the retention of first-year fellows for additional years of academic training has been difficult. Incentives will be needed to attract the best graduates of U.S. family practice and internal medicine training programs into academic careers in geriatric medicine.

Geriatric psychiatry fellowship programs in the United States: findings from the Association of Directors of Geriatric Academic Programs' longitudinal study of training and practice

OBJECTIVE

The authors document the development and growth of geriatric psychiatry fellowship training in the United States (U.S.) through 2002.

METHODS

A cross-sectional survey of the 62 U.S. geriatric psychiatry fellowship programs was conducted in Fall 2001. They also analyzed longitudinal data from the American Medical Association (AMA) and the Association of American Medical Colleges' (AAMC) National Graduate Medical Education (GME) Census, along with data from the Accreditation Council for Graduate Medical Education (ACGME).

RESULTS

Forty-six (74%) of 62 training directors (TDs) responded. The number of fellowship programs has slowly increased over the past 7 years. During 2001-2002, a total of 94 fellows were in training (all years of training). Seventy-eight percent (N=36) of responding programs offered only 1-year fellowship training experiences. TDs reported that application rates for fellowship positions were stable during the academic years 1999-2002, with a median number of eight applications per program for first-year positions in 2001-2002. The fill-rate for first-year geriatric psychiatry fellowship positions dropped from 84% in 1999-2000 to 61% in 2001-2002. During 2001-2002, 73% of programs reported having two or fewer first-year fellows, and 16% had no first-year fellows. Seventeen programs reported having no U.S. medical school graduates (USMGs) as first-year fellows.

CONCLUSION

Recruiting high-quality USMGs into geriatric psychiatry fellowship programs remains a challenge. Furthermore, retaining first-year fellows for additional years of academic training has been difficult. Findings indicate that specific strategies need to be developed to stimulate undergraduate and graduate interest in careers in clinical and academic geriatric psychiatry.

The "Goldilocks model" of overtime in construction: not too much, not too little, but just right

PROBLEM

Little research exists on the relationship between working overtime and possible adverse health and safety outcomes for construction workers.

METHOD

Five focus-group discussions were conducted with construction workers from around the United States. From the analyzed transcripts, a model of overtime was developed.

RESULTS

The model includes three dominant themes: (1) work organization issues [(a) definitions of overtime, (b) scheduling, and (c) economic conditions], (2) why workers choose to work overtime [(a) management expectations, (b) career, and (c) money], and (3) the effects of working overtime [(a) health and safety, including sleep deprivation, injury, fatigue, and stress, and (b) productivity].

DISCUSSION

Health and safety is only one of the adverse outcomes related to working too much overtime. A list of worker-inspired recommendations for addressing overtime issues is provided.

IMPACT ON THE INDUSTRY

Both employers and workers need to better understand the potential adverse effects of working too much overtime.

Effects of retrofit emission controls and work practices on perchloroethylene exposures in small dry-cleaning shops

The effectiveness of commercially available interventions for reducing workers' perchloroethylene exposures in three small dry-cleaning shops was evaluated. Depending upon machine configuration, the intervention consisted of the addition of either a refrigerated condenser or a closed-loop carbon adsorber to the existing dry-cleaning machine. These relatively inexpensive (less than $5000) engineering controls were designed to reduce perchloroethylene emissions when dry-cleaning machine doors were opened for loading or unloading. Effectiveness of the interventions was judged by comparing pre- and postintervention perchloroethylene exposures using three types of measurements in each shop: (1) full-shift, personal breathing zone, air monitoring, (2) next-morning, end-exhaled worker breath concentrations of perchloroethylene, and (3) differences in the end-exhaled breath perchloroethylene concentrations before and after opening the dry-cleaning machine door. In general, measurements supported the hypothesis that machine operators' exposures to perchloroethylene can be reduced. However, work practices, especially maintenance practices, influenced exposures more than was originally anticipated. Only owners of dry-cleaning machines in good repair, with few leaks, should consider retrofitting them, and only after consultation with their machine's manufacturer. If machines are in poor condition, a new machine or alternative technology should be considered. Shop owners and employees should never circumvent safety features on dry-cleaning machines.

The intervention research process in occupational safety and health: an overview from the National Occupational Research Agenda Intervention Effectiveness Research team

The goal of occupational safety and health intervention effectiveness research is to determine whether specific interventions work to prevent work-related injury and illness. But that is not the whole story. It is also important that the development and implementation of the intervention be evaluated. All three phases (development, implementation, and effectiveness) are central to a model of intervention research proposed by the National Occupational Research Agenda Intervention Effectiveness Research team. Areas for future research are also presented.

Women in construction: occupational health and working conditions

Construction is one of the largest industries in the United States, employing 7.6 million workers, or about 5% of the US work force. More women have taken jobs in the construction industry over the last two decades, as they have in other nontraditional industries. In 1997, there were 8.1 million construction workers, of whom 781,000 (9%) were women. Approximately 2% of those were employed as skilled tradeswomen. There is no disputing that construction work is dangerous. Seventeen percent of all fatal on-the-job injuries occur in construction, which is about three times its 6% share of total employment. In this paper, we review the medical literature on the safety and health hazards for women working in the construction industry. Women have a different pattern of fatal injuries and some differences in patterns of nonfatal injuries than men and report unique problems and concerns related to working in this industry.

Concerns of the dry-cleaning industry: a qualitative investigation of labor and management

BACKGROUND

Occupational scientists agree there are hazards associated with dry-cleaning, but do dry-cleaning owners and workers concur? Knowledge of owners' and workers' perceptions can help guide intervention efforts to reduce worker exposure. To better understand these issues, a qualitative study was conducted using focus group methodology and constant comparative analysis.

METHODS

Two owner and four worker focus groups were held.

RESULTS

Findings suggest that overall, health and safety issues were not of great concern. Owners were primarily concerned with the economic impact of regulations. Workers did express some anxiety about solvent exposure and burns, but most felt that these hazards were "just part of the job." Also, other than the installation of air-conditioning in the shops and the provision of health benefits, workers could not think of ways health and safety on the job could be improved.

CONCLUSIONS

These findings will be used to develop comprehensive safety and health interventions (e.g., engineering plus education and training) in dry-cleaning shops.

Stressors and adverse outcomes for female construction workers

The authors examined the impact of a number of job stressors, including sexual harassment and gender-based discrimination, on female construction workers' level of job satisfaction and psychological and physical health. Results from a telephone survey with 211 female laborers indicated that having responsibility for others' safety and having support from supervisors and male coworkers was related to greater job satisfaction. Increased reported psychological symptoms were also related to increased responsibility, as well as skill underutilization, experiencing sexual harassment and gender-based discrimination from supervisors and coworkers, and having to overcompensate at work. Perceptions of overcompensation at work and job uncertainty were positively associated with self-reports of insomnia. Finally, sexual harassment and gender discrimination were positively related to reports of increased nausea and headaches.

Occupational stress, safety, and health: conceptual framework and principles for effective prevention interventions

The authors present an overarching conceptual model of occupational stress, safety, and health, incorporating multiple factors from diverse disciplines. They examine specific implications of the model for the development of prevention interventions (e.g., context-specific interventions and primary, secondary, and tertiary prevention). They review prevention interventions and describe and analyze 4 case studies that address exposure to environmental, ergonomic, and psychosocial stressors and a combination of physical-environmental and psychosocial stressors. The authors examine lessons learned from these interventions in light of the conceptual model (e.g., role of top management and integrating research and intervention).

Tradeswomen's perspectives on occupational health and safety: a qualitative investigation

Qualitative research methods were used to determine the health and safety concerns of women employed in the construction trades. Major categories of concern were identified, including: 1) exposure to chemical and physical agents; 2) injuries from lifting/bending/ twisting, falling, and lacerations; 3) lack of proper education and training; and 4) the health and safety risks related specifically to tradeswomen. Many of the issues identified by the workers are amenable to change through either engineering, behavioral, or administrative interventions.

Operationalizing theoretical constructs in bloodborne pathogens training curriculum

This article describes how the protection motivation theory (PMT) was used to inform the production of video curriculum for a bloodborne pathogens training program for hospital nurses. Although hospital nurses are well acquainted with the work practices designed to prevent bloodborne pathogen exposures (universal precautions), there is evidence that they do not always follow them. First, the original PMT is adapted to reflect what is currently known about the role of affect in health behavior prediction. Second, the authors show how the four PMT message constructs-probability of occurrence, magnitude of noxiousness, response efficacy, and self-efficacy-guided the planning, shooting, and editing of the videotapes. Incidental to this process was the operationalization of these message constructs in such a way that affective reactions would result. The results show that this video curriculum successfully aroused negative affect in the target audience. Only by carefully planning and documenting how message constructs are operationalized in health education materials can one be sure of achieving theory-based (and thus the most replicable) message design.

Methodological issues for intervention research in occupational health and safety

This article presents a brief summary of the nature and extent of intervention research being conducted in the area of occupational safety and health. Articles were classified either as engineering, administrative, or behavioral, according to the type(s) of interventions that were evaluated. Findings suggest that many of the intervention studies conducted lacked a theoretical basis, used small samples, and tested interventions lacking the intensity to cause the desired change. Most study designs were either nonexperimental or quasi-experimental. Recommendations for conducting future research are presented.

Intervention research: science, skills, and strategies

Despite a rich history of etiological research, the field of occupational safety and health does not have a rigorous history of research on what works and does not work to prevent and control occupational diseases and injuries. National and global transformations of economies and workplaces with enhanced competitiveness require more attention to options for interventions. A three-pronged approach to building a body of knowledge on intervention research in occupational health and safety is identified in this paper. The approach focuses on the science, skills, and strategies that can be useful in intervention research. Scientifically, researchers can draw on constructs and techniques from epidemiology, evaluation practice, and clinical trials. Experimental and nonexperimental approaches have value for occupational studies. The skills needed represent a range of disciplines beyond those traditional of health and safety; social scientists, economists, and organizational theorists often need to be part of research teams. Strategic approaches involve more labor-management partnerships, prospective study designs, and the use of intermediate and surrogate indicators. The strategic challenge will be to conduct intervention research against a backdrop of overriding political and economic pressures.

Intervention research in occupational health and safety

This paper reviews occupational health and safety intervention studies published between 1988 and 1993 to gauge the nature and extent of research in this area. Generally, the studies often lacked a theoretical basis, used small samples, and tested interventions lacking the intensity to cause the desired change. Most designs were either nonexperimental or quasi-experimental with uncontrolled sources of bias. Recommendations for future research include methods of minimizing the problems and biases caused by these weaknesses. Nonmethodological issues such as the costs of implementing interventions and the cultural and political dimensions of the workplace are also addressed. Although many methodological issues associated with field-based research are not easily addressed, researchers should make a stronger attempt to address these issues if the field of occupational health and safety intervention research is to be productive.

Acculturation and psychological distress in three groups of elderly Hispanics

The goal of this study was to evaluate the relationship between acculturation and psychological distress in three groups of older adults who have immigrated from Mexico, Cuba, and Puerto Rico. Financial strain and social isolation are specified as intervening mechanisms that are thought to link acculturation with well-being in late life. Data from a recent nationwide survey of older Hispanics suggest that levels of psychological distress tend to vary across Hispanic groups and that these differences may be attributed in part to the complex interplay between educational attainment, language acculturation, financial strain, and social isolation.